The arrival of gynecologic oncologist David A. Fishman, MD, as Director of the American College of Surgeons-accredited Cancer Program at NewYork-Presbyterian Queens, demonstrates the hospital’s commitment to working on the front lines of personalized gynecologic cancer care. Dr. Fishman, who is Vice Chair of Obstetrics and Gynecology, Director of Gynecologic Oncology at NYP Queens and a Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medicine, sees patients at the NewYork-Presbyterian Medical Group Queens (NYPMGQ) offices in Forest Hills as well as the hospital.
David A. Fishman, MD, Director of the American College of Surgeons-accredited cancer program at NYP Queens, Vice Chair of Obstetrics and Gynecology, Director of Gynecologic Oncology, speaks with a patient about an ultrasound in the ultrasound room.
Dr. Fishman embraces a philosophy that is shared across the department: prevention. With the exception of cervical cancer, women’s gynecologic cancers are notoriously hard to predict or detect early — there is no accuracy equivalent to a mammogram or a Pap test for ovarian, fallopian or other similar cancers. Instead, many women receive diagnoses when their disease is advanced. However, Dr. Fishman, along with NYPMGQ gynecologic oncologists Tarah L. Pua, MD, and Long Nguyen, MD, is using advanced techniques in ultrasound, genetics, molecular biology and proteomics to identify cancers as soon as possible. They hope to predict which patients may develop gynecologic cancers and offer early preventive strategies.
“The earlier we find a gynecological cancer, the better the outcome,” Dr. Nguyen says. “Our program and group focus specifically on the prevention, early detection and treatment of ovarian cancer. We look to biomarkers and genetic markers to identify ovarian cancer earlier and to predict the patient’s response to a particular treatment.”
The First Step: Identification
The program’s optimistic mission is a direct contrast to a history of frustration in the field of gynecologic oncology, especially when it comes to ovarian disease.
“The problem with ovarian cancer is that it is still extremely difficult to detect this disease when it’s curable,” Dr. Fishman says. “Today, as in 1960, 75 percent of women who are diagnosed with ovarian cancer are found to have it spread throughout their bodies in an advanced-stage disease.” Although ovarian is not the most common gynecologic cancer, it is the deadliest, accounting for about half of all gynecologic cancer deaths in the United States, Dr. Fishman explains.
“Each year, 22,000 women are diagnosed with ovarian cancer, and 14,000 die from it,” Dr. Fishman says. He describes ovarian cancer’s progress as similar to that of pancreatic cancer, which is typically detected late, when there are few effective treatments available. With that dilemma in mind, Dr. Fishman focuses on prevention, rather than early detection. He hopes that identification of high-risk patients leads to testing when it is most needed.
“With genetic advances, we’ve been pioneering the ability to identify people at risk for ovarian cancer and all cancers, such that we could say, ‘You’re at an increased risk, so let’s do something to prevent it from developing,” Dr. Fishman says. Preventive measures might include taking oral contraceptives, or, for women with certain mutations, having prophylactic oophorectomy or salpingectomy.
There are now more than 50 known cancer markers, Dr. Fishman says. At NYP Queens, genetic counselors have difficult conversations with patients about this complicated trail of indicators, helping to determine the proper tests.
“How can basic science be used to improve patient care? That’s the whole focus of our research. Our mission is to try to understand not just gynecologic cancers, but all cancers.”
—David A. Fishman, MD, director of the American College of Surgeons-accredited Cancer Program at NYP Queens, Vice Chair of Obstetrics and Gynecology, Director of Gynecologic Oncology at NYP Queens and a physician with NewYork-Presbyterian Medical Group Queens
An ultrasound of a mass in the ovary taken using new high-tech ultrasound techniques. Combining color Doppler and elastography with ultrasound allows Dr. Fishman to diagnose potential cancers early.
Genetics: Deciding Whom to Test
How do physicians use genetics to predict which patients are at risk for cancer? There are no tried-and-true formulas, according to Dr. Pua.
“Unfortunately, we don’t have any new genetic strategies to do this for us,” Dr. Pua says. “We have to know when to send patients to a genetic counselor. Any patients with a strong family history of ovarian cancer that suggests it could be hereditary should be sent for genetic counseling. We also look at personal history of breast cancer. We ask, ‘Are you of Ashkenazi Jewish descent? Do you have first- or second-degree relatives with cancer, from breast or ovarian cancer to colorectal and renal cancers?’ We’ve moved to using a more expansive family history for a risk assessment.”
Tarah L. Pua, MD, attending physician, Gynecologic Oncology, and Long Nguyen, MD, attending physician, Gynecologic Oncology, review a CAT scan.
Dr. Pua points out that while genetic laboratories heavily market testing, she cannot rely on genetic test results to counsel a patient. Genetic panels are more complex than simply identifying whether people have a BRCA1 or BRCA2 gene mutation; rather, there are a complicated set of indicators which may interact in myriad ways.
Dr. Pua recommends that patients be referred to qualified genetic counselors based on certain guidelines. At-risk groups include women with multiple cancers, women who have multiple relatives with early breast cancer, premenopausal women with breast cancer and women younger than 50 with endometrial cancer, she says.
Dr. Pua and Dr. Fishman discuss treatment options for a patient.
Minimally Invasive Surgical Techniques
Dr. Fishman describes his team’s work as moving toward precision medicine now used to analyze individual cancers.
“With the computer sophistication and new tools we have, we can use precision medicine technologies to understand the individual’s cancer,” he explains. “Your cancer or mine, while they may look the same under a microscope, are biologically very different. In our program, we take an individual’s cancer and investigate it at the molecular level and trying to understand what makes it a cancer. We then use this information to identify therapies unique to that person’s disease, hoping that will allow us to cure the cancer, not just treat it.”
NYP Queens offers minimally invasive surgery for ovarian cancer whenever possible; however, that approach is not always feasible for advanced disease.
Dr. Pua speaks with a patient about an upcoming procedure.
“Most of the time, when ovarian cancer is detected, it’s very difficult to treat it with minimally invasive surgery,” Dr. Pua says. “Most cases require a large incision — what we call a laparotomy — to remove everything that has been affected, which typically includes the uterus, cervix, both ovaries, the related lymph nodes and any affected part of the peritoneum.”
Accurate cancer staging is necessary to make sure nothing is missed.
“The goal of cancer staging is to basically take out all the cancer that can be seen with the naked eye,” Dr. Pua says. “Any remaining microscopic disease will be dealt with via adjuvant chemotherapy.”
In the rare cases in which ovarian cancer is detected at an early stage, minimally invasive surgery is an available treatment option, Dr. Pua says. In those instances, the lab examines suspicious nodule samples while the patients are still in the operating room, and, if the sample is found to be cancerous, the surgeon can remove only the ovary if the cancer is in the early stages.
Dr. Nguyen, who has been performing minimally invasive surgery since his medical school training, has seven years of experience with these procedures. In cases of uterine cancer, as well as select instances of ovarian cancer, a robotic approach through tiny incisions is often quite feasible, he says.
“The type of surgery depends on the pre-operative workup,” Dr. Nguyen says. “We use ultrasound, CT and MRI, combined with the physical exam, to determine the nature of the cancer. For most uterine cancer patients, we can perform minimally invasive laparoscopic or robotic surgery. In the case of cervical cancers, it depends on the patient and the cancer — we can perform a radical hysterectomy and staging procedure using the robot for women with early stage cancers, whereas if cervical cancer has spread, surgery is not an option. The patient will instead undergo chemotherapy and radiation.”
It is far easier for patients to undergo minimally invasive than open surgeries — they lose less blood and experience less pain.
“That’s the beauty of a minimally invasive procedure,” Dr. Nguyen says. “If the patient’s cancer is in an early stage, they can have surgery, stay overnight and go home the next morning.”
One procedure offered at NYP Queens benefits patients with cervical cancer who wish to preserve their uterus — robotic-assisted surgery.
“Sometimes, when a patient has had surgery for abnormal bleeding, for example, we opt to leave the cervix in place,” Dr. Nguyen explains. “But if the pathology report shows the cervix is diseased, we can perform a trachelectomy [removal of the cervix] using the robot. This procedure is important for patients who want to preserve their fertility.”
At NYP Queens, chemotherapy is personalized for both the cancer and the patient to ensure the most effective response to the disease.
“We offer standard Carboplatin and Taxol, with or without Avastin, for frontline treatment,” Dr. Pua says. “It’s important that patients get genetic testing, because if they do have the BRCA1 or BRCA2 mutation, then, further down the line, they may be eligible for an oral chemotherapeutic agent — a PARP inhibitor.”
PARP inhibitors are protein inhibitors that affect how DNA responds to damage, preventing cancer genes from repairing DNA. According to a 2016 article in Gynecologic Oncology Research and Practice, PARP inhibitors are especially useful against BRCA-deficient ovarian cancer, since such cancers lack the ability to repair themselves easily.
Soon, these treatments will be readily available in NYP Queens’ new infusion center, slated to open in 2017.
Integrative Medicine: A Holistic Approach
The gynecologic oncologists at NYP Queens take a holistic approach to patient care, treating each woman as a person rather than a diagnosis or collection of symptoms. This warmth extends throughout the ancillary services offered. It is also formalized in the discipline of integrative medicine, in which Dr. Pua is board-certified.
“Integrative medicine is a relatively new field focused on the patient as an individual,” Dr. Pua says. “It’s not only the disease being treated. It also takes the mind, body and spiritual beliefs into account. Sometimes a patient’s primary concern is not her disease but something else, such as problems at home. In integrative medicine, we can discuss these concerns with her.”
Vitamins, minerals, herbal medicines and acupuncture also fall within the domain of integrative medicine. A physician versed in integrative medicine knows to inquire sensitively into which herbal medicines a patient is taking, and can help her understand whether this medicine might or might not be appropriate in conjunction with chemotherapy.
“Not everybody is comfortable talking to their physician about alternative medicine because we tend to discount it,” Dr. Pua says. “Lately we have been seeing more acceptance of acupuncture, for example, with data showing it may decrease pain and nausea in postoperative patients or patients undergoing chemotherapy. Slowly but surely, we are achieving an integrative approach — it is just a matter of time.”
Dr. Nguyen in his office
Proteomics: A New Frontier
Although Dr. Fishman and his colleagues at the NCI pioneered proteomics — the study of proteins in the body — in the 1990s, this technology is now expanding rapidly in the field of oncology.
“Proteomic techniques are used to identify and detect disease before it’s detectable by any other technology,” Dr.Fishman says. “Proteomics is one prong of a multi-armed assault that we’re doing globally to improve patient care — it’s a work in progress.”
Proteins differ from individual to individual, but not in the same way genes do, Dr. Fishman explains.
“The production of proteins is an extremely complicated process,” Dr. Fishman says. “Despite having the same gene, two individuals can produce different amounts of proteins. Or the proteins may be slightly modified in each individual.”
“A series of such slightly modified proteins may cause a person to develop a cancer,” he continues, “These subtle differences are critical because before we had these technologies, we couldn’t detect such fine nuances. Now we can.”
Ultrasound for Understanding Tumors
The NYP Queens team is on a quest to make the diagnostic process less invasive and timelier. In fact, the hospital just received an award from the Phillips Company recognizing their use of ultrasound to optimize the early detection of cancer and to determine which masses are malignant.
Up until now, ultrasound has been used to identify uterine and ovarian masses, but it has not been able to provide information as to whether a mass is cancerous. This is a simple approach with the potential to be used around the globe, helping women where MRI or CT is not available.
Dr. Pua, Dr. Fishman and Dr. Nguyen in front of the NewYork-Presbyterian Medical Group Queens physician practice, located in Forest Hills
Molecular Research: A Benefit for All Cancers
“Our primary focus is on the process of how cancer spreads,” Dr. Fishman says. “We collaborate with scientists at NCI and The Center for Applied Proteomics and Molecular Medicine at George Mason University. We’re trying to use new technologies and knowledge of cancer genetics to understand the process of how disease spreads and what cellular pathways it uses to avoid immune surveillance.”
NYP Queens physicians also collaborate with George Mason University experts on personalized medicine — examining a tumor to identify which therapy will be most effective for an individual patient.
“At NYP Queens, we combine both approaches to cancer — practice and research,” Dr. Nguyen adds. “Our goal is to improve medical care for all patients.”
To learn more about gynecologic cancer care service at NYP Queens visit nyp.org/queens. For referrals or to make an appointment with these NewYork-Presbyterian Medical Group Queens gynecologic oncologists, visit http://nyp.org/medicalgroups.