Meeting Expectations with Excellence
Indiana University Cancer Center Wins Clinical Designation from National Cancer Institute.

In a perfect world, there would be no need for cutting- edge medical research because all people would enjoy robust health. The word 'cancer' would not describe insidious, life-threatening diseases except in fictional writing.

But the world is not perfect, and that is why there are more than one hundred scientists and physicians, nurses, social workers and technologists at the Indiana University Cancer Center dedicating their professional lives to remediation of these life-altering diseases.

In our imperfect world, people from all walks of life and of all ages deal with the facts of cancer. Two of these people are grown-up Linda Ewing and preschooler Stephanie Estrada; both patients are alive because of treatments that are still in research stages.

Standard therapy doesn't help all cancer patients; that is why researchers at IUCC continue their search for new treatments and, hopefully, new cures. But until they do, patients turn to cancer centers like IUCC for the most current treatments, and, perhaps, new therapies that could make a difference. Both Stephanie and Ms. Ewing found more time in investigative therapies; in Stephanie's case, a cure is the result.

Both patients are among the many who have benefited from the bench-to-bedside development of treatments, which recently brought the IUCC recognition as a National Cancer Institute - designated clinical cancer center. It is a designation that reflects the commitment of faculty and staff in the IU Cancer Center to provide the highest quality care to their patients.

Living on Research
Linda Ewing can testify to the importance of the quest for more effective treatment that characterizes the work of IUCC physicians and research scientists.

Ms. Ewing has been battling renal cell carcinoma off and on for thirteen years. An advocate of the clinical research process, she has become incredibly savvy at ferreting out and evaluating clinical trials for her type of cancer. It is a skill born of necessity, hope and perseverance. Ms. Ewing, who is associate dean of students at Purdue University in West Lafayette, uses the Internet and other resources, including her relationship with Michael Gordon, MD, associate professor of medicine at IUSM, to stay informed about the latest trials at IUCC and elsewhere. An optimist at heart, she believes that clinical trials could hold the answer for her recovery and sees each chance to participate in a clinical trial as a window of opportunity.

First diagnosed with renal cell carcinoma in the summer of 1986, she underwent a nephrectomy that August. All went well for nine years. Then in May, 1995, an X-ray taken during a routine physical revealed a suspicious image on her left lung. Her cancer had spread, and surgeons removed a lobe of the lung.

In the fall of 1996, a nodule on her breast-bone took her back to the doctor where a scan revealed that her kidney cancer had again spread. That is when she became acquainted with IUCC and Dr. Gordon. The recommended treatment, which she received at IU, was radiation. Two more years passed before other malignant spots were found in her left hip and lung, and since then she has enrolled in nearly half a dozen clinical trials.

This past fall she began an experimental treatment using the drug combination 5-fluorouracil (5-FU) and gemcitabine, designed to attack her cancer cells. Dr. Gordon offered the treatment based on some promising results from initial trials at the University of Chicago. This summer, while waiting for her current trial to begin at IUCC, Linda enrolled in a different trial at the University of Chicago. That trial was to determine if a specific drug could bolster patients' immune systems, but the results were not as positive as Linda had hoped.

"Cancer is an insidious disease that affects entire families," says Linda during a recent visit to the Indiana Cancer Pavilion, which adjoins Indiana University Hospital and where the IUCC provides most adult clinical oncology care. "It is not only the physicians I value, but the dedication and caring of everyone - from the receptionists to the technicians to the nurses - that makes IUCC a special and supportive place. I have received treatment at other medical centers, but when I return to IU Cancer Center it always feels as though I am coming home."

Hope Realized
About a half block north of the Cancer Pavilion, across from the Indiana Cancer Research Institute, Riley Hospital for Children is home to the full range of clinical care for cancer's youngest victims. Here IU hematologists/oncologists are investigating another type of cancer treatment that is attracting worldwide attention.

Blood cell replacement via bone marrow transplantation (BMT) or stem cell blood transplantation has proven successful in treating some cancers by replacing diseased blood cells and blood cells damaged by the toxicities of chemotherapy. The use of umbilical cords as a source for blood cell transplantation is relatively new; newer still is the science of growing cells ex vivo from cord blood to augment the small number harvested in the delivery room.

This pioneering work was made possible by the advanced thinking of Hal Broxmeyer, PhD, director of the Walther Cancer Institute at IUSM, and physicians applying his research, Frank Smith, MD, Kent Robertson, MD, and Blythe Thomson, MD, who were the first to transplant a patient with ex vivo (grown outside the body) stem cells.

One benefactor of their efforts is Stephanie Estrada, who at age two was diagnosed with acute myelogenous leukemia (AML) and who in 1998, at age three, made medical history.

When chemotherapy failed to keep her AML in remission, her doctors at IUSM advised her parents that BMT was Stephanie's best hope. But when no match could be found in the national cord blood bank, her physicians turned to an ex vivo cord blood transplant. The procedure was offered at Riley Hospital as a Phase I trial designed to determine if the small amount of stem cells found in cord blood can be increased in the laboratory and safely infused into the patient. Stephanie is now five and dreams of becoming a doctor or a nurse.

Research Holds The Key
Researchers are continuing to compare the benefits of cord blood relative to bone marrow transplantation because cord blood is more readily available than bone marrow and is believed to hold fewer engraftment complications. They hope to demonstrate whether cord blood cells adapt to a new host with a lower incidence of severe immune reactions. They also seek to reveal whether increasing the number of cord blood stem cells transplanted into a patient will increase efficacy and decrease the negative side effects associated with cord blood transplantation.

"If ex vivo expansion works, then it may decrease some of the toxicities associated with cord blood transplantation because the expanded cells may grow sooner and, perhaps, decrease the risk of infections," explains Dr. Smith, associate professor of pediatrics, of medicine and of microbiology/ immunology. He also is co-director of the IU Bone Marrow and Stem Cell Transplantation Program.

If ex vivo expansion works as well as researchers hope, it could open the way for cord blood transplantation to benefit large children and adults with cancer, who currently are not good candidates for the procedure due to the small quantity of cells found in cord blood.

Research efforts like these - resulting in improved clinical care for patients such as Ms. Ewing and Stephanie - were pivotal in gaining IUCC the NCI designation. Institutions must not only show that their focus on cancer research is a predominant part of their mission but that they support their research programs with adequate funding and space. Two new buildings on the IUMC campus testify to this level of commitment.

The Indiana Cancer Pavilion, a $13-million clinical care facility with contiguous office space for physicians in all areas of cancer care, was dedicated in October, 1996. The following year the $22-million IU Cancer Research Institute was dedicated. Like the Indiana Cancer Pavilion, the Cancer Research Institute was designed to facilitate collaboration among faculty and expand opportunities for innovation and progress.

To win NCI designation, institutions also must have a proven track record for organizational capabilities, showing that a mechanism exists to comprehensively oversee research and clinical care. The IU Cancer Center fulfills that role at Indiana University Medical Center. A portion of the five-year, $6.5-million support grant that is awarded with the NCI designation will be used to bolster the effectiveness of the administrative arm of the program. These funds will also provide seed money for new research and shared research resources, such as collaborative projects now being considered with Purdue University, which holds an NCI cancer research center designation.

Sharing The Credit
Achieving the NCI designation is a significant achievement for the IU cancer program. But as with all milestones, it marks not an end but only a significant point in a continuing journey. The program continues to grow and mature.

"An NCI designation complements our long-standing recognition as one of the top clinical programs nationally," says Stephen D. Williams, MD '71, IUCC director and professor of medicine. "The NCI grant enhances the collaboration of research scientists and physicians throughout Indiana and will offer advantages in care for all Hoosiers."

In turn, IUCC shares credit for its new designation with many Indiana physicians and health care professionals, individuals and philanthropic groups. Oncologists across the state support the program by referring patients and carrying out clinical protocols. Funding that has made a difference comes from individuals and major organizations, not the least of which are the Walther Cancer Institute, Riley Memorial Association through the Herman B Wells Center for Pediatric Research, the Howard Hughes Medical Institute, the Indiana Lions Cancer Control Fund, the Indiana Order of the Elks, the Catherine Peachey Fund and Clarian Health Partners.