New Leaders For New Times, Part 1

Jonathan W. Friedberg, M.D., M.M. Sc. & Hartmut K. Land, Ph.D.

On a clear day, the view from the top floor of the James P. Wilmot Cancer Center stretches well beyond the City of Rochester, and that is where Director Jonathan W. Friedberg, M.D., M.M. Sc. & co-director Hartmut K. Land,Ph.D. are extending their vision as well. We feel a responsibility to advance the quality of cancer care, not just at Strong Memorial Hospital, but throughout the region. "We feel we are the best equipped and most appropriate cancer center to do that," says Friedberg.

Appointed as Wilmot director this spring, Friedberg was the unanimous choice of URMC senior leadership. The hematologist and national leader in lymphoma care and clinical research is joined by co-director Land. Land, who also serves as research director, has been making critical discoveries related to the role of gene mutations and cancer for nearly three decades.

Friedberg and Land say the concept of regional cancer was not even on the Medical Center's radar screen a decade ago. Nor was URMC ready to take on such a prominent role. In the late 1990's, the roughly 25-year old main cancer facility was showing its age.

In 2001, Richard I. Fisher, M.D. became director, endeavoring to turn things around.

"He spent a number of years fundraising, with the vision of putting up this building," Friedberg says from his airy office. "As you can see, it's been quite a success."

Now more comprehensive than ever, Wilmot houses inpatient and outpatient care, family amenities, radiation treatment, and both clinical- and laboratory-based research in the same seven-story building, which is filled with natural light and open spaces. Friedberg is only half-joking when he says the building makes it easy to recruit top scientists and clinicians; they have steadily arrived to fill the Center with world-class expertise. They have been accompanied by a dramatic growth in the number of patients, as well as millions in competitive research grants such as the $11.5 million Specialized Programs of Research Excellence (SPORE) grant supporting lymphoma research and clinical trials.

"Our growth has been double-digit each year in volume, revenue, and many other metrics since 2009," Friedberg notes.

Now Friedberg, along with Land, the Center's co-director and director of research, is charged with building on this success, in an era of diminishing resources and pervasive reform coupled with rapid scientific and clinical advancement. Friedberg says the URMC's entire leadership team is backing cancer as a priority, and that is why he is predicting success.

"I feel a tremendous sense of responsibility to deliver, in the sense that we're in a position where we should succeed because everybody really wants it to succeed."

Friedberg and Land have drawn up a blueprint for progress that is somewhat less tangible than Fisher's was. Rather than building walls, it focuses on building on four dynamic objectives: assuming greater responsibility for cancer care in the region, adopting a new strategic plan for research, providing true, multi-disciplinary cancer care, and steering the community through outreach and advocacy. Dictating quality of care for the region At the end of 2012, the URMC acquired Pluta Cancer Center, an independent cancer care center situated in a nearby suburb. Pluta had earned an excellent reputation as a small, compassionate provider. Given the multitude and complexity of changes in health care, however, Pluta recognized it could not sustain high level of care. Leaders from both organizations developed a plan to preserve much of Pluta's individuality while making it part of the much larger entity.

Friedberg says Pluta is just the beginning. He anticipates making other acquisitions and affiliations throughout the Finger Lakes and Western New York. His says this will lead to patients receiving the same level of cancer care, including diagnostics, wherever they live.

"Just diagnosing cancer is far more complex than it's ever been. It used to be — you have breast cancer, or you don't. Now you need to know if the breast cancer is estrogen receptor positive, progesterone receptor positive, or HER2/neu positive," Friedberg notes. "These are specialized tests that require interpretation, and they have therapeutic implications because we have new treatments that target these small subgroups of cancers."

New partners will have access to Wilmot's more sophisticated facilities for the most accurate, modern diagnoses available. He says similar opportunities exist in other areas, such as the sharing of surgical techniques, radiation techniques, and types of chemotherapy.

"It's not practical for a 75-year old woman with metastatic breast cancer to drive two-and-a-half hours to see us for an appointment. But it shouldn't be all or nothing. There should be ways that we can positively affect the quality of care throughout the region, and that's really what we are looking to do," says Friedberg. Taking a new approach to research As they develop the Wilmot's new strategic plan for growth, Friedberg and Land are keeping an eye on four key points scribbled in Expo marker on Friedberg's office whiteboard: hallmarks of cancer, blood malignancies, solid tumors, and cancer control and survivorship.

"We've narrowed down our focus to these four main research areas that are appropriately broad in scope, but allow us to recruit and invest in areas of strength," he explains.

It sounds simple, but when there are faculty members in virtually every department of the medical center who are studying cancer — it's not. Friedberg and Land formed a committee to comb through the entire portfolio of research across the URMC. Members then fit the vast majority of that research into the four buckets.

"We're going to try to provide resources in a way that will help as many of these groups as possible," says Friedberg. "For example, if a new machine helps all of the groups, that is something we should invest in."

A key area of research in Land's mind is called Hallmarks of Cancer, which are a set of biological features common to most cancer cells. Land has been at the forefront of this pioneer approach to exploring cancer treatment, and he has been successfully building a research program around it since 1999. Despite mounting evidence suggesting no two cancers are alike — given the many different types of cells of origin and mutated gene combinations — Land suspects every cancer does not necessarily need its own specific treatment.

"Rather than focusing on the diversity of cancer, we really need to focus on the underlying commonalities of cancers," says Land, who is also the Robert and Dorothy Markin Professor and chair of Biomedical Genetics. "The idea to focus on this concept is — at the moment — quite unique."

By studying the molecular architecture of blood cancers and solid tumors, scientists at Wilmot are finding fundamental features that drive all cancer cells to behave differently than normal cells. They are then locating vulnerable spots in this architecture, and investigating the potential for new or repurposed drug interventions at these susceptible points. Other studies are looking at how to protect cancer patients from tissue damage and other adverse side effects from treatment.

Ultimately this research could lead to highly precise cancer treatments, with minimal unwanted side effects. Land calls this "targeted demolition."

To add depth to its areas of strength in research, URMC is collaborating with Roswell Park Cancer Institute in Buffalo to conduct joint investigations. Friedberg and Land add, working together, the two institutions can accomplish a lot more than they could separately in this era of increasingly competitive funding.

Treating patients, after they've gone home A patient is diagnosed with testicular cancer, treated, and cured. Now what?

"The primary care physician doesn't necessarily know what to do because he may have had one patient in his career with testicular cancer. The oncologist is more focused on the next patient than the survivor," says Friedberg, explaining the rationale behind the clinical cancer survivorship program, one of several new clinical initiatives being introduced by the Wilmot. "One of the most wonderful challenges we have today is managing the ongoing health care needs of a rapidly expanding population of cancer survivors."

Cancer and cancer treatment are often followed by delayed or long-term physical and psychological effects such as heart or lung impairments, osteoporosis, chronic fatigue, emotional difficulties, and a higher risk of developing a secondary cancer. Under the clinical survivorship program, patients and their families receive recommendations for follow-up visits and surveillance tests, monitoring for signs and symptoms of disease reoccurrence, diet and exercise, and even financial issues. If problems develop, the survivorship program has a panel of specialists who can quickly step in. Becoming the ultimate cancer resource for Rochester "Cancer is a disease that touches virtually everybody, either personally or through someone they know," notes Friedberg.

Research and cancer care are critical, but there is also a widespread need for timely, accurate information and learned advocacy. Wilmot is positioning itself to be the region's leader in filling that need. Friedberg is planning to put more energy into educational programs, free cancer screenings, and partnerships with community organizations.

"As the region's academic medical center, we owe the community a lot and I really want to increase our visibility," he says. "I am optimistic we will succeed."