 Lakeland Public Television presents Currents. And welcome to Lakeland Currents. I'm Bethany Wesley. The American Cancer Society reports that more than a million people in the United States get cancer each year. Locally, 419 new cancer patients were diagnosed and treated at Sanford Bemidji Medical Center in 2015 with more than 45% of such patients coming from outside Beltrami County. Indeed, the Sanford Bemidji Cancer Center treats about 400 cancer patients a year with breast cancer being the most common and lung cancer the second most common. The Sanford Bemidji Medical Center now is poised to break ground this year on its new 20,000 square foot Sanford Joe Lucan Cancer Center. A new facility planned to bring all of Sanford Bemidji's cancer services together, providing not only more convenience for its patients, but also increased efficiencies for medical personnel. The construction of the new facility continues a 15-year expansion of cancer care services at the Bemidji Hospital. Tonight, as we prepare to examine and discuss those health care expansions, we welcome to the program two key members of the Cancer Center team. Dr. John Bollinger, a Radiation Oncologist, and Dr. Jasmine Cambos, Medical Oncologist and Hematologist. Welcome to the program. Thanks for coming. Thank you. Thank you. As we get started here, why don't we just go through your background? How long you've been at the Sanford Hospital, your background in medicine? Dr. Bollinger? Sure. I'm a Radiation Oncologist, and I graduated from Residency in 1986, and I practiced in Georgia and several other areas, moved to Grand Forks. Before I came to Bemidji, I actually knew the doctors in Fargo, and when Merit Care at the time expanded their services to include Radiation Oncology in Bemidji, they recruited me, and so I came here in 2001. So you've been here since 2001. And Dr. Cambos? Yeah, I'm relatively a new addition to Bemidji and to Sanford. So I did my med school from India. I graduated from the med school in 2007, did residency from Chicago Rosalind Franklin University, and did my fellowship in Medical Oncology and Hematology at Baylor College of Medicine in Houston, and then I came to Bemidji. And when did you come to Bemidji? I started in June, so I'm relatively new. Well, welcome. Yes, thank you. First, I want to look back, Dr. Bollinger, to when you first came in 2001 to Bemidji. Can you tell us a little bit about what the state of cancer care was at that time, how were treatments being offered? I didn't think Bemidji was big enough for Radiation Oncology, and the doctors in Fargo said, well, just give it a chance, you know, and so when I came, I was surprised that it was bigger, even though the population in Bemidji proper wasn't, you know, huge, but the area that we draw from even then was much bigger than people realize. And we had the support from Fargo. They had the cancer program there, and so Medical Oncologists came to Bemidji as outreach, and that outreach clinic expanded, and by the time I came in 2001, it was quite a big chemotherapy infusion area. I think it was three or four different Medical Oncologists would come up, you know, for a day and go back. But in 2001, Radiation Oncology opened, and that's when I came. That was the first time that Radiation Oncology was here, before patients would have to drive to Grand Forks or to Duluth or, you know, farther. Some patients did that, others just didn't get the service, so at the time, cancer care was, what should I say, simpler, because there wasn't all the multidisciplinary protocols there are now. They were starting, but when patients came and they needed complicated care, they'd have to leave the area. Now that's slowly changed since 2001. It was sort of a slow progression up until, I would say, the last five to six years, and then it's been a very rapid progression since then. But if I'm understanding you correctly, even when you initially came here, you could see there was plenty of room, opportunity to have a growth of services. Well, the Radiation Oncology service, you know, took off immediately because they had been waiting, you know, for it. And so many people were thankful that they could, you know, get their treatments here and didn't have to drive, you know, longer distances. We recruited a medical oncologist in 2003 that was the first one that was full-time, and then we gradually built that, and now we have three. We think that four is probably the right number for long-term, and we're looking for a partner for me now for Radiation Oncology. I want to kind of take a second before we get too much further. I want to take a second to kind of go through some terminology if I can for our viewers. There's three main specialists or primary specialties. You've got Radiation Oncology, Surgical Oncology, and then Medical Oncology. Could you tell us a little bit about what the difference is between all three? Dr. Campbell? Yeah, so I mean, broadly, as you mentioned, you know, cancer care is broadly divided into these three areas. And so Radiation Oncology comes into picture when we need to burn some tumor tissue. So that's a local treatment. Surgical Oncology obviously comes into picture when we want to resect the tumor. So that's kind of limited from stage one through stage three. Medical Oncology comes into picture when we need to do systemic treatments. And these days, systemic treatments involve chemotherapy, immune therapy, hormonal therapy, or any kind of oral-targeted therapy. So all this comes into systemic therapy. So depending on the stage of the patient or what kind of cancer it is exactly, all three specialties come together to kind of take the best care for the patient. And then what exactly is hematology and how does that play a role in cancer? Is there overlap? There is an overlap. So hematology basically entails benign hematology and malignant hematology. So there are two major parts to it. Benign hematology involves all the cases like anemia, which is low hemoglobin, thrombocytopenia, which is low platelet count, which are the clotting cells, or a lot of white blood cell disorders, which are the immune fighting cells. The malignant hematology is the cancer of blood. Now cancer of blood in itself is a very broad term. There can be cancer of different kinds of cells, multiple myeloma, acute leukemias, chronic leukemias, that all comes under malignant hematology. So you're right, there's a little bit of overlap there. Okay, interesting. We talked a little bit on the statistics when we first got started here, but I wanted to just highlight a couple here again. In 2015 there were 419 new patients, just over 53% from Beltrami County. But that is up from 372 new patients in 2013. Since you've arrived in 2001, have you seen a fairly steady growth in terms of the number of people diagnosed? Well, I think there has been an increase in Sanford, formerly MeritCare in North Country. But there are many more cases that aren't coming to us. They're going to other places. And because there's programs like this help, because there will be an awareness that we can do pretty much everything that places like Mayo or University of Minnesota can do. There are a few things that were limited, but most things we can do here now. Cancer care has become very complex. And so you have to have multidisciplinary team, not just the doctors but the nurses and various specialists that we'll talk about as part of the entire team. So we'll see an increase in volume. We do what we call trying to think of the term for it. It's needs assessment that we try to see what the population needs. And in those needs assessment, we can see that there are more cancer cases. The smoking rate is high in this part of the state. So we think that we're going to see an increase. It's not necessarily that there's an increase, you know, cancer rate in general. It's just that the ones that we're going to see are going up. Mainly by geography there's so much population that's not being served. And I would imagine, Dr. Campbell, that technology has also changed. We learn more, we know more. Our screenings, our prevention, is that catching people perhaps earlier? Is that increasing the numbers as well? Perhaps you're seeing more because you're catching it better? You know, I would say that we are catching it earlier, which is the exact same reason why we are doing the screening methodology in the first place for breast cancer, colon cancer primarily. Now there are guidelines coming for the lung cancer as well. And as Dr. Bolinger pointed out, there's a high smoking rate and we are catching a lot of lung cancers in the very preliminary stages, which is a very good success rate, I would say. So Sanford is now starting 3D mammography and MRI of the breasts for patients who have significant family history or they have genes present in their families, which put them at higher risk for breast cancer. So all those patients, they can get those things done here at Sanford now with their 3D mammography, the MRIs, colonoscopy obviously. We do the low volume lung screening, low volume CT scans. So yeah, I mean, with the better screening methods we are catching cancer earlier. I won't say we are catching more cancer, but I would say we are catching it earlier. So the same cancers, if they are not caught earlier and they present at a stage 3 or 4, obviously it's a much harder core for us to kind of take care of those at later stages. So it's beneficial for the patients and for us. Okay. So this year you guys are expected to break ground on your new facility, the Sanford Joe-Lukin Cancer Center. How long has this been in the making, Dr. Bolinger? How long have you guys been chewing this over and really saying this is something we need to do? It's been a need for quite some time. Historically when medical oncology came they grew out of the main clinic quickly. I would say by, I think it was 2005, there was no more room and they had to expand out. And there's been a need since then. But it's hard to explain, but there's numerous reasons why we need all the cancer in one physical location. Now our processes and our protocols, we still do multidisciplinary care now, but it's more difficult if you think about it. When you have the medical oncology staff in one area and the radiation oncology staff in another area, and all the support services that go back and forth have to go back and forth. Now the patients do too. So we've done, we've made tremendous strides having two physical locations, but having one location is going to allow us to grow much more efficiently. So tell me a little bit in terms of like when did you start trying to raise funds? When did that campaign really continue? So that occurred around 2011, I think it was. We made the decision then that we needed to be an independent cancer center not just affiliated through Fargo. And so we started the process, we established tumor registry, we formed cancer committee, and we formally obtained accreditation here in Bemidji as a cancer center and also as a breast center. I think about that same time the foundation started a project to raise money for the cancer center. And that has been very successful the community just participated very enthusiastically. I think, I mean, we knew it, we knew the support was here, but the response was overwhelming. How big is it going to be? What are some of the highlights from the new facility? Could you tell us about that, Dr. Kambush? It's going to be, I think, just roughly over about 20,000 square feet. I think 20,000 square feet. It's going to be on the south end of the clinic. The radiation oncology department is currently there, but it will extend out in the parking lot for quite a ways on that side. And I understand it's going to offer some different options for patients that perhaps they don't have now. Perhaps either privacy, if they want more privacy, they could have people join them. Is that accurate? The infusion center, the way they're laying out the infusion center, it will be right next to the garden area. Patients will have the freedom to kind of hang out in the garden area. They will have the choice if they want to just go visit the coffee shop with their family members. There will be some private suites, so they will have their own privacy if they require that. So it will be much more patient oriented and their preference oriented. So I hope their whole experience is much better with the new center. We'll be coming to the patients more instead of the patients having to travel all over the place. There's a one stop shop that patient comes in and they're immediately welcomed and we want them to feel at home and they're escorted to where they need to go and they don't really have to leave. Everyone else comes to them. So all the different specialties they need to see to help cycle through. And my understanding is as expected, assuming construction goes on time, it would open sometime next year in 2018. That's the plan. Obviously it's called the Sanford-Joe-Lucan Cancer Center. So tell us, obviously in Bemidji, people may be familiar with that name, but could you tell us a little bit about Joe-Lucan? Who was he and how did he become attached? Well, I mean, he was the owner of the grocery store chain here that's still here. He had experience with cancer himself and the family made a very generous donation and about the time that we were raising funds for the cancer center, they came forward and it's been just a tremendous thing that a local person like that would make a gift like that. There's another center or another part of the hospital on the campus and that's the Edith-Sanford Breast Center and I want to touch a little bit about that because it's connected with and yet it's a little bit separate from this. So that was actually founded, I believe, in 2014, if that's correct. Tell us a little bit about what exactly the Edith-Sanford Breast Center is and is that going to be affected by this new facility? Yes. So Denny Sanford, the founder of Sanford Health, his mom had breast cancer in Edith-Sanford and so as sort of a memorial to her, he donated money for the Edith-Sanford Breast and so it's available in all of the Sanford sites so the main push is to have all the services available no matter where you go in the Sanford system. Now for us here in Bemidji, it's been great because we, for example, as Dr. Kamboj mentioned, 3D mammography, breast MRI, the ability to have all breast services in one place, not just for cancer but for women's health, breast health in general. Women can go in one place and all the services are there. You want to expand on that a little bit as far as... There's another program that Edith-Sanford has recently started in Bemidji. We launched it in August, which is the Athena program. So we're in all the women who are coming for screening mammography. They are given a questionnaire and they fill that questionnaire and based on that their lifetime risk is assessed for breast cancer and any women who is identified with having a higher risk for lifetime for the breast cancer, they are kind of followed up. So that, you know, they are not just hanging around in the system and they are not let loose. So there is a letter which goes to them. There's a phone call which goes to them. There's also an update to their primary care physician. So there's like a very kind of, you know, intense effort from the team to follow up on those patients who have high risk so that, you know, appropriate measures can be taken by giving them preventive measures. So that's another part of Edith-Sanford Breast Center. We are also, like semi-annually, we also have this meeting which usually happens at Fargo where in all the Sanford Enterprise-Wide will come together and, you know, we will discuss different researches going on in breast cancer. We will discuss whatever modalities of treatments we are doing so that we have like one uniform platform in Sanford Enterprise-Wide so that, you know, every patient is granted the best care even if they are in remote areas and stuff like that. All of us will go there like radiation oncologist, medical oncologist, surgical oncologist, and other people as well, like, you know, our social workers, research people. So everybody comes together kind of to have a uniform approach. Oh, interesting. And so the training, you know, for the staff in the Breast Center is very specific for breast health. We have a nurse that's qualified as well as a nurse practitioner. So when patients present there, they're assessed. They get what they need. We have a genetic counselor that's there. We never had any of that before. As Dr. Campbell has mentioned, the Athena Health Initiative is a very sophisticated analysis of the risk for breast cancer. Not just a simple model, but when a patient wants to participate, they run through multiple models. And so if they are indeed high risk, they get the education they need and the referrals that they need. My understanding is that what's kind of unique about Athena is that it takes little pieces of all of those models that exist because there's different questionnaires for different things. And that that is supposed to, in theory, give you a more legitimate look at what your risk is. Right. It uses Gale model, which is the model that Athena uses. And if you have a lifetime risk of more than 20 percent, then we kind of start chasing around our patients. And that's offered to all the women who go in for screening. The other thing about the breast center is that, for example, when a patient presents for their mammogram and if something is found, the breast radiologist is there. And so many times the breast radiologist will meet with the patient and they'll do the follow-up exams if needed or the biopsy the same day. So the other thing about the 3D mammography is that the callbacks are much less. They're much more specific the first time. The indeterminate mammogram and then you have to wait a week for an appointment and all that is pretty much eliminated. Usually they'll leave the breast center with some answer to what problem. Without going and fretting about what it could be or what might happen. They have something a little bit more concrete. Interesting. And this is actually one of the goals for our cancer center also. Like when we all come together, we will try to kind of eliminate all this wasteful time that happens or that can occur between different visits. So when the patient is there and all of us kind of visit with the patient on the same day, that eliminates a lot of wasteful time here and there for appointments. Interesting. I want to touch on something you had brought up a few minutes ago that we didn't expand too much on it and that was the genetic counseling piece of all this. So much of cancer has a genetic link these days. Tell us a little bit about how genetics was added to Sanford and when kind of that started to expand here in Bemidji. Well, Sanford's a leader in that area and that's filtered down to us. So I don't know if you want to expand on the genetic component, but it's very complicated. The average doctor wasn't trained. At least I wasn't trained in that because we didn't have a lot of the knowledge then. But we know now that a lot of cancers have a genetic signature. And so what that actually means takes a long time to explain. So basically, you know, with genetic testing, there are two major things that we want to achieve. One, we want to make sure that the person who is genetically tested positive for a particular gene, we want to make sure that all the cancers associated with that gene, we are, you know, kind of, we are being cognizant about all those cancer for that one person. Second aspect is that for the immediate family or the distant family, we kind of need to alarm them that, hey, look, you know, such and such in your family has a positive gene and so you may or may not be having it and so you may want to get tested. So I feel that's really important. Now, there are two main, again, you know, the breast cancer and the colon cancer. These are the two main areas in the general population which are caught most commonly for genetics. There are other cancers and other, you know, tumors which also have genetic association but these two have the most powerful impact. So the BRCA1 and BRCA2, I think Angelita Jolie did a lot of advertisement for that. So we have a, we actually have a quite a few number of patients who are tested positive here and so their sisters and their daughters are being taken care of, as well in our screening clinics and in our high-risk clinics and the genetics clinics. Like a lot of them are in their 40s and 50s and their kids are like 18 years old or 20 years old so they will have a heads up from the beginning and so they will have a, you know, they will have a much more information about themselves whether they're positive, if they're positive they need to take precautionary measures for breast cancer versus ovarian cancer and other cancers. For colon cancer, each time a patient has, you know, a surgery or a biopsy, every colon cancer under the age of 70 years automatically is tested for certain genetics, you know, risks. And if you are tested positive then automatically we go down the algorithm to kind of, you know, make sure that it's a genetic versus a sporadic. Sporadic means like, you know, a random association for that particular cancer and if genetics are found positive for that one person, then of course, you know, we kind of alarmed the patient and their family. So this is in the nutshell. Those are the germ cell mutations or hereditary in families, but there's also the analysis of the tumor itself and the genetics of the tumor and targeted therapy. You want to talk about that quickly? So all these are very complex areas. So I'll just try to kind of give you a nutshell about the targeted therapy. So, you know, this is a very exciting time for oncology in general and I feel very happy that I'm a part of oncology at this moment because, you know, there's so much research going on and the moment we find, so what targeted therapy does is like for example, if we find a tumor and that tumor has a particular marker on it, we want to target that one marker with our therapy so that only the tumor cells get killed. So there are two good things about this therapy. One is that we are much more specific in terms of our approach towards cancer and second that we eliminate the side effect profile. So in colon cancer there is KRAS mutation testing, BRAF mutation testing, then there are three or four different ones in lung cancer. In breast, we are trying to find some. We haven't really found any, like, mutation that we can target but we do have some HER2 agents that target specifically the HER2 but that's not a mutation, that's just a receptor on top of the breast cells. So, you know, it's a complex area. There is. It's like four-hour lecture but you know, the bottom line is that we are doing a lot of research and newer agents are coming up and Sanford is not at all lacking behind in all using all those newer agents as soon as something is approved in the market and sometimes even before the approval it's available here. If it's before approval it's available on a compassionate basis. We have a really nice drug assistance program that we have. Brittany is our drug assistance gal and she's wonderful in taking care of patients and something people might not realize because I didn't realize this until we started prepping for this but some of the medications that people can take whether they be oral or otherwise they can be $10,000 to $25,000 a month correct? They can be much more than that and so that's why, you know, the drug assistance program that we have is so imperative for cancer care because as much as we want them to get the best treatment available we also don't want them to land in poverty. So, you know, that's where Brittany's role comes and she's wonderful working with the patients to try to get them the best possible option with the cheapest possible source. So, you know, patients are really grateful to her and we are very happy to have her. I have to imagine that even from a health standpoint that if you're financially stressed about the cost of the medications to keep you healthy that has to adversely affect your treatment process. That's a huge part of it. And now I wanted to touch just a few moments here about some of the programs that exist to keep people at home. Are people better off when they don't have to travel? You've got oral kivos. I know that if your primary oncologist is perhaps at another facility perhaps like the male that Sanford works with those patients to make sure that they can still receive that care locally. How important is it to keep it so people maybe are as close to home as possible? I feel that's really important and a lot of our patients at the end of their care like on the third or fourth line of treatment when they are they really put their foot down and they're like I'm not going to go to Mayo because they're doing exactly the same thing which you guys are doing here and why should I travel like so many hours back and forth when I'm nauseated or I'm having a bad day. So I feel that's really important. So not only is Sanford preventing those extra trips to the bigger cities or to Mayo but we are also sending out our physicians to outreach programs. So one of my colleagues Dr. Chell Hoop he's a medical oncologist with us so he just recently started his program at International Falls so he's doing going there every other week and we will be starting a program, our outreach program to park rapids soon. So those are important things coming up. Well I want to thank you both for joining me here tonight. This has been enlightening not only about the services that are provided thank you for tuning in tonight for Lakeland Currents. I'm Bethany Wesley please join me next time.