“I was the one patient they should never have missed,” says Sue Morrow Flanagan. The New York-based journalist’s mother and grandmother had died of breast cancer, and, convinced that she had the disease, Flanagan visited several doctors. Unfortunately, they didn’t find anything. Some even told her she was neurotic. By the time she was correctly diagnosed in 2002, the cancer had metastasized.

Flanagan began calling researchers and combing through summaries of clinical trials. Eventually, she was referred to UW Medicine oncologists Nora Disis, Fel.’93, and Lupe G. Salazar, Fel. ’02, Fel. ’03.

She wasn’t eligible for the breast cancer vaccine trial then under way, says Salazar. But she wasn’t deterred. “Sue worked hard at finding physicians who would work with her and get her to the point where she would be potentially eligible,” Salazar says.

Then Salazar and Disis designed a clinical trial for women just like Flanagan — women with progressive, HER2/neu-specific breast cancer. In 2004, Flanagan started treatment, and in 2006, she moved to the Puget Sound region to be closer to the source of that treatment: the Seattle Cancer Care Alliance (SCCA).

Flanagan remembers her first visits to the SCCA with her husband, Tom. “The more I saw the SCCA — the atmosphere, the nurses — for the first time, it wasn’t just the two of us fighting alone,” she says.

Sue Morrow Flanagan, seen here with Lupe G. Salazar, Fel. ’02, Fel. ’03, is part of one of the SCCA’s clinical trials. Flanagan, who has had breast cancer for eight years, says the trial has been an extraordinary experience. “I’ve been able to take back some kind of control in knowing I’m part of scientific work that is most likely going to change the world — and possibly save my beloved daughter,” she says.

The Seattle Cancer Care Alliance

Approximately 1 in 8 American women will contract breast cancer at some point, and approximately 40,000 women — and 440 men — die from the disease every year.

The Seattle Cancer Care Alliance (SCCA), a consortium comprising UW Medicine, Fred Hutchinson Cancer Research Center, and Seattle Children’s, is working to change those statistics by providing comprehensive patient care, conducting research into breast cancer (and many other types of cancer), and teaching future cancer physicians and researchers.

It’s an innovative, expert, and compassionate place that attracts physician-researchers like Sara H. Javid, assistant professor in UW Medicine’s Department of Surgery, who wanted to work with a cadre of cancer specialists in various disciplines. Hired in September 2008, Javid sees patients at the SCCA and performs surgery at UW Medical Center.

“That’s a big part of what drew me here, in terms of clinical practice … that multi-disciplinary approach,” says Javid.

“I may not have a study that’s open to a patient, but one of my colleagues may. It’s really an opportunity for patients.”

The opportunity for patients

There’s no question that bringing breast cancer specialists together — the SCCA’s surgeons, medical oncologists, radiation oncologists, radiologists, pathologists, nurses, social workers, and other professionals — is good for cancer patients. Javid explains that this multi-disciplinary group meets twice a week to discuss new patient cases, get patient input, and make nuanced and thorough treatment recommendations.

The sheer number of cancer specialists at the SCCA also is good for patients, who, like Sue Morrow Flanagan, can investigate and potentially access multiple clinical trials run by UW Medicine and Fred Hutchinson Cancer Center.

“It’s a big plus,” says Salazar. “I may not have a study that’s open to a patient, but one of my colleagues may. It’s really an opportunity for patients.”

Breast MR images of a 52-year-old woman with newly diagnosed cancer. LEFT: Pre-treatment image shows a large enhancing mass in one breast (arrow); the dark void within the mass is a biopsy marker clip. RIGHT: Image after neoadjuvant chemotherapy shows near-complete resolution of the mass (arrow).

The immune system: helping out with cancer

Adoptive T cell therapy, a method being used in a clinical trial run by Salazar, Disis, and their colleagues at UW Medicine’s Tumor Vaccine Group, provides one such opportunity. In fact, it’s the only adoptive T cell therapy trial in the country that addresses progressive HER-2/neu-positive breast cancer, the kind that Flanagan has.

HER-2/neu breast cancer is prone to recurrence, and in it, HER-2/neu, a protein involved in normal cell growth, is overexpressed — causing uncontrolled tumor cell growth. Salazar’s study investigates the use of adoptive T cell therapy as a strategy to encourage certain cells from the patient’s own immune system to attack and destroy HER-2/neu cancer cells.

First the researchers vaccinate the patient with a HER-2/neu cancer vaccine, to encourage her T cells to generate an immune response against the HER-2/neu protein. Then they remove the T cells — about a cup’s worth of fluid, says Salazar — and culture them, converting millions of T cells into billions. After 24 days, these T cells, many of them HER-2/neu-specific, are infused back into the patient.

The hypothesis, says Salazar, is that the increased numbers of HER-2/neu-specific T cells will “go back home to the HER-2/neu-positive tumor and destroy it in a targeted fashion.” Preliminary data are promising, showing that adoptive T cell therapy results in anti-tumor responses in patients with advanced stage HER-2/neu-positive breast cancer — patients who were no longer responding to conventional therapy.

Immunotherapy studies like this one are a sign that the field of breast cancer research and care is changing. “Previously, it was always about using chemotherapy and cytotoxins to kill the tumor cells,” says Salazar. In the coming years, she says, therapy will focus more on enhancing individual immune response in combination with chemotherapy.

“We really do think that your own immune system is going to have to help out,” says Salazar.

Constance D. Lehman, Res. ’95, professor of radiology at UW Medicine and director of imaging at the SCCA, says that detecting cancer early is key to curing it. For high-risk women, MRI improves early detection of breast cancer. “Together, the UW and SCCA are working hard to increase awareness of the importance of early detection in all women, especially those at high risk,” she says.

A better future through screening

When Constance D. Lehman, Res. ’95, director of imaging at the SCCA, takes a look at the future of cancer care, she sees imaging tools playing a central role, particularly in breast cancer detection. “If we detect breast cancer at its earliest stage, we have a 98-percent or greater cure rate,” she says. Still, you need the right tool. “Not every imaging tool answers every clinical question,” she says. Mammography, ultrasound, MRI, CT, and nuclear medicine scans all play distinct roles in breast cancer care.

Together, these tools are essential to screening, diagnosis, and treatment — and to collaboration among radiologists, surgeons, and oncologists at the SCCA. Surgeon Sara Javid notes the usefulness of MRI scans prior to surgery. “Anywhere from 15 to 30 percent of patients are found to have additional spots of disease in either the same breast or opposite breast,” she says.

Imaging also has a role to play in assessing whether therapy is working, says Lehman. Tumors can take months to shrink, and determining the efficacy of therapy takes a long time. Imaging tools are being studied, Lehman says, that may reduce the assessment time from months to weeks or even days, allowing doctors and patients more flexible and responsive treatment options for breast and other cancers.

Lehman has a special interest in breast cancer screening. The SCCA’s mobile mammography van, funded by the Safeway Foundation, has helped her team reach thousands more women in the Puget Sound area. And researchers at Fred Hutchinson Cancer Research Center and UW Medicine are attempting to develop another method for detection — a simple blood test that could identify tumor markers even earlier. In preparation for testing this tumor-marker process, the SCCA is creating a blood bank with blood donated by the many patients who visit the SCCA for screening, tests, and treatments.

“It is amazing to me how many patients so much want to give back, so much want to make the future better for other people,” says Lehman.

The rewards of partnership

In 1992, when Julie R. Gralow, Fel. ’95, came to UW Medicine for training, the SCCA did not yet exist. What did exist, she says, was an excellent multidisciplinary breast cancer care program.

With the formation of the SCCA in 1998, says Gralow, the doctor-patient relationship didn’t change. Rather, the researcher-physician relationship changed. “We [the researchers and physicians at the UW] now had more interaction with basic science researchers at Fred Hutchinson,” says Gralow. The result is that scientists and doctors have more opportunities to exchange information and to refine research and care for all sorts of cancer.

With the advent of a new program at the SCCA — the creation of a phase I development drug program, a project spearheaded by John A. Thompson, Res. ’82, professor in the Division of Oncology — this exchange may reach a whole new level. The program will allow SCCA physicians and researchers to do more phase I clinical trials with a larger number of promising new agents. How will this benefit patients? “The main thing that this does,” says Thompson, “is provide cancer patients with access to promising new drugs earlier than they would have access otherwise.”

Gralow lists other advantages the SCCA partnership has brought specifically to the breast cancer program: dedicated space and resources for breast cancer care, for instance, such as the Women’s Wellness Clinic she founded a few years ago. And the incorporation of other professionals who focus on cancer-specific care, such as psychiatrists and psychologists, dentists, and physical therapists.

The SCCA also has provided a more in-depth training experience for UW Medicine’s cancer fellows. “We’ve added a lot of faculty in solid tumors, so the fellows get a much broader training with a lot more exposure to all tumors,” says Gralow. “I think that’s been a big plus.”

It’s a plus that benefits not only the fellows, but a much wider community. “It’s been so rewarding to have these incredibly smart, bright, talented, and dedicated people come through our training program and then go out into the community and provide better care to patients all over the country,” says Lehman.

Julie R. Gralow, Fel. ’95, is dedicated to ensuring that breast cancer survivors’ health-care needs are met. In this photo, Gralow addresses primary-care doctors, attendees of a continuing medical education program organized by the Fred Hutchinson Cancer Research Center Survivorship Program.

An extraordinary organization

Since its creation, the SCCA has cared for thousands of patients, engaged fellows and other trainees, and helped set the standards for cancer care nationwide. And breast cancer research, now in the genomic era, is moving ever closer to more targeted and less invasive treatments. Perhaps this explains why new recruit Sara Javid, as well as more seasoned faculty like Lupe Salazar, Julie Gralow, John Thompson, and Connie Lehman, are — more than a decade after the SCCA’s founding — energized about the potential of the SCCA.

“I think that ‘we can do anything together’ tone was set early on by the leadership,” Lehman says. “I still feel it in the hallways.”

Patient Sue Morrow Flanagan feels something in the SCCA’s hallways, too — from her patient care coordinator, her radiologists, her doctors.

“There’s such love and compassion, and my God, in the face of this illness, that takes strength,” she says. “It’s an extraordinary organization.”

By Delia Ward