In New Jersey, Focus in Fight Against Cancer Changes, and Care Comes Closer to Home

If one thinks “cancer” and “New Jersey,” the images that come to mind might be those that have long defined the state: plumes of smoke along the Turnpike, acres of oil refineries, or fleets

of trucks spewing exhaust.

An actual map of cancer incidence reveals something else. For starters, most of the cancer occurs in South Jersey (Figure), where cornfields have given way to retirement communities. As for images that evoke emerging threats, think sun and sand, not smokestacks.

In line with the recent warning from Acting US Surgeon General Boris D. Lushniak,¹ rising rates of melanoma in counties along the famous 126-mile shoreline have drawn attention from both state health officials and leading researchers.² In summer months, the NJ Department of Health (DOH) sends teams right on to the beaches, both to educate sun worshippers and to screen for early cases of skin cancer, according to spokeswoman Dawn Thomas.

New Jersey’s cancer threats are similar to the rest of the nation’s; the difference is the degree (Table 1). While overall cancer rates have fallen over the past 20 years, the state still ranked seventh in cancer incidence in 2011 with 49,080 cases, according to the American Cancer Society.³ That report stated the “big 4”—lung, prostate, breast, and colorectal cancer—still account for most of the state’s cancers; 52% of all cancer incidence and 49% of all cancer deaths. Lung cancer, with most cases caused by smoking, is the single biggest killer, accounting for 4100 of the state’s 16,370 cancer deaths in 2011.⁴ Rising rates of melanoma among the young and overall higher rates of thyroid cancer, which may or may not be explained by better detection, ^4,5 are also part of New Jersey’s complicated cancer story, which is one of great strides on some fronts and frustration in others.

If New Jersey once sat in the shadow of New York City and Philadelphia, it doesn’t act that way anymore. In the wake of Lushniak’s warning, the home page for the Cancer Institute of New Jersey (CINJ) was overhauled to highlight the “Call to Action” on melanoma, featuring both the work of CINJ behavioral scientist Eliot Coups, PhD, and of Howard L. Kaufman, MD, FACS, associate director of clinical science, who had just presented important phase 3 results using talimogene laherparepvec to treat melanoma at the American Society of Clinical Oncology in Chicago.⁶

To be sure, New Jersey has come a long way from the 1970s, when it had the highest cancer rates in the country^2,3 and a hard-to-treat case almost certainly meant crossing a river to one of its neighboring cities for treatment. Today, cancer rates among African American men have fallen and disparities between whites and minorities are narrower than in many other states.^3,4,7

Best of all, a state known for its bruising politics has achieved a bipartisan consensus that cancer patients should not have to travel out of state for care. Against a backdrop of state budget cuts and a recession that was deeply felt, cancer care for many has come closer to home, with governors and legislators from both parties overseeing significant investments in infrastructure. A $139 million medical school to serve South Jersey, discussed for decades, opened in Camden in 2012.⁸ Next door is the $100 million MD Anderson Cancer Center at Cooper, which opened in October 2013, transforming both a section of a beleaguered city and care itself.⁹

More hard-won was a 2012 law, brokered by Republican Governor Chris Christie and Democratic Senate President Stephen Sweeney, who comes from Gloucester County in South Jersey, that restructured New Jersey’s higher education assets.¹⁰ Leaders of the major research institutions say this step is finally dismantling the silo effect that for decades prevented research entities from collaborating as fully as they might have and from taking full advantage of their close proximity to leading pharmaceutical manufacturers.Research today emanates from CINJ, a National Cancer Institute-designated center based in New Brunswick, NJ, that became part of Rutgers University in 2013 and had 476 active clinical trials last year, according to spokeswoman Michele Fisher.¹⁰

Eight medical centers across the state enjoy major partnerships with CINJ, and even more have relationships. In South Jersey, the hub for cancer care is Camden, NJ, where a year-old collaboration between Cooper Medical School at Rowan University and the world-famous MD Anderson Cancer Center is ramping up; spokeswoman Wendy Marano reports that between October 2013 and June 2014, the center experienced 18% growth in patient volumes across all areas, including an 11% increase in complex cancer cases.

The medical school itself is still very new, having accepted its first class in 2012 (third- and fourth-year medical students from Robert Wood Johnson Medical School had previously trained at Cooper).⁹ At both CINJ in New Brunswick and MD Anderson at Cooper, leading oncologists report that the old pattern of New Jersey patients automatically going out of state for cancer care is quickly ebbing. In some cases, they say, cancer patients cross the Delaware or Hudson rivers into New Jersey to receive care. Marano said between October 2013 and June 2014, MD Anderson at Cooper experienced a 30% increase in cases from outside the traditional service area, including cases from Pennsylvania.

Amid these good signs, however, is a lingering undercurrent: the state’s ongoing financial distress. For more than 20 years, multiple governors have patched over or ignored the growing unfunded retirement obligations for New Jersey’s public employees. This spring, another revenue shortfall caused Gov. Chris Christie to propose cutting $1 million from the New Jersey Commission on Cancer Research and $10 million from CINJ.¹¹ In April, Christie blamed the cost of public employee pensions for the proposed cut.¹² Although the Legislature restored all the funding for budget for the fiscal year that began July 1, 2014,¹³ New Jersey’s ongoing challenge of how to meet the cost of retirement obligations to public employees threat-en every part of the budget, including cancer research, which has widespread support.

Overlooked in the budget debate is the fact that not a dime that New Jersey receives from the 1998 Master Settlement Agreement (MSA) with the 4 largest tobacco companies goes to combat smoking.¹⁴ Like 17 other states, New Jersey took the payout from the agreement upfront, and sold bonds that are paid off as settlement dollars arrive, a process called securitization. Unlike some states, New Jersey did not carve out settlement funds for smoking cessation.¹⁵ Instead, New Jersey uses $2.2 million in federal dollars for cancer screening and prevention; Generosa Grana, MD, director of MD Anderson at Cooper, had strong praise for the state health department efforts, which DOH’s Thomas said are based in all 21 counties. “We are catching cancer at an earlier stage,” Grana said, attributing this to 3 factors:

• sustained public education efforts, including attention from the media

• better screening and detection services, including broader access

• more access to genetic testing services, and a recognition of the role that testing and genetic counseling play in overall survival.

As with other parts of New Jersey’s cancer story, the onset of the Affordable Care Act (ACA) has been a mixed bag.

While some patients who previously lacked insurance now have it, CINJ’s Kaufman said some patients insured by the exchanges who have tried to get a test or scan out of state had trouble doing so (Table 2).

Fighting Cancer in New Jersey

The state’s environmental history is strongly connected to cancer’s footprint here, but just how much has been the subject of debate for decades.

Concerns about air and water pollution, and about toxins in landfills in a state where people are abundant and open space increasingly scarce, have driven state planning and environmental policies since the 1980s. New Jersey remains home to one of a handful of cancer clusters tracked by the CDC: the area around Toms River, NJ, where local concerns over possible connections between childhood leukemia and waste from Ciba-Geigy arose in 1996.¹⁶

But Grana said studies of connections between environmental causes and cancer have not pinpointed a single factor. By contrast, she said, higher rates of smoking in South Jersey undoubtedly contribute to higher cancer rates in those counties, along with the older demographics of the population.

Overall, only 16.8% of New Jersey adults over the age of 18 years smoked in 2011, according to the CDC,¹⁷ but Grana said rates are higher in South Jersey, and this is reflected in lung cancer statistics. She said, however, that treatment for lung cancer is improving: CDC figures reflect that of the 4 major cancers, only lung cancer rates are lower than national averages (Table 1).

The state’s cancer prevention efforts flow through NJ Cancer Control and Early Detection (NJ CEED) program, which operates through the state’s counties to provide education, outreach, and screening for breast, cervical, prostate, and colorectal cancer, according to Thomas. She said in the fiscal year that ended June 30, 2014, the program screened 24,700 women for breast, cervical, and colorectal cancer, as well as 847 men for prostate cancer. Ten task forces that cover 2 counties apiece operate statewide (including 1 through MD Anderson at Cooper). In a state that has long valued local control, this disbursement of screening services matters.

Evelyn Robles-Rodriguez, RN, MSN, APN-C, AOCN, who is the director of Oncology Outreach Programs at MD Anderson at Cooper, offered an example of the kind of program NJ CEED funds. Robles-Rodriguez received a call from an Indian temple in a nearby suburb a decade ago informing her that women at the temple weren’t being screened for cancers, and she was able to get funds for a screening program and a translator to ensure “culturally competent” services. On the very first visit, 38 women were screened, and today that clinic sees women at the temple once a month.

Another effort addresses the needs of Vietnamese women living in Camden, many of whom work as nail technicians throughout the area. A nurse practitioner at the hospital has just received funding to examine data from these 2 initiatives, “to see what inroads we have made,” Robles-Rodriguez said. Could New Jersey do more? Cancer control advocates succeeded in getting the legislature to ban minors under the age of 17 years from using commercial tanning beds, after the infamous case of the “tanning Mom,” whose 5-year-old showed up at school with burns.¹⁸

Most of the 2013 recommendations from the American Cancer Society advocate getting more money aimed at the war against tobacco.⁴ A February 2014 report by another national group, the Campaign for Tobacco-Free Kids, criticized several states for the gaps between what they collect in tobacco taxes and MSA funds and what they spend on smoking cessation. In that report, New Jersey was listed with $947.2 million in overall tobacco-related revenue for fiscal year 2014. Instead of spending the CDC-recommended amount of $103.3 million on tobacco prevention, New Jersey was spending zero, according to the group.¹⁴

A spokesman for the NJ Department of Treasury, Christopher Santarelli, said in an e-mail that $391.5 million in cigarette tax revenues are deposited “for general state use.” Currently, 76% of the MSA funds are used to pay bondholders and the rest goes to the Treasury; Santarelli said that this use is consistent with the purpose of the MSA, which is to repay states for the cost of tobacco-related illnesses.

“Would it be ideal to have more money?” Grana asked rhetorically. It would always be better to have more, but she and Robles-Rodriguez sounded hopeful about how far they have come, using funds from multiple public and private sources. Said Grana, “The governor’s Office on Cancer Prevention and Control has done a great job of building the infrastructure we have.”

At CINJ, Getting the Right Therapies to Patients

The annual retreat on cancer research, co-sponsored by CINJ and the Commission on Cancer Research (CCR), came on May 21, 2014, at the height of the effort to restore millions in research dollars to the state budget. It was a display of contrasts, which at the time were quite serious. At the check-in table, a CCR commissioner hawked the familiar “Conquer Cancer” license plates while grumbling about Christie’s proposed cuts to research. Meanwhile, keynote speaker Arnold J. Levine, PhD, formerly of Princeton and Rockefeller Universities and today a professor at Rutgers Robert Wood Johnson Medical School, treated medical students to a high-level talk on his decades of work with p53-knockout mice, which has revolutionized the study of how cancer develops.

The breadth of studies at New Jersey’s research retreat was impressive: posters featured everything from preclinical studies on agents to treat pancreatic cancer, to studies of breast cancer among women veterans at the East Orange Veterans’ Administration hospital. With 134 clinical trials in various phases, the East Orange VA is yet another important source of cancer research.

At a session designed for the public, medical oncologist Janice Mehnert, MD, a Rutgers graduate, covered the rising incidence of melanoma along with CINJ’s ability to deliver newer immunotherapies to treat it through clinical trials. Mehnert was among those sounding the alarm about the dangers of too much sun. “Many of my patients come from Monmouth and Ocean counties,” she said.

In a later interview, CINJ’s Kaufman said getting the best, new therapies to cancer patients is among the institute’s main goals. “The division of clinical science is dedicated to identifying the most promising new drugs in development, to looking at new technology, in terms of diagnosis as well as treatment, and to fostering that translation into getting these things to the patient,”

Kaufman said.

Bringing CINJ into Rutgers, he said, has allowed better integration with the research units that do basic science; for example, the chemistry department has faculty that work on drug development, but in the past lacked the connections to get their work into clinical trials. “We’re also trying to develop much stronger relationships with Newark, which has a different population of patients and different types of cancer,” Kaufman said. Both Rutgers and the state medical school have long had a presence in Newark, and the integration will open doors for more clinical trials at multiple sites that attract both larger numbers and a more diverse patient population.

Already, Kaufman said, CINJ is expanding its precision medicine program; the program has treated an initial 100 patients and is in the process of treating 500 patients. Of the first 100, Kaufman said, “40% had a change in clinical management based on information identified in genomic analysis.”

For South Jersey, a School of Its Own

Arguments for giving South Jersey its own medical school and cancer center have been around for years. The population is growing. The demographics tilt toward seniors, who don’t want to travel far for care. Putting new medical facilities in Camden would provide jobs and economic development the city desperately needs. But most of all, the case makes sense medically. All one has to do is look at a map.

The southernmost counties that make up the area MD Anderson at Cooper serves have higher rates of cancer incidence and mortality than the rest of the state, according to CDC data. Higher smoking rates and demographics account for most of this, Grana said.

A visit to MD Anderson at Cooper reveals a hospital built from scratch with customers in mind. A wide driveway designed for easy pickups and drop-offs gives way to an airy entrance, and the facility features ample room for families and a healing garden. Patients receiving infusions can do so together or in private rooms. There’s no more hurrying to multiple appointments on different floors; instead, the doctors take turns visiting the patient in a state-of-the-art “pod.”

The relationship between MD Anderson and the medical school is close, with the cancer center’s physicians serving on the Cooper Medical School faculty, according to Grana. She said members of the incoming class were admitted based on both academics and their embrace of Cooper’s service ethic, for the purpose of “populating South Jersey with physicians who are well-trained and committed to the mission of the school.”

Cooper’s third class is highly competitive, according to data supplied by John McGeehan, MD, associate dean for student affairs and admissions. Some 5200 applicants vied for 72 spots in the class of 2018, and 53 members of the incoming class are from New Jersey.

Bringing the MD Anderson name and relationship to Cooper was no small feat, Grana said. Three factors that made MD Anderson interested were Cooper’s “completely employed physician model,” an existing infrastructure that supported clinical research and strong community outreach for cancer prevention and control, Grana said. After initial meetings took place, a 6-month due diligence period followed during which MD Anderson reviewed “every aspect” of Cooper’s program, she said. The agreement was signed in September 2013, and the new facility opened a month later.

There’s plenty of back-and-forth travel between Houston and Camden; faculty from the 2 sites sit on each other’s tumor boards and take part in numerous committees that cover everything from health information technology to patience experiences. Outreach is expanding, too. Robles-Rodriguez is seeing her role grow into new prevention and survivorship programs, which will be measured more than ever under the ACA. Cooper’s historic role as the provider for those without insurance is allowing the hospital to take the cancer screening data on patients who now have coverage, and deliver it to new patient-centered medical homes.

For those who have survived cancer, group sessions are allowing those who have had similar diseases to support one another as they work with Cooper to get nutrition information and develop a treatment plan, a new ACA mandate.

During 17 years at Cooper, Robles-Rodriguez has seen plenty of change, and she sounds optimistic. Years ago, patients fighting breast cancer “only had a handful of medications,” she said. “Now we have an arsenal of weapons. That has made a big difference, especially for those with more aggressive disease.”

More and more people are hearing the message, she said, “The earlier you detect the cancer, the higher your chances of surviving the disease.” References

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