Specialties

Patient Care Services

Leukemia Service

The leukemia inpatient service was established in 1986 to facilitate patient care and maximize research opportunities.  Each year between 40 and 60 patients with untreated AML are evaluated and treated.  A similar number of patients with relapsed or refractory AML receive re-induction therapy.  Between 10 and 15 new patients with ALL are also treated each year.  In addition, patients with myelodysplastic syndromes and selected patients with aggressive lymphomas or chronic leukemias are also treated by the leukemia service.  A large percentage of these patients are entered into clinical research protocols frequently with concomitant entry into companion protocols exploring basic science issues related to their disease.  This large patient population serves also as a resource for clinical trials in supportive care.

Current attendings on the Leukemia Service include Dr. Powell, Director of the Leukemia Service, Drs. Leslie Ellis, Denise Levitan and Tim Pardee.  Other key personnel include two board certified physician assistant and a nurse practitioner who participate in inpatient and outpatient management of the leukemia patients and a full-time nurse coordinator.  These individuals meet weekly to discuss individual patient problems, review results of clinical studies, and identify potential areas for investigation.  Consolidation of leukemia patients on a single in-patient service, organized by a core of key individuals, has allowed for optimal recruitment for research studies.  The service has an established reputation for excellence in clinical care, clinical research, and teaching for housestaff and students.  The leukemia service has long been recognized for its teaching.  The faculty members have been recipients of the Tinsley R. Harrison teaching award and Master Teacher Awards presented by the Internal Medicine housestaff in recognition of teaching excellence.   In addition to the usual rounds and teaching interactions, the leukemia team participates in a hematopathology conference daily to review bone marrow samples.  Ongoing clinical trials include Cancer and Leukemia Group B (CALGB) studies, CCCWFU initiated translational studies, NCI sponsored studies, industry-sponsored studies which frequently are initiated at CCCWFU, and supportive care studies.

The combination of the large patient population and commitment to clinical research has made it possible to actively participate in studies with CALGB while completing institutional phase I and phase II trials.  Physicians from Wake Forest School of Medicine are among the leaders in protocol accruals to CALGB clinical trials.  Notwithstanding national research participation, the emphasis of the leukemia group is in the application of locally generated laboratory ideas to clinical trials and the subsequent translation of clinical results back to the laboratory.

Blood and Marrow Transplant Program

Blood and Marrow Transplant Program at the Wake Forest Baptist Medical Center began in May 1990 with the first autologous transplant.  The first allogeneic transplant was performed in November 1990.

From the beginning, there has been an adult emphasis to the Program, however, children over the age of 12 are considered on a case by case basis.  While the initial focus of the Transplant Program was autologous, both related and unrelated allogeneic transplants account for one-third of all transplants performed on an annual basis.

This Center has been an approved Collection Center for the National Marrow Donor Program (NMDP) since October 1990 and an approved Transplant Center for the NMDP since September 1993.  In 2002 the Center was approved as an Apheresis Collection Center for the NMDP.  As a Marrow and Apheresis Collection Center, our Program has consistently has been in the top five as the number of collections performed.  As an Unrelated Transplant Center for the NMDP, our Program participated in a clinical trial on the role of T-Cell depletion for the prevention of graft versus host disease (GVHD) in unrelated allogeneic transplants.  The Transplant Program regularly participates in the clinical trials of the Blood and Marrow Transplant-Clinical Trials Network (BMT-CTN).  The Transplant Program is also accredited by the Cancer and Leukemia Group B (CALGB) for clinical trials involving autologous and allogeneic transplantation.  In 2001, the Transplant Program became the first program in North Carolina to be accredited by the Foundation for Accreditation of Cellular Therapy (FACT).  Since then, the program has been reaccredited by FACT every 3 years.

Blood and Marrow Transplant Unit (BMTU) / Inpatient Nursing and Medical Team

The BMTU is a 12 bed nursing unit dedicated to transplant patients and other oncology patients needing a higher level of nursing care than can be provided on other Oncology Nursing Units.  Air-handling is by central HEPA filtration.  The BMTU is staffed by nurses trained in oncology, hematopoietic stem cell transplantation, and all aspects of critical care needed to manage these patients.  On average, the nurse-to-patient staffing ratio is 1:2.  The BMTU is a designated Intensive Care/Specialty Care Unit so that the patients do not need to be transferred to another unit should they require intubation, invasive line monitoring or other aspects of critical care.

The In-patient Medical Team includes an attending physician, a fellow in training in Hematology and Oncology, and a nurse practitioner.  House officers (HO-2 and HO-3) from the Internal Medicine Training Program may elect to rotate on the In-patient Service.  A nurse coordinator makes rounds with the team daily to coordinate treatment, transfusions, discharge planning, and admissions.  In addition, a PharmD level pharmacist, and a medical social worker participate in rounds.  On a weekly basis, a member of the Infectious Diseases Section of Internal Medicine makes rounds with the Team.  All intubated patients are also followed by the Critical Care Consult Service from Pulmonary Medicine.  There is a 24 hour/day in-house coverage by an upper level house officer with full back up from the fellow and attending physician on call for the transplant patients.  In addition, there is full support from all specialties and sub-specialties at the Medical Center.

Outpatient Clinics Responsibilities for the Fellows

Transplant Clinics meet daily in the Outpatient Comprehensive Cancer Center.  Fellows rotating in the Outpatient Clinics get experience in managing these patients in conjunction with the attending physicians and physician extenders (Physician Assistants, Nurse Practitioners).  New patients being considered for transplant, patients undergoing active treatment in preparation for transplant, patients recently discharged from the In-patient Service, and long term follow-up patients are seen in these clinics.

Faculty

Dr. David Hurd has been the Medical Director since the inception of the Program.  Dr. Ken Zamkoff, Dr. Seema Naik, and Dr. Denise Levitan are the other faculty from the Section on Hematology and Oncology who regularly attend on the Inpatient Service and see transplant patients in the Outpatient Clinics.

Dr. Kathryn Greven and Dr. Kevin McMullen provide direction for all radiation therapy planning for the transplant patients requiring total body irradiation, total lymphoid irradiation or involved field radiation.

Dr. Kevin High is the primary faculty member from the Section on Infectious Diseases to provide ongoing input in the care of the transplant patients.  As such, he also has a cross appointment in the Section of Hematology and Oncology and makes rounds with the team on a regular basis.

Richard McQuellon, PhD is a Clinical Psychologist who directs the Cancer Patients Support program.  He and his team provide psychosocial oncology services / assessments for all transplant patients.  He has been a key figure in the development of Quality of Life assessments for patients undergoing hematopoietic stem cell transplantation.

LeAnne Kennedy, PharmD oversees the support services from Pharmacy for all Oncology Inpatient and Outpatient Services.  She routinely makes rounds with the Transplant Team to provide appropriate input to the care of the patients.

Other Personnel / Services

The BMT Laboratory is under the direction of Greg Pomper, MD who also services as the Director of Blood Bank Services.  Technical support is provided by two full time individuals.  This Laboratory provides all needed services for both autologous and allogeneic blood and marrow transplantation.  These include, but are not limited to:  controlled rate cryopreservation of autologous hematopoietic stem cells; red blood cell and plasma depletion for ABO incompatible transplants; CD34 isolation for positive section of hematopoietic stem cells precursors; and other negative selection technologies that have been applied during the course of our clinical investigations.  A member of the Laboratory is present for thawing of all cryopreserved products at the time of infusion.

There are four nurse coordinators and three physician extenders dedicated to the Blood and Marrow Transplant Program.  Their responsibilities are many but can be summarized by saying they coordinate the flow of work needed to insure that the appropriate patients are coming to transplant with all of the needed pre-transplant evaluation, appropriate initial treatment orders, coordination of post transplant follow-up, and dealing with a multitude of phone calls generated by patients, insurance companies, support services, and home health nursing agencies.

Michael Gautreaux, PhD serves as the director of the HLA Laboratory which is a fully approved and accredited Laboratory by the American Society of Histocompatibility and Immunogenetics.  All HLA typing of family members and confirmatory typing of unrelated donors are performed in this Laboratory using the most current techniques for testing of histocompatibility.

Hematopoietic Stem Cell Collections

Bone marrow harvests are the responsibility of one of the transplant attendings.  Harvests are performed either in the Outpatient Surgical Center or the Main Operating Room.  Peripheral blood stem cell collections are obtained by the Leukapheresis Unit located within the Outpatient Hematology and Oncology Clinic which also has the responsibility of collecting unrelated donors for the NMDP.

Reporting of Data / Transplant Experience

The BMT Program routinely reports all transplants to the Center for International Blood and Marrow Transplant Registry (CIBMTR) and the NMDP.

Non-Malignant Hematologic Disorders

Although there is no formal separation of function in the Section of Hematology and Oncology, there have been operational definitions of various groups.  Patients with non-malignant hematologic disorders are admitted to either the "A" or "B" Hematology and Oncology service.

Consultations

In-patient hematologic consultations are handled together with Oncology consultations on a combined Hematology and Oncology consultation rotation.  Primary responsibility for the consultation falls to the individual faculty member on rotation at that time.  Considerable latitude is allowed to the fellows to direct consultations to individual faculty members with specific interests.  Disorders of coagulation and benign disorders are directed to Dr. John Owen or Dr. Mary Ann Knovich.

Outpatient consultation fundamentally follows the typical pattern of private practice.  Referral patterns are established over time, and patients tend, in general, to be referred directly to consultants with whom the referring doctor has had a previous experience.  In some instances, this has been superseded by the development of specific areas of interests and expertise, and patients may be referred specifically for that kind of service.

Other Hematologic Activity

A number of other factors, which do not fit neatly into any of the above categories, nonetheless have a major impact on non-malignant hematology as practiced in this institution.  In order to test the feasibility of performing rigorous clinical trials in this area, we have established and collected data from a systematic treatment protocol for thrombotic thrombocytopenic purpura.  A single treatment protocol was established, and all patients treated since the establishment of that protocol have been successfully accrued to the study.  The success in accruing patients and the willingness of all faculty to adhere to this protocol has clearly demonstrated the facility with which such studies can be carried out here.

It has been the specific intent to join together as far as possible the Section on Hematology and Oncology within the Department of Medicine and the hematology related components of the Pathology Department.  Dr. Owen is the Medical Director of the Coagulation Laboratory and Associate Medical Director of the Hematology Laboratory, an association which has proved valuable in establishing compatible goals between the clinical and pathology departments.  All pathology residents are required to participate in a full time rotation through the Coagulation Laboratory in concert with a rotation through the Blood Bank.  The hope is to bring these disciplines even closer together, thereby increasing the visibility of coagulation related services within the institution.

Research in Hematology

A significant body of research exists in the institution in the hematologic field with a number of investigators working in coagulation based research.

Within the section on Hematology and Oncology, Dr. John Owen pursues his interest in control of coagulation.  The major effort currently underway is to probe the role of ADAMTS13 in TTP and related disorders.  Other fields of study are RBC folate and BsaXI kinetics.

Dr. Maria McGee has contributed significantly to the field of cell surface coagulation kinetics.  She is interested in factor X activation and the role the membrane plays in controlling the rate of factor X activation.  Dr. Reidar Wallin is a recognized authority on the intercellular processing of vitamin K dependent proteins.  His major efforts are directed towards understanding and elucidating the control and specificity of the post transitional modification of the vitamin K dependent coagulation factors.

In the Department of Biochemistry, there are researchers working directly in coagulation.  Dr. Roy Hantgan has a well established reputation as an expert in the field of physical measurement of biochemical phenomenon.  He is currently using laser scattering technology to study the role of platelets in clot stability and clot resistance to lysis.

Solid Tumors

Patients with solid tumors (including non-leukemic hematologic malignancies) are distributed among two services.  Patients with acute problems are admitted to the A service which is staffed by an attending oncologist, an upper level resident and two first year residents.  Patients who require hospitalization for chemotherapy are admitted to the B service which is staffed by an attending oncologist, an oncology fellow and a Physician's Assistant.  Acutely ill hematology and oncology patients are also admitted to the B service in the event that the A service exceeds its allowable census.  Each service has a dedicated oncology nurse clinical coordinator, social worker, and a pharmacist.  A third year medical student is usually assigned to the A service as part of the Internal Medicine inpatient rotation and fourth year students may elect to spend a month on the A service as an acting intern.

Patients receive established chemotherapy regimens as well as investigational, protocol therapy; the Section on Hematology and Oncology has access to CALGB, NSABP, RTOG, GOG, POG protocols, as well as our own CCCWFU protocols.

Multidisciplinary programs are established in the areas of breast cancer, head & neck cancer, sarcomas, genitourinary and thoracic oncology.  Patients with these tumors are often initially evaluated and followed in multidisciplinary clinics where surgical oncology (otolaryngology, orthopedic oncology, neuro surgery, thoracic oncology, and general oncology, as appropriate), radiation oncology, medical oncology, and diagnostic radiology expertise is readily available; certain clinics also contain expertise in plastic and reconstructive surgery, pediatric oncology, and pathology.  Formal multidisciplinary conferences are available for brain cancer, head & neck cancer and sarcomas whereby patients are presented for discussion of management, and current literature is reviewed.  Members of the Section on Hematology and Oncology involved in these programs include: Dr. Steve Akman (breast cancer), Dr. Glenn Lesser (brain cancer), Drs. Antonius Miller and Jeff Petty (thoracic oncology), Dr. Paul Savage (sarcoma), and Dr. Mercedes Porosnicu (head & neck).