Global Health at The Bell House, Brooklyn, April 29

Talks on Global Health to benefit the Brooklyn Free Clinic, followed by a night of comedy

BFC What’s Next: Global Health Here at Home

April 29, 2017

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Six medical and public health professionals will share personal narratives about the challenge of providing quality health care in the harsh social and political realities of our time. Follow their quests to serve their patients and their communities from own backyard in Brooklyn to sub-Saharan Africa, the capital of post-earthquake Haiti, Nepal and more. Hear about their confrontations with poverty, natural disasters, racism, mass incarceration, and other systemic barriers to successful health care delivery. Hear how far they’ve come – and how much further we have left to go.

Find more information, including speaker biographies, on our website. All donations and proceeds from the Silent Auction will be donated to The Anne Kastor Brooklyn Free Clinic, an entirely student-run branch of SUNY Downstate Medical Center that has been providing free primary health care to uninsured people in Brooklyn since 2007.

Where & When

The Bell House, 149 7th Street, Brooklyn (http://www.thebellhouseny.com)

Saturday, April 29th at 1:00PM, Doors and Silent Auction starting at 12:00PM

F/G trains to 4th Ave/9th St or R train to 9th St

Tickets

Register here. Entry is free, with a request for donations to support our cause (suggested $20).

About The Brooklyn Free Clinic

Donations will go toward The Anne Kastor Brooklyn Free Clinic (BFC), a student-run FREE clinic offering medical, psychiatric, physical therapy, and social work services at no cost to uninsured patients in New York City. BFC provides preventive screening services and free or low-cost medications and medical referrals for our patients. BFC is entirely staffed by volunteers comprised of students and medical professionals at SUNY Downstate Medical Center.

For more information

Contact Katie Lee at fundraising@brooklynfreeclinic.org for inquiries. Find out more about our work at www.brooklynfreeclinic.org.

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Running Down a Dream: Downstate Students Marathon for the Free Clinic

SUNY Downstate students and supporters raise $21,000 during the New York Marathon to benefit the Anne Kastor Brooklyn Free Clinic

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From left to right, second-year medical student Mike Levine, first-year Katie Lee, Ben and Jim Naughton

 

When Ben Naughton was 10 or 11, he got the opportunity from his aunt Anne to make someone else’s life better. The late Dr. Anne Kastor, who helped found the Brooklyn Free Clinic, offered to donate to her nephew’s non-profit of choice for his birthday.

This was the dawn of Bionicle and PlayStation 2, and “birthday money” usually means gifts, but “she wanted me to research and find something I was passionate about for her to give to,” Ben said. “And so started the tradition where, every Christmas, I asked others, as well, not to give presents, but instead to donate. From that, and in the way she lived, she instilled in me, to put it simply, this idea of living to help others, especially those less fortune than you.”

The Alumni Association allocates money annually to the program run by SUNY Downstate students.

The $21,000 that Ben, his father Jim Naughton, and three Downstate med students raised will go toward covering prescription medication for the Brooklyn Free Clinic’s uninsured patients. The runners crowdfunded for the clinic on Crowdrise.

Ben, now 25 and an associate producer for CNN in Atlanta, ran as a member of the Brooklyn Free Clinic’s Marathon Team Nov. 6. It was his fourth marathon. He has run seriously since high school, and when “my dad and I found out we could combine two of our passions in running and non-profit work and for a place like the Brooklyn Free Clinic, it was a no-brainer.”

Ben’s aunt, Dr. Kastor, had been a primary care physician, a SUNY Downstate faculty member, and one of the founders of the clinic in 2006. She died of ovarian cancer at 49 in 2013.

“After her death, I thought what better way to honor her then to ask every year for people to give to the Brooklyn Free Clinic, a cause she was so passionate about,” Ben said.

The Brooklyn Free Clinic moves to the Downstate campus January 4, 2017, but has operated at 840 Lefferts Avenue, Brooklyn, since its inception. The clinic opens once a week to walk-in patients, many without insurance and from underserved communities.

Students from all of Downstate’s divisions, the colleges of Medicine and Nursing, to Health Related Professions and Public Health, run the clinic together. It’s a hospital in miniature, and seems to feed the students’ passion for medicine and public health.

“I got to know about the clinic from Anne telling me about her involvement in during its early days,” Ben said. “And I would say we, in our immediate family, watched it as it came to be and grew up. Then when Anne died, I think it is this way when people die, especially, at a young age from something like cancer. This brought us all closer to everyone and everything that Anne touched. David Marcus, one of the students who started the Brooklyn Free Clinic, wrote a post about Anne, and what she meant to him and the clinic. I knew it before, but I really saw and heard, through that post, how passionate he and all the people at BFC are about what they are doing.”

In his remembrance, Ben Marcus, MD, wrote, “Anne was key to the development of the BFC. I know there was much more to her than this simple, minor act, but this is how we knew her. She was an amazing mentor to the leadership group. She was an inspiring clinician to all of the volunteers, and she reminded us that primary care is not dead. Even in this difficult practice environment, Dr. Kastor showed us, and taught us, the essential role that the primary care physician plays in her or his patients’ lives.” Read the rest of Ben Marcus’ tribute, here.

Ben finished the New York Marathon and gave his cousin, Holly, Anne’s young daughter, his medal. There are things more important than objects, like family, giving, and inspiring others to give.

“The Brooklyn Free Clinic is a place that is very near to my family’s heart, both because of Anne’s connection to it, and what it stands for in that way,” he said. “And also because of the amazing work that they do.”


Student Profiles: Mike Levine and Katie Lee

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Katie Lee is a first-year Downstate medical student, a runner, and former collegiate pole-vaulter from her alma mater, the University of California, Santa Barbara. She went on to complete a master’s in Human Nutrition from Columbia University before enrolling at Downstate.

Do you have a specialty in mind?
I am really interested in emergency medicine, but as a first-year, I may fall in love with anything.

Have you run a marathon before?
It was my first marathon. I was a pole vaulter in college, but at the end of college I wanted to get involved in long distance running.

Have you gotten an opportunity to volunteer yet with the Brooklyn Free Clinic?
My work right now is very behind the scenes, though, I would love the opportunity to work within the clinic. What’s cool about it is, they say 98 percent of the students, med students at least, are involved in the clinic in some way.

How did it feel to support the clinic?
We’re able to be so sustainable, and to really have an impact in the community, and to provide every part of health care for free. It was really great to run the marathon and to support it.


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Mike Levine, a second-year Downstate medical student, got into shape after college by training for a Spartan obstacle race in 2014, followed by a spate of races around New York, including the Brooklyn Half Marathon in 2015. He is planning on a career in emergency medicine.

What is your “hometown?”
I’m originally from Central CT, near New Haven

Was your first marathon everything you thought it would be?
I only just ran my first half marathon in May. I had a lot of fun actually, and it was a beautiful day. I had very competitive goals for it, so I was pushing pretty hard, but nevertheless it was very fun seeing the thousands of supporters.

What was one moment of personal victory?
I pushed really hard during the last four miles. Because I did, I was able to run the second half of the race about one minute faster than the first (a ‘negative split’), which was goal #1 and I’m really proud about that. It validates the work I put into training. My goal was to run at an eight minute per mile pace, which I missed by about six minutes total, but I’m happier about getting the negative split.

What does the BFC mean to you? What did it mean to run, to benefit the clinic?
It’s an opportunity to do some good for this local community, for so many people who really don’t have a lot of stability or support in their lives. All the work I’ve been able to do for the clinic helps to reaffirm that I’m doing my best to be my best. The clinic has become a tremendously central aspect of the Downstate education. It is a place where students from the entire university come together to sharpen their clinical skills while also serving their community. Getting to interact and learn from older students is something I always look forward to. I look forward to devoting a lot more time and energy into making the clinic the best it can be.


Support the Brooklyn Free Clinic, med student scholarships and more.
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The Student-Run Brooklyn Free Clinic moves to Clarkson Avenue January 4

The Brooklyn Free Clinic is one of many programs supported in part by medical alumni

Photo courtesy of SUNY Downstate

The student-run Brooklyn Free Clinic moves to the University Hospital of Brooklyn January 4, 2017, on the SUNY Downstate campus, after a decade at its first home, UHB Health Associates at 840 Lefferts Avenue. The clinic had borrowed the office space after hours.

The new location, Suite A on the first floor near the University Hospital entrance, is already a working clinic, but was also available to the Brooklyn Free Clinic, 5 pm to 7 pm, Wednesdays. The difference is that BFC patients will now be closer to a larger health network if they need a referral or emergency care, said Shifra Mincer, second-year Downstate medical student, and BFC communications officer.

Read about the Brooklyn Free Clinic’s recent New York Marathon fundraiser

The location is also more convenient for student and physician volunteers coming from class or work, she said. This may encourage more doctors to volunteer as attending physicians, which could expand the clinic’s capacity to help Brooklyn’s underserved, and provide more students with valuable training.

“We’re swamped on Wednesdays,” Mincer said. “People make appointments in advance, and we try to take walk-ins, based on what we can do. If we could get two attendings one night, we could move much faster.”

The clinic is run by a team of students from across Downstate, the colleges of Medicine and Nursing, the College of Health Related Professions and School of Public Health. Students handle everything from scheduling and administrative work, to screening and caring for patients, overseen by attending physicians and faculty advisors. Patients are often referred to a network of specialists who agree to treat them for free.

“The proximity (of the new clinic location) to the rest of the hospital has multiple benefits – easier access for volunteer attending physicians, closer proximity of referral services for patients, better synchronization of medical records with Downstate systems, and consolidation of care into a single locale,” said Patrick Eucalitto, third-year medical student and Chief Operations Officer for the Brooklyn Free Clinic. “This simplifies the often daunting task that patients face when navigating multiple providers.”

The team will miss the clinic’s first home, he said, but the move will be positive for volunteers, patients and students. Mincer agrees.

“One of the most important things about the clinic, in addition to serving people who wouldn’t otherwise get care, is that it’s an opportunity for students to learn and to practice in real life what we’re learning about. Normally, students don’t get to do that until third year,” Mincer said. “This is an opportunity for us to actually practice. It’s a double mission of serving people and learning.”

Working with students from other disciplines is also an opportunity to practice “socially conscious” healthcare, she said. It’s a collaboration.

“BFC leadership is using the move as a strategic opportunity for self-assessment, reevaluation, growth, and change, and we’re really excited about it,” Eucalitto said. “We get a chance to rethink our logistics, to recreate a clinical environment that reflects our organization’s core values of access, education, and inclusivity, and to optimize our unique balance between student education and excellent patient care for those who need it most.”

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SUNY Downstate Student Profile: Eileen Harrigan, COM 2018

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Where did you do your undergraduate education and what did you study?
I went to Wesleyan University, and I studied Biology and Neuroscience & Behavior.


Who is/was your favorite professor at SUNY Downstate College of Medicine and why?
I’ve enjoyed learning from lots of professors at Downstate, but I have to say that the person who has influenced me most is Dr. Yaacov Anziska, an alumnus of Downstate. I had the opportunity to work with Dr. Anziska during the Neurology clerkship and I was so impressed by the way he educates and advocates for his patients. He is one of the most knowledgeable educators I have come across during my time on campus, and he is constantly seeking educational opportunities for his students. His level of clinical expertise is something I really aspire to.


What is your favorite memory so far of your time studying at Downstate?
I think my favorite memory at Downstate has to be when a few classmates and I organized an event to raise awareness of racism and discrimination in medicine. We set out to join students together in a conversation on social responsibility in medicine, and we were unsure of what to expect in response to our campus-wide invitation. We planned for days and days. We organized for days and days. When the time of our event finally arrived, I was so thrilled to see dozens of students, faculty and staff members in attendance to join us. Some students shared their experiences with racism, while several faculty members offered their support and solidarity. It was incredible to witness such deliberate mutual support on our campus, and I am so grateful for that experience. It makes me so proud to know that I am part of a community that is both diverse and passionately dedicated to equality and justice.


What is/will be your specialty?
I expect to pursue a career in Neurology.


How has the Alumni Association for the College of Medicine at SUNY Downstate helped you (scholarships, clubs, events, white-coat ceremony, senior week, research, summer research, technology, healthcare in developing countries elective or other)?
The Alumni Association supports groups like the Brooklyn Free Clinic, which is a student-run clinic at Downstate. With the support of the Alumni Association and others, we offer free and very-low-cost healthcare to our uninsured neighbors in Brooklyn. This clinic serves as a major milestone in our careers. It is often the site of our first doctor-patient relationships, where we can explore both the compassionate and practical sides of the healthcare system. The BFC also provides an environment where we can find mentorship from volunteer attending physicians and build our clinical skills.


Is there anything else that you think Alumni would like to know about you?
I grew up as the youngest of four in a small town on Long Island called Manorville. My dad worked as a plumber and my mom became a policewoman when I was in middle school. I moved to Brooklyn after graduating from Wesleyan and began working in the lab of Eric Nestler at Mount Sinai. There, I studied the neural mechanisms of substance abuse and mood disorders. I became determined to attend Downstate after meeting several Downstate-educated physicians and taking an interest in the public healthcare system. Since my time at Downstate, I’ve been involved in the Student Ethics Society, the Brooklyn Free Clinic, Flu Shot club, and a new student organization called Downstate Dialogues, which a few classmates and I recently created. Through this group, we host conversations and events on campus focused on issues of race, gender, and identity in the medical field. My long-term goal is to use my experiences from Downstate to work towards creating a more equitable healthcare system.


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Brooklyn Free Clinic Thanks Downstate Alumni Volunteers

bfcThe Brooklyn Free Clinic is completely run by students from Downstate’s five schools.

In August, the Brooklyn Free Clinic recognized Downstate alumni volunteers for “dedication to student medical education and community service,” said Cleopatra McGovern, Chief Operating Officer. “We are so grateful to them for working with us.”

The list of clinic volunteers includes former and current (and future) attendings at the BFC who are also Downstate alumni, as well as Douglas Lazarro, MD ’90, who offers patients free ophthalmology appointments at Downstate.

James Ferguson

Ernest Garnier

Amanda Harris

Michelle Haughton

David Marcus

Michael O’Brien

Lorenzo Paladino

Richard Sadovsky

Sarah Yu

The Anne Kastor Brooklyn Free Clinic is a free clinic for the uninsured that was founded by SUNY Downstate students in 2006. It is staffed and operated by Downstate students from the College of Medicine, the College of Nursing, and the College of Health Related Professions. In addition to student volunteers, the clinic operates under the supervision of volunteer attending physicians, many of whom are SUNY Downstate alumni. Read our 2015 profile, here. And click, here, to learn how to become a volunteer.

The Alumni Association contributes financially to the Brooklyn Free Clinic annually. All gifts, including $6,000 for the 2016-17 academic year, come from alumni and return to students and the Brooklyn community. Students screen hundreds of patients annually at 840 Lefferts Avenue.


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David H. Abramson, MD: Leaps in Retinoblastoma Treatment in the Span of One Career

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To watch a video of the lecture, search for SUNY Downstate on iTunes University.

Lecture given at the annual Alpha Omega Alpha Honor Society lecture and dinner, March 22, 2016, funded by the Downstate Alumni Association. The speaker was David H. Abramson, MD, FACS, Chief, Opthalmic Oncology Service, Sloan Kettering, Professor of Ophthalmology atWeill-Cornell Medical.

 

AOA – Alpha Omega Alpha Honor
Annual Lecture: Ocular Oncology Update, David H. Abramson, MD, FACS
Chief, Ophthalmic Oncology Service
Memorial Sloan Kettering Cancer Center
Professor of Ophthalmology, Weill Cornell Medical School
SUNY Downstate – Ophthalmology Lecture, transcript

Douglas Lazzaro, MD: What is Alpha Omega Apha? It’s a professional medical organization, actually the only one in the United States, that recognizes and advocates for excellence and scholarship and the highest ideals in the profession of medicine.

AOA was started in 1902, the first chapter in the United States, and currently 133 chapters exist for US medical schools. Downstate was Chapter 49, started in 1948. There are numerous categories one can be elected into, into AOA, as a student, as a Junior AOA, and a Senior AOA, as a house staff member, based on the size of the institution. Here at Downstate, we can have up to six house staff. Up to two alumni can be elected, up to two faculty members. There’s one honorary faculty elected every year, and then there’s a charter member of a new chapter.

What’s the mission statement of AOA? It’s dedicated that, in the profession of medicine, we will improve care by recognizing high educational achievement. You all have done that. We honor gifted teaching, by the way the faculty, in particular, the honorary faculty member is selected by the AOA students. It encouragements the development of leaders in academia and the community, supports the ideals of humanism, and promotes service to others. Even though healthcare is changing radically year by year, these are all things that you can take in your careers for the next thirty and forty years.

You can go onto the AOA website that tells you all the categories of elected positions. There are 57 Nobel laureates. Downstate had one in 1998, Dr. Robert Furchgott, for his work with nitric oxide. He was the AOA faculty member in 1967. I had the honor of having him as my pharmacology teacher. After tonight, going back to the 1940s, we will have had more than 2,200 members. By the way, you all have been nominated, but to complete the process, you will have to connect with the AOA national society, send in your dues, to be an official member of AOA.

Now, some words on our speaker today. Dr. David Abramson is a tenured professor of pediatrics and ophthalmology at the Weill Cornell Medical School, currently running the largest ocular oncology service in the United States, and the largest retinoblastoma service in the world. He actually is the founder of the ocular oncology service at Memorial Sloan Kettering after serving many years, doing similar service at Cornell. He’s a graduate of Albert Einstein Medical School, resident of ophthalmology at New York-Presbyterian. He’s published over 400 books, chapters and original articles, and over 340 peer-reviewed articles. He’s the editor of the American Academy of Ophthalmology’s instruction book on ophthalmic oncology, and he’s delivered more than 400 lectures, worldwide.

He’s received awards from all over the United States and beyond, including the Swiss Ophthalmological Society, the Association for Research in Vision, the Hellen Keller Society, a lot of teaching awards, really, really, a great teacher, and I think you’ll enjoy his lecture. He’s received the honor award, and the senior honor award, and the lifetime honor award from the American College of Ophthalmology.

He’s publishing constantly, and improving the field. When I was a resident in ophthalmology, most of the eyes that had retinoblastoma were enucleated.  Currently, under Dr. Abramson’s leadership, only 5% of these eyes currently get enucleated. These are some of the recent articles. He and his team are single-handedly changing the way this devastating disease is managed. So, without further ado, Dr. David Abramson, it’s an honor to have you give the AOA lecture.

Dr. Abramson: Thank you, my friend, Doug. Congratulations, to all of you, it truly is a huge honor, and something you will carry with you, the rest of your lives. I salute you. I’m thinking about my comments, and I think I should be giving you wisdom, since I graduated from medical school almost 50 years ago.

And then I was thinking, well, I don’t have that much wisdom, so it would be a very, very short talk. And you know, when I finished medical school, I didn’t know how much about medicine I understood. When I finished my internship, I thought I had some level of competency. When I finished my residency, I thought, I’m pretty close to the top. When I finished my fellowship, I was convinced I knew everything there was to know.

So, what I’d like to do is take you through the changes that have occurred since I finished my fellowship to now. Many of these, I’ve done, but so have many in the field. To give you a clue about how far you can go in your career, from what you think is the pinnacle of knowledge, to realize that it’s just a pimple on the surface of knowledge.

I have no financial interests at all, but I think at this point I have to declare that I do have a relationship with Downstate. It’s not that both my parents grew up in Brooklyn. It’s not that I and two brothers and father went to Brooklyn Tech, but my older brother, Allen, recently stepped down as the chair of EMT tech at Long Island North Shore-Jewish, is a graduate of the medical school here.

I am going to talk about the off-label use of drugs. You know, it’s remarkable, that we have no chemotherapy drugs that are FDA-approved for children. Everything you do is off-label.

Retinoblastoma is the most common primary cancer to affect the eyes of children worldwide. It’s a relatively rare cancer, and it’s actually not the most common cancer to affect the eyes of children. Retinoblastoma is on your left, and on your right is the most common cancer to affect the eye of children, and that is leukemia. So, depending on your institution, it is between the fourth and seventh most common pediatric cancer. There might be a slight increase in survival, but it is a cancer that affects young children. And perhaps about 10% of all children in the first year of life who develop cancer have retinoblastoma. Now, the incidence of retinoblastoma is exactly the same, worldwide, independent of who you are, where you live, what your environment is, but the incidence of melanomas of the eye, which occur in adults, is very much related to ethnicity. As a result of that, in the United States, we have about four times as many melanomas as retinoblastomas, because we have so many people of European origin.

But throughout the rest of the world, retinoblastoma is actually the most common form of cancer that occurs in the eye of children or adults. There are about 300 cases a year in the United States, making it rare. Almost all the children in the US present with the disease in the eye, which is important, which you will see in a moment. Boys and girls are the same, right and left eye are the same. In 12% of the time, there’s a family history, someone else has retinoblastoma. This is a clue that almost 100 years ago there was a gene involved. It can present unilaterally or bilaterally. When it presents, it presents like this so called leukocorially, white pupillary reflex.

It is the cancer success story of the 20th century. We have gone in 100 years, which is not when I finished medical school, to now, from 95% of children dying in the US to more than 95% of children surviving. It is, in all of pediatric oncology, the cancer with the highest cure rate. It was not that when I finished my fellowship.  Worldwide, at the present time, it’s still a devastating disease because 50% of the children who get this worldwide die. In the United States, survival in all centers is over 95%. Doug mentioned that the center I run over at Memorial is the largest by far in the world, and the oldest. And our present survival rate is actually over 99%. And, remarkably, 90% of these children have 20/20 vision in at least one eye.

In fact, the most common cause of death of children with retinoblastoma is not retinoblastoma, it is their subsequent, so called “second” malignancy related to their gene and environment. If you would ask, “Why is that 50% of the children in the world die?” Your immediate response would be, “Well, they don’t have the resources or facilities you have at Memorial Sloan Kettering.” But the reason is very simple. Children who are brought in, worldwide, are sometimes brought in like this, with very advanced disease, but are more commonly brought in and told, to cure the cancer, all you have to do is remove the eye. It’s an operation I’ve done, and Doug has done, but around the world it’s an operation that is unacceptable in most societies. So the child is seen, correctly diagnosed, goes home and is never treated. They die because they’re not treated. The treatment, which is available, and curative, they do not accept.

This is not a simple medical problem. This is a social, this is a cultural problem. In the entire continent of Africa, there is not one country with a survival rate that is even as high as 50%.

Now retinoblastoma has some very curious genetics behind it, and I suspect you’ve had this in more than one course. It is the first tumor suppressor gene that was ever cloned in 1986, and it curiously develops in two different forms: one, we’ll call it “genetic,” and the other, we’ll call it “non-genetic.” We’ll get back to that in a moment.

The retinoblastoma is a gene on chromosome 13, with 200,000 base pairs and 27 exons. It is a gene all of us have functioning, all the time. It’s a cell cycle inhibitor so it is a gene, if you will, that is built into human cells so that those cells don’t have uncontrolled division and develop cancer. It is the loss of this normal gene that gives you the cancer. So, on the simple level, it’s an autosomal dominant gene but it’s a tumor suppressor on the molecular level.

So let’s briefly go through the two forms. In the genetic form, the first mutation happens either in the sperm or the egg, so that there is a hit, there’s a defect in chromosome 13 in every cell of the body. Now, that defect has to occur in the sperm or the egg. It would be most interesting to see the future generation tell me, how many of you think that occurs in the sperm? Okay, how many of you think it’s most commonly in the egg? (Not everyone votes.) Is there something else in Brooklyn I don’t know about?

So, it’s actually more than 95% of the time found in the sperm; which is true about many genetic diseases, so this is when I point to the men in the room and say, “Your biological clocks are ticking.” So, the first mutation occurs, and if there’s a second mutation, you lose the protein, you lose the cell-cycle control, and you develop retinoblastoma. But there are other consequences of this. Your gametes, the child, now have one haplotype that’s affected. So, you’ve got a 50% chance of passing this on to your children. It’s an autosomal dominant.

Because you have one of the most important chromosome gene defects known to give cancer, you are at risk for cancers, through life; so called “second” cancers. And, because every cell in the body is affected, it is likely you will get multiple tumors, including multiple in the eyes, and retinoblastoma is, in fact, in both eyes, 30% of the time.

The second form, nothing wrong with the sperm or the egg, you don’t pass it on, you don’t have second cancers, and just one cell in the retina of one eye, when it gets that second hit, will develop retinoblastoma and, characteristically, one tumor in one eye.

So, as I mention, I thought I would, for fun, go through ten major shifts we have undergone in the treatment of retinoblastoma management since I finished my fellowship. The first is, the introduction of PGD. How many of you even know what PGD is? Okay. I’ll tell you about PGD. We were the first to do it for retinoblastoma, but not the first to do it. PGD stands for preimplantation genetic diagnosis, so it is an assisted reproductive technique. In one sense it is very simple. It is in vitro fertilization but, if you wait three days – in three days, you’re an eight-cell embryo. We go ahead and remove one cell. Now, you’re a seven-cell embryo. Seven-cell embryos develop quite normally.

With nested PCR techniques, you can say whether this embryo has the retinoblastoma gene or not. It takes about an hour and a half in the lab. You then implant the embryo or embryos that have mom’s genes and dad’s genes, you haven’t added a gene, you haven’t taken away the gene, you’ve pre-selected the embryo that doesn’t have the gene defect.

This is what we did for the first case that was done for retinoblastoma, done by us in 2003. I decided to go through the alphabet to find at least one example for every letter of PGD that’s been done for genetic diseases. It’s now been done for large numbers of genetic diseases. The first family that was done in the world was done for my patients. This is a child that, many years ago, had bilateral retinoblastoma, grew up, had normal vision in one eye, got married years later, had a child who had bilateral retinoblastoma. There was a 50/50 chance. That child went on and developed a second cancer, a brain tumor, pineal tumor. They liked mom’s genes, they liked dad’s genes, they were not so crazy about the retinoblastoma gene. So we did PGD, and this is the child at birth, perfectly normal eyes, and actually, ultimately, in this family, three of these four children were born with PGD, all looking like each other, because they’re brothers and sisters, three of them don’t have the retinoblastoma gene, the one does. She’s gone on and gotten a third cancer.

The introduction to PGD is major. When I finished my fellowship, there was not one survival of metastatic retinoblastoma in the world. Not one. Not even a case report. One-hundred percent of those children died. We introduced some protocols that are now used worldwide, and in all centers adopting these protocols, more than 75% of these children survive. They still die, we don’t salvage all of them, but I’ve seen, from the end of my fellowship, go from zero to 75%. That’s a big step. Similarly, these children are at risk for what is called trilateral retinoblastoma, the so called “third eye,” the pineal gland. They go on to develop cancers in the pineal gland, which often kill you.

When I finished my fellowship, we just described trilateral retinoblastoma, it wasn’t even known. There were no survivors of this disease at all. Now, worldwide, with protocols we introduced, about a third of these children are surviving. Again, that may not sound good, but when you’re coming from zero percent and you’re a family, that is a step up.

Now, during my residency, when we saw a child with retinoblastoma, we did X-rays routinely to look for calcification because retinoblastoma calcifies in the eye.  When CT scans were introduced in the early 70s, we switched to CT. It was obviously more elegant. But then we’ve come to recognize that CT scans in children are something you really, really want to avoid. This is the alert sent out by the National Institute of Health in 2003 on the web, pointing out that CT scans, especially in children, contribute to the development of subsequent cancers. Figures published by the NIH, those that are interested in this, we can talk and argue, point out that 2.2% of all deaths in the United States are from diagnostic radiation. This year in the United States, there will be more X-ray procedures on humans, than there are humans in the United States.

And rarely do the people who have X-ray procedures, CT scans or whatever, have it only once. So, abandoning CT is something we’ve done. We no longer do CTs. During my fellowship, and residency, I learned about radiation for retinoblastoma. Retinoblastoma is one of the very few solid cancers that can be cured with radiation alone. That’s a powerful statement. An entire generation of children worldwide were treated with external beam radiation, they were cured, their eyes were saved, their vision was saved and they lived.

I wrote an entire book on radiation and retinoblastoma and, as you mentioned, I’m tenured in radiation oncology, and we haven’t used it in ten years. And the reason why we haven’t used it in ten years is we realized that, long term, the children with this RB1 defect are exquisitely sensitive to the damaging effects of radiation. And so the exact treatment that allowed them to live, to save their eyes and vision, shortened their lives because of the cancers we induced.

So, when I finished my fellowship, I was an expert on radiation, but knew that, over the years, we’d develop better and better radiation techniques. I had no idea that I’d be the one responsible for it being abandoned in the world, but I am.

When radiation was abandoned, everyone decided, well, if radiation is bad, then chemotherapy must be good, right? It certainly had shorter follow-up, and everything with shorter follow-up looks better. So, systemic chemotherapy for retinoblastoma was introduced. You know, unfortunately, systemic chemotherapy rarely causes a cure for a solid cancer. And, in fact, it doesn’t cure retinoblastoma, but it does cause it to shrink, and if it gets small enough, you can laser it and cure it. But there are significant problems with the systemic chemotherapy in children. There are deaths reported from the chemotherapy in China. Ten percent of children given systemic chemotherapy die from the chemotherapy alone. Obviously, they have transfusions, fever and nutropenia, permanent hearing loss from Carboplatin, and they too develop second cancers, so-called “secondary AML,” mostly induced by the topoisomerase inhibitors.

As Doug mentioned, when he was a resident, retinoblastoma was treated by the removal by one or both eyes. It’s a very good treatment for the cancer, it’s not such a great treatment for the eye, and certainly isn’t a good treatment for vision. And so you’ll hear, very shortly, about the technique I introduced so that we don’t have to do as many enucleations. And, in fact, we are now treating eyes with very advanced disease that, years ago, I and everyone else would have removed. Not only that, but using the same treatments, we have enabled us from removing, just ten years ago, 95 % of the eyes in unilateral blastoma, to only about five percent.

Now, if you want to go into something where you can make a difference, please figure out how to screen for cancer, because the previous generation has done a lousy job.  The most common cause of death in the United States is rapidly becoming cancer, as you know, as our disease management as gotten better and better, or its outcomes have gotten better and better. And we have increasing numbers of people living, and increasing numbers with cancer. You know it’s coming, but the screening has been very disappointing. In pediatrics, the only cancer pediatricians are required to screen for is retinoblastoma, even though it’s not the most common cancer. So, we don’t pick up cancer any earlier today than we did when I was a medical student. We’re better at treating it, but we’re not picking it up any earlier.

We’ve been interested in this for the second cancers because the children from conception have a gene that is ticking, waiting to give them multiple cancers. And we’ve instituted a screening program, and published on this, and our data would suggest that the screening program that we have not only picks up on it earlier, which is simple, but actually prolongs life and doesn’t just have, so called, lead time bias. I think that’s an important development.

Now, when we give systemic chemotherapy, it always causes a response, as it does in most cancers, and almost never cures the cancer. And why is that? That bothered me for years. Think about phase 1 trials. What you do in phase 1 trials is determine, basically, what kills 50% of animals, humans, whatever you’re studying. Then you take that dose and decrease it, because you really can’t have a treatment that kills 50% of your patients can you? Or can you? And you go down in the dose. So you use a dose that is toxic, but a toxic that we can handle, that doesn’t kill your patient, or doesn’t often kill your patient. That makes no sense. That guarantees that you’ll fail. Why would you ever think that a cancer cell is more susceptible to chemotherapy? The way they got to be a cancer cell is that they’re devious in a variety of mechanisms and can survive, not dying. So you’re doomed by that.

But wait. If you give a dose that kills the patient, you’ll kill the cancer. All right. There’s a little problem with that. I understand that. But the point is, that’s how high you have to go in the dose to kill a cancer. Maybe even higher. You say, “Thank you very much, you taught me how to cure cancer – kill my patients.” Very good. So, I wondered one day if we could deliver a dose so high that that concentration would kill the cancer, but the exposure to the patient would be so low, it wouldn’t make the patient sick. Could we put a catheter in the groin of babies, pass it up through the abdomen, bypassing the heart, go through the abdominal aorta, thoracic aorta, into the internal carotid artery, on that side … And then, could I go – and now I’m injecting to see exactly where we’re going, and could I pass a catheter into the ophthalmic artery? The ophthalmic artery is 900 microns. It’s pretty thin. It’s like Doug’s cornea that he operates on. It’s actually the size of angel hair pasta when it’s dry. I have no financial relationship with angel hair pasta.

If I put that catheter directly into that blood vessel remotely, I could deliver an extremely high concentration in an extremely small volume. So here we are going up in the internal carotid artery I’m going to go up to the first major branch of the internal carotid artery, which is the ophthalmic artery. It’s not the first branch of the internal carotid artery. No one had been able to do this, ever. Obviously, I wasn’t the first person to think of this. They couldn’t do this because the ophthalmic artery does kind of an abrupt, right-hand turn. Kind of like some of the streets here in Brooklyn. You’re driving and the next thing, you want to go that way (he gestures sharply to the right).

So, what we did was develop a technique where you go above, and it’s a flow-directed catheter so when I get to the ophthalmic artery, it’s going to pop in. Pop. And now I inject dye, and I’m in the ophthalmic artery. Yea, you can do that. When you do that, you can show the ophthalmic artery. And here, you’re actually seeing the eye and the branches. And as we do that, this is the kind of angiogram you see of the eye with all of the blood vessels that you memorized for exams.

Now, I have what I call a “parentheses,” here. I’ve had the opportunity to write a chapter for the newest Gray’s Anatomy. When you do that, you don’t have a lot of original work, but you do add some things. And this is the drawing from Gray’s Anatomy. This anatomy, we’ve now done 1,600 angiograms we have never seen in a human. Nonetheless, it’s the way you’ll pass the exams and get to the boards, but we’ve yet to see a human that has this. But it’s not that simple, because, the ophthalmic artery, though it is very small, has laminar flow, and the ophthalmic artery itself has branches that go to the muscle, the lid and the eye. So, if you inject directly into the ophthalmic artery, it will go down the center of the ophthalmic artery, and not get into the eyeball.

So what we realized we had to do is create eddy currents, so we actually physically push once a minute for 30 minutes with a push that creates these currents and now they’ll get to the sidewall and into the eye. The largest branch of the ophthalmic artery is not to the eye. You’d think it is, wouldn’t you? The largest branch of the ophthalmic artery is actually – doesn’t anyone know this? Now, it’s been awhile since you had anatomy, right? The largest branch of the ophthalmic artery actually goes to the supratrochlear artery, which supplies the upper inner part of the orbit onto the lid. Here it is. And that’s why, in these children, sometimes they’ll have this hyperemic area because we injected it in the eye. Can you see some of the lashes are lost? Because the supratrochlear artery is supplying that, and it’s all transient. At least it’s telling you you’re in the right place.

So in May 2006, after my IRB was approved, we did our first patient, and this was our first patient. Scheduled for an enucleation, I think you can appreciate that this eye is largely filled with cancer, total retinal detachment, the vessels that you see are on the surface of the retina, which is detached behind the lens. There’s a little bit where there’s no cancer. This is an eye that is appropriate to take out.

We did it. We had no animal experiments before to tell us what dose, we chose the drugs and waited three weeks. And three weeks later, the cancer was almost completely gone. We realized, boy, we are on to something. Since then, there are more than 200 publications on this technique, most of them ours.  More than 45 countries in the world have come to us, and we’ve trained them on how to do it. Interestingly, more than half of them are in developing nations. Remember I said the main cause of death is children not being treated. But even in countries where you’d be shocked to think that medical care couldn’t do this, they can do this, and there, the children can come once or twice for this treatment, and don’t have to have blood transfusions, they don’t have complications, so it’s actually being adopted in developing nations.

By 2014, which is eight years after I did the first, the survey, in the world, showed that this treatment that I introduced is the main treatment for children with unilateral retinoblastoma. We’ve learned it can be done worldwide, we learned that it can save eyes that were previously enucleated. We’ve learned that for very advanced eyes, we can save most of the eyes. This is what you asked me earlier, Doug. This is our experience, published lately, showing our experience between 2006 and 2009, then, 2010 and 2014 for very advanced eyes. And doing the same technique, but simply getting smarter.

We’ve moved the curve up so that 95% of these eyes are saved. Some of these results are so good, they’re hard to believe. So here’s an eye largely filled with tumor, an ultrasound showing the vitreous completely filled with tumor. One treatment, three weeks later, the tumor is completely calcified, flattened down, calcific here, just about gone. One treatment, one drug.

So, these very advanced eyes, before and after, are nothing less than dramatic. With total retinal detachment, the retina settles down. Now, I mentioned earlier that the systemic chemotherapy causes tumors to shrink, but doesn’t cure them. What do you do in cancer when you do a treatment and you have regrowth?

Unfortunately, that’s common in cancer, and rarely do you have a patient survive that. The reason is, you’ve done the most potent, appropriate treatment in the first-line treatment. Second-line treatment is second line because it doesn’t work very well. But actually, we’ve been able to salvage about three quarters of the eyes that have failed conventional treatment, offering them a treatment that never existed.

Same for subretinal seeds. Vitreous seed populates the vitreous and grows like crazy, but it has no blood supply, and has been very difficult to defeat because they don’t respond to anything.  Here’s an eye before and after treatment with intra-arterial chemotherapy, it’s extremely effective for this. Now, I was taught, in my residency, so were you Doug, that if you have a retinal detachment that’s there for more than – some people say hours, some people say a day or two – that even if you get it back, surgically, you never regain vision. And that’s definitely true, unfortunately, in adults. And that’s why retinal detachment is a semi-emergent procedure for ophthalmic surgeons. So, when we had children like this, with total retinal detachment, we said to the families, we’ll save the eye, but this retina has been detached for weeks, maybe months, we really have no hope for vision. The family said, “Well, at least, if you can save the eye,” but 30% of these eyes, this is the ERG tracing, have regained vision. Eyes with total detached retinas, with total blindness, the exact indication for removing a human eye. Hopeless eye. But that was hopeless when I was in your seat. Not hopeless. Now I’m here (indicating podium).

Money. Deans care about money, don’t they? Well, one way or another. It’s nice to have new treatments but, you know, some of our new treatments for cancer are thousands of times more expensive than the old treatments, and people question whether that increased money is truly worth it. So I decided to look into this. Two-thirds of the money you spend in treating childhood cancer is not treating the childhood cancer, it’s treating the complications caused by treating the cancer. It’s a huge amount of money. These children don’t have ports. These children don’t develop fever/neutropenia, or need transfusions. We compared the costs at Memorial Sloan Kettering of the two treatments we’ve had, and then the same study was repeated in Argentina, and in Chile, and this treatment, which is more expensive, per day, is half the price of the standard treatment.

Well, are we compromising lives by trying to save these eyes? That’s a very good question. So, just about three months ago, we got together with the three largest centers in the world, Argentina, Philadelphia and Switzerland, to look at our collective results, and out of 634 cases that had been treated up to that point, there was one death. So, clearly, we’re not increasing the chance of patients dying.

Well, it obviously avoids the side effects of chemotherapy and radiation, but it does something very interesting. Years ago, I was intrigued and published extensively on the observation that, with time, in children with retinoblastoma, new tumors develop – remember they’re genetically primed, every cell in the body is affected – and, with time, even if you cure tumors in the back of the eye, within a few months, they’ll develop tumors in the mid-part of the eye and, a few months later, in the periphery of the eye. And that’s something we’ve all dealt with, and published extensively.

And it’s common, if at birth, or in the first months of life, you have retinoblastoma in an eye, 96% of the time you’ll develop a new tumor. It varies with age. By six months it’s 50%, and overall, in the world it’s 25-50%, and at Memorial, previously published, it’s about 53%. So commonly, these children develop new tumors, and when people ask me, since I’m the one who wrote about this, I always said, well, the retina develops from the optic nerve out, cell division, Thymidine, however you want to do it, ends more at the posterior pole than it does in the periphery, so it’s those dividing cells at the end which ultimately get the second hit and develop cancer. I said that. I wrote it many times. I got some awards for it. Nobody ever questioned it. Of course, I was wrong.

When we began to do the intra-arterial one day, I realized, we’re not seeing any of the new tumors. This is something I treated every week of my life for thirty years. I took me about a year to realize, I wasn’t seeing them. Why wasn’t I seeing them? What was wrong with my explanation?

So, in 2015 we published a very nice paper in Nature on the cell of origin for retinoblastoma to be a cone precursor. Then we realized that there is no cell division in the human retina after birth. In fact, cell division during the third trimester. And we realized that the molecular events that occur are such that all these retinoblastomas form between 26 and 28 weeks intrauterine. On a molecular level, they form. Now, the children at birth may not have any visible tumors in the eye, but they’re there. And what the intra-arterial is doing is treating these tiny tumors that are not visible ophthalmoscopically, but are visible, if you will, on a molecular level. So, it’s not preventing cancer, it’s treating tumors that were there all along. It’s an interesting observation.

Now, we’ve broken two golden rules of cancer. When you go to break the golden rules of cancer, I strongly suggest you get tenured before you do it. The first is, don’t use a single agent, drug, for chemotherapy. Why? Because you develop resistance. No doubt about that. In the conventional doses that you give intravenously, you cause tumors to shrink. But if you only use one drug, it will come back with a vengeance. You will regret it. So, when I started treating these children with single agent … a drug first used in the 1950s, so it’s not a new drug, people said, Dummy, don’t you know that single agent leads to resistance? Yea, but intravenous chemotherapy is like a gentle rainstorm. You get wet, it’s a little messy, some side effects. But the intra-arterial chemotherapy is like a tsunami. If you give a does that is 100 to 1,000 times what kills humans, you kill all the cells. You don’t have to worry about resistance. There are no cells to give resistance. So, this is the first major time that single agent chemotherapy for solid cancers has worked. It has worked before, and, historically, the first person to ever do this at the NIH, for choriocarcenoma, when she first did it, and had survival, was fired from the NIH.

The second, I don’t understand, but we’ve broken the rule. If you treat a patient with cancer, with some modality, and the cancer then regrows, you say, “It didn’t work well enough,” right? Therefore, the next time you treat shouldn’t be that same treatment. It makes no sense. When we talk about resistance, we talk about all kinds of molecular mechanisms. And so we have a golden rule, if it didn’t work the first time, don’t do it. But of course, we’re not going to do it a second time, because that treatment’s not that good.

So, we have children, we have a reoccurrence rate that’s about 10%, and with those children, we went back and treated them the same way, with the exact same drug, same dose, and 90% of those eyes have been saved. We published on that. It’s now been done in Philadelphia, done and published from Switzerland, the other large centers. I don’t really understand why this works, but we now have years of experience with this. It’s quite dramatic. There’s something wrong with our understanding. Fortunately, we didn’t pay attention to what we thought we knew. Overall, we’ve done it more than 1,600 times.

And finally, the other advance that was inconceivable to me, at the end of my fellowship, was the idea of injecting chemotherapy directly into the eye. This is something people have tried over the years. The concern is we know that if you do operations on children with retinoblastoma and enter the eye, a cataract operation, glaucoma operation, a retinal detachment operation, in all of these, it’s been reported, that through that tiny opening, the cancer cells come out, the cancer grows and the children dies.

So, it is a large no-no, to do this. But we’re doing it. Frances Munier from Switzerland introduced modifications of the technique, and we then modified his technique. We do an electro-retinogram, there’s a softening of the eye, so when the needle goes in, the likelihood of fluid coming out is less. Under sterile conditions, it’s a very small needle, a 33-gauge needle, right into the eye, and before removing it, that is, the needle, we freeze where the needle is, so there is no hole in the eye because it’s just ice. And this is the kind of result you can get from vitreous seeds, this cloud. Vitreous seed, gone. These balls of vitreous seed, going away and, ultimately, gone. These recurrent seas of vitreous seeds, disappearing.

Originally Frances thought you needed weekly injections, between eight and 17. We now do them monthly, and the average child is only getting two or three. They get .072 CCs. We’re getting down to minimalism.

It has some toxicity. We have published on the safety of this. We have washed all of our needles and looked at them to see if there were cells, and published a series of 200 consecutive needle samples and there were none. We washed the surface of the eye, collected the effluvient, there were no cells in 200 consecutive series also. So these are ten shifts, some of them absolutely something I was told I should never do, when I was in your position. All of which have helped humans. I look at you and I think, my goodness, what you’re going to do in the future. I hope to be there for part of it. Thank you, very much.

 


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Approved Alumni-Supported Programs for 2016/17

 

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For more information on the above programs, click here:

Support for students presenting at conferences
SUNY Downstate full-year research scholarship
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Brooklyn Stories Celebrates Another Journal Well Done

The annual journal of poetry, fiction, art and photography gives Downstate the chance to shine creatively, and is funded by alumni giving.

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The inscription inside the cover dedicates Brooklyn Stories XV to “those who recognize the art in medicine.” Then, it lists the Alumni Association, which contributed $1,475 toward the project this year, the College of Medicine, Medical Student Council, University Council, Dean of the College of Medicine, and Art and Anatomy, from a collective 14 editors and 29 contributors.

If you doubt Downstate’s enthusiasm for the project, borrow a copy from the Alumni Association (Basic Science Building 1-6), and flip through 88 pages of incredible photos, paintings, short fiction and poetry. The artists, editors and other interested parties celebrated the release party May 12 in a Downstate classroom.

“Art is a wonderful outlet for reflection,” Elizaveta Efuni, editor in chief, said earlier this year. That is evident in the pages.

Editors accept submissions annually from students, faculty and staff from late fall, generally, until Jan. 1. For more information, contact the Alumni Association at alumni@downstate.edu, or call 718-270-2075.

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Arts and Science: The Brooklyn Stories journal

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Elizaveta Efuni is a SUNY Downstate third-year medical student, with plans to go into internal medicine and a special interest in neurology. She’s also an artist, poet and president of Brooklyn Stories, an annual collection of visual art and writing by the Downstate community.

Downstate medical alumni donated $6,000 this year to give students and staff the creative avenue for expression. Submissions are accepted from students, faculty and staff until Dec. 30, and published in April or May.

The arts and sciences dovetail naturally, Elizaveta said.

“Many physicians are also writers because they see so much life and death,” Elizaveta said, noting Sir Arthur Conan Doyle and Anton Chekhov, two famed doctor-authors.

People tell doctors their stories, she said. Doctors are eyewitnesses to life and death, and art offers an opportunity to respond, reflect and learn. Literature is full of psychology, history and philosophy. Paintings and visual art offer glimpses into how a disease or injury affected daily life – and how disease was perceived – throughout history.

A love of medicine and painting, writing and poetry inspired Elizaveta to volunteer with the journal three years ago. Now, in addition to her medical education, she’s responsible for club promotion, funding and operation. She oversees editing, design and distribution involving 40 Downstate volunteers.

“Art is a wonderful outlet for reflection,” Elizaveta said.

For more information, write sunybrooklynstories@gmail.com.

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Downstate students run the TCS NY Marathon to benefit the Brooklyn Free Clinic

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Four Downstate second-year students will run the 2015 TCS New York Marathon November 1 to raise money for the Brooklyn Free Clinic.

Daniel Burack, Kenny Chao, Emmy Coleman and Cole Murphy-Hockett, all from the Class of 2018, will run 26.2 miles through New York’s five boroughs for Brooklyn’s uninsured.

The student-run clinic provides primary care, screenings and education for the uninsured. The services are funded by grants and alumni donations, exclusively.

Daniel Burack, from New Rochelle, has run two half-marathons, including the 2015 Brooklyn half, but this will be his first marathon. He’s looking forward to the challenge, and proud to run on behalf of the clinic.

“It’s a phenomenal organization, a sort of clinical oasis in which everyone I’ve met is singularly dedicated to improving the lives of others through effective and conscientious medical care,” Daniel said. “I personally have been involved with RISE, a screening organization which provides counseling and free HIV and Hepatitis C testing. It’s been an unbelievable experience thus far, and I’ve been able to develop a sort of kinship with patients through interviews and powerful conversations.”

The TCS New York Marathon guarantees entry to runners running for charity, and publicizes a link to the charity site. Runners, however, are responsible to meet their own fundraising pledges of at least $2,500.

The Brooklyn Free Clinic is staffed by volunteers, students and physicians from the SUNY Downstate College of Medicine, College of Health Related Professions, College of Nursing and School of Public Health.

To support the Downstate runners, visit https://www.crowdrise.com/brooklynfreenyc2015, or email run@brooklynfreeclinic.org.


For more information on the Brooklyn Free Clinic, visit www.brooklynfreeclinic.org and read our recent post on the Brooklyn center.

Alumni donations support scholarships, help students travel to conferences, fund the annual White Coat Ceremony and other projects, in addition to the Brooklyn Free Clinic.

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