This column’s goal is for medical students to have a go-to resource where new issues and literature relating to patient- and family-centered care in IR are addressed and abstracted.

 

Approaching Challenges in Patient-Centered Research

Article: Brown DB. Interventional oncology: adding options to the care of patients with cancer. Journal of the National Comprehensive Cancer Network. 2015 Jun 1;13(6):825-6.

As I shared this article with my other colleagues who sit on the PFCC committee, I realized it would be worthwhile to create this column with their help to give medical students a quick read of recent advances in PFCC. As an icebreaker, I think Dr. Daniel Brown’s Editorial offers an interesting perspective on conciliating patient enrollment in research projects and patient care in community-based settings.

The recent advances in IR have made it so that interventional oncology (IO) is now seen as a subspecialty of IR. IO has also been called the fourth pillar of cancer care (with the three others being medical, surgical and radiation oncology)[1]. Just like radiation oncology has become a distinct field from radiology, one could predict the potential establishment of IO as a separate field, following the progression of the IO knowledge base. Nonetheless, this expertise is built on evidence-based medicine that stems from the completion of well-designed and well-carried-out research projects.

To introduce the challenges behind research projects, Dr. Brown relates how one of his patients had an unexpected excellent disease-free outcome after an IO procedure. It should be kept in mind that not all patients will have similar results and potential outcomes like this one are currently impossible to predict. Because prospective trials are particularly hard to design and execute, some IO procedures like yttrium-90 radioembolization, which are known to be anecdotally useful, are not necessarily integrated in all settings especially in community practices. By sharing his own experience as a lead site investigator, he describes how recruiting patients from community-based settings is a challenge as IO procedures are most popular in academic centers.

In the end, Dr. Brown emphasizes the commitment to better understanding patient outcomes through these clinical trials. By expanding the gamut of management strategies and knowing the strengths and weaknesses of each, IO, through its collaborative role, will be able to continue to better address the needs of patients.

Alain Nathan Sahin

Medical student at the University of Montreal

 

Q&A with Dr. Daniel Brown:

 

Alain: Two years have passed since the publication of this article. What has changed and what has not?

Dr. Brown: Several large trials have been completed in the last year. In advanced HCC, Y90 is of equal benefit to Sorafenib with less toxicity as demonstrated in the SARAH and SIRveNIB studies. On the the other end is the FOXFIRE study, which demonstrated that Y90 added to first line chemotherapy for colorectal carcinoma did not add to overall survival.

Alain: How does IO integrate tumor boards? How different is this from one center to another?

Dr. Brown: Tumor board set-up and participation varies from institution to institution. At academic centers, there are often multiple boards, each focusing on specific tumor types (neuroendocrine, lung, colorectal carcinoma, liver transplant). The level of specificity usually depends on the participants involved in setting up the board initially. The level of hyperfocus may be less in smaller institutions. Participation of IO, at least at VUMC led to growth of the overall number of procedures. This growth is continuing at a double digit rate 5 years since development of the service. Our original project, published in JACR https://www.ncbi.nlm.nih.gov/pubmed/27297700    showed that IO participating in tumor board led to practice growth. We published this specifically to help other IO’s get traction with their department leadership to do the same.

Alain: How do you envision IO in five years?

Dr. Brown: The Radiation-Emitting SIR-Spheres in Non-resectable Liver Tumor (RESIN) registry data should be mature in 5 years. We have almost 900 patients enrolled to date. This information will hopefully help define future targets for prospective trials with Y90. I believe that combination with second-line therapy for colorectal carcinoma, with biologic or immune agents for salvage in colorectal carcinoma or with immune agents alone for any other number of tumor types will be of interest. The best chance for IO to continue to grow over time will be data-based incorporation into existing paradigms for treatment by combining with accepted therapies.

 

We thank Dr. Brown for his collaboration on this article.

 

[1] Li D, Madoff DC. Interventional Oncology as the Fourth Pillar of Cancer Care: Essential Role in Gastrointestinal Cancer Management. 2017 Gastrointestinal Cancers Symposium Daily News. http://gicasym.org/daily-news/interventional-oncology-fourth-pillar-cancer-care-essential-role-gastrointestinal-cancer