Issue 28Spring/Summer 2013
- Simultaneous Colorectal-Liver Surgery Improves Outcomes for Selected Stage IV Colon Cancer Patients
- Treatment Advances with Intraoperative Radiotherapy
- Measuring the Price of Success: Cost-Effectiveness Study of Alternative Donor Transplants
- Still a Leader in Treating Rare Cutaneous Lymphomas
- Pancreatic Cancer Patients Benefit from Gemcitabine plus Abraxane
- A Bridge from Cancer Treatment Back to Primary Care
- Exercise and Thrive
Clinicians have long questioned which surgery should come first in stage IV colorectal cancer metastatic to the liver: the primary colorectal surgery or the liver metastasis surgery. In an innovative approach that may reduce patient morbidity and offer improved outcomes for patients, UW Medical Center (UWMC) colorectal and liver tumor surgeons offer combined surgical approaches for carefully selected patients.
Liver metastases most commonly arise from colorectal cancer. They are seen in an estimated 60 to 70 percent of colorectal cancer patients and are the only site of metastasis in up to 35 percent of these patients.
If stage IV colorectal cancer metastatic to the liver cannot be surgically resected and is treated with chemotherapy alone, the five-year survival rate is only 5 to 10 percent. When surgery clears the primary disease and metastases, the five-year survival rate with adjuvant chemotherapy can be as high as 58 percent.
“Often times, patients with colorectal cancer metastatic to the liver are young, active, and high-functioning folks,” said James Park, MD, UW Medicine associate professor of Hepatobiliary Surgical Oncology. “These stage IV patients have the best chance at being cured through a team-based approach. UWMC surgeons, in coordination with Seattle Cancer Care Alliance (SCCA), are treating many of these patients with one simultaneous operation, where both colorectal and liver procedures are performed concurrently, often through the same incision(s).”
Reducing the number of surgeries is easier on patients
The innovative combined operation to simultaneously remove colorectal cancer and liver metastases is increasingly employed by surgeons at UWMC. “Thanks to refined surgical and anesthesia techniques, technological advances, and specialized post-operative care, even the most complex liver operations have become routine,” Park said. “In selected cases where colon or rectal with liver surgery can safely be combined, the patient experiences fewer operations and hence, less trauma.”
Patients with more complex surgical needs may also benefit. For example, patients with multifocal disease involving both sides of the liver often require a staged liver operation, first to clear one side of the liver and then the other. Combining one of these two stages with the colorectal procedure therefore reduces the overall number of procedures that the patient undergoes from three to two.
Temporary ostomies and ostomy reversals can also be performed in this simultaneous fashion. As an example, by performing the ostomy takedown with the operation for one side of the liver, what once took four operations—one rectal with ostomy, one liver, another liver, and one ostomy takedown—can now be done as one liver with rectal, and one liver with the ostomy takedown, resulting in two operations instead of four.
“The idea is to minimize morbidity for the individual patient,” said Alessandro Fichera, MD, UW Medicine professor of General Surgery and director of the Colorectal Surgical Oncology Program at UWMC/SCCA. “We take an individualized approach for each cancer and each patient, taking into consideration also their social concerns.”
Coordination of care is easier on the patient when the number of operations is reduced. In terms of neoadjuvant and adjuvant care, for example, two separate operations add more complexity to the timing and coordination of additional chemo and radiation therapies. By combining the colorectal and liver surgeries, chemotherapy is discontinued only once, and the patient has to recover only once from surgery.
“The surgical management of colorectal liver metastases is evolving,” Park said. “With the advent of more effective chemotherapeutic agents, we are able to offer liver surgery to patients who were once considered inoperable. As more patients become candidates for liver surgery, more will benefit from having the primary and metastatic disease treated simultaneously.” Patients are also carefully considered for minimally invasive approaches when appropriate to minimize incisions. Minimally invasive colorectal and liver procedures can also be combined.
The key to successful simultaneous colorectal-liver surgery: Early communication and planning among all providers
It’s important to optimize chemotherapy, which needs to be timed perfectly, so the patient can go into surgery at the right time to minimize disruption to the patient’s life, minimize morbidity, and minimize recovery time. “Patients who are candidates for surgery often get referred after progression on chemotherapy when surgery is no longer feasible or after many cycles of chemotherapy, which can damage the liver,” Park said. “We’d like referring physicians to know this option for simultaneous surgery exists for their patients. We have successfully coordinated the timing of chemotherapy and/or radiation with several patients’ medical oncologists and radiation oncologists near home.”
Simultaneous surgery requires expertise and clear communication between the medical oncologist, colorectal surgeon, liver surgeon, and, for rectal involvement, the radiation oncologist.
The Secondary Liver Tumor Clinic at UWMC is the longest-running dedicated liver tumor clinic in the Northwest, created by Raymond Yeung, MD, professor of Surgery at UWMC, in 1998, to address this important patient population.
Contact the Secondary Liver Tumor Clinic’s Jan Thomas with questions or to set up a case review at (206) 598-8710. To make an appointment, call Tee Florence at (206) 598-2352 or fax (206) 598- 1984.
A fast and effective form of radiation therapy, intraoperative radiation therapy (IORT) is now part of the technically advanced arsenal of treatments available to patients at SCCA.
IORT uses electron-beam radiation during surgery. When tumors cannot be completely removed from the pelvic or abdominal regions because they are attached to important organs or nerves, or if residual cells are left over after a tumor is resected, surgeons can move normal structures out of the way during surgery to expose the tumor for high-dose irradiation.
The SCCA IORT program eliminates the need for a dedicated lead-shielded radiation room and patients may remain in the sterile surgical environment throughout the IORT procedure, which takes only a few minutes to deliver. Using a fraction of the radiation dose of a traditional course of external beam treatment, IORT delivers precise irradiation to the tumor while limiting exposure to surrounding tissues.
UW Medicine surgeons and SCCA radiation oncologists have years of experience with this technology and recently installed a new system called the Mobetron from IntraOP Medical. There are only 15 of these machines in use in the United States. UWMC is the only hospital in the Pacific Northwest to offer this treatment.
During surgery, the machine is docked into position over a patient but never touches the patient. The machine is aligned to the patient with a special cone that focuses the treatment beam on the target so surrounding tissues and organs are unaffected by stray radiation.
At UWMC, examples of the types of tumors radiation oncologists use IORT to treat include:
- Locally advanced rectal cancers that are attached to unresectable normal structures such as nerves, blood vessels, or the pelvic side wall
- Abdominal sarcomas that are attached to the back wall of the abdomen
- Locally advanced gynecologic tumors such as uterine or cervical cancers
- Recurrent tumors
- Select early stage breast cancers
Treatment time is a short two minutes, and the procedure adds about 60 minutes to the total length of surgery. The radiation dose a patient receives is also reduced, compared to post-operative external radiation.
“IORT is a powerful tool that can help increase control rates for tumors that are difficult to remove completely with surgery,” said Edward Kim, MD, assistant professor of Radiation Oncology at the UW School of Medicine. “The technology is exciting, but we want to make sure we’re using it selectively and appropriately. Along with neutron therapy, brachytherapy, and proton therapy, IORT is one of the many radiotherapeutic technologies available to cancer patients treated at the University of Washington and SCCA,” Kim said.
For more information about how IORT may help your patient, contact Dr. Kim at firstname.lastname@example.org or call (206) 598-1168.
Many patients needing a bone marrow transplant (BMT) never find HLA-matched donor cells. Others fall gravely ill during the long search for a suitable match. All told, about a third of patients requiring BMT—thousands of patients every year in the United States—fall into this “marrow match gap.”
In recent years, two alternative donor transplant methods have been developed for these patients. One uses umbilical cord blood, and the other uses HLA-mismatched marrow from a family member. Both methods are now being evaluated in a multicenter randomized trial at SCCA. A description of these trials can be found online at www.seattlecca.org/clinicaltrials.
Although the alternative donor trial started in September 2012, researchers at SCCA are already looking down the road to determine the cost associated with more patients being able to receive a transplant. The answer will have implications for patients, families, insurers, and society as a whole.
A piggyback study of costs
Scott D. Ramsey, MD, PhD, is principal investigator of the new SCCA cost-effectiveness trial. Paul V. O’Donnell, MD, PhD, and Mark E. Bensink, PhD, are his SCCA co-investigators on this NIH-funded trial.
Ramsey said the alternative donor study provides a unique opportunity to capture all economic impacts of the new methods—from start to finish and from multiple perspectives. That’s exactly why his study was designed as an economic evaluation to parallel the parent multicenter study.
“Bone marrow transplants are one of the most expensive interventions in health care,” Ramsey said, citing an average direct medical cost of around $800,000 per allogeneic transplant. This estimate is based on proprietary claims data from Milliman, the large health care and insurance consulting firm, in one of its recent studies to look at the cost of transplant in the United States.
According to Ramsey, the alternative methods may be even more expensive. “For example, the costs of umbilical cord blood procedures may increase costs by up to 40 percent because of the extra costs for acquiring and storing the cord blood,” he said.
Ramsey, who leads the Research and Economic Assessment in Cancer and Healthcare (REACH) group at Fred Hutchinson Cancer Research Center, said these high costs alone make it critical to project the full budget impacts of expanded access to transplantation.
Ramsey also points to the need for determining the exact cost differences between the two alternative methods, as well as any differences in outcomes such as engraftment, infection risk, progression-free survival, overall survival, and quality of life.
“Only by measuring all these unknowns in prospective fashion,” he said, “can we construct a solid cost-effectiveness analysis that is capable of guiding insurance coverage decisions that refl ect the interests of both patients and payers.”
Patient perspectives on cost
Many patients or families who have been through a transplant can tell you that the financial aspects of the procedure—even if insurance covers the bulk of it—can add major stress to the process. The financial planning and bill paying can be nightmarish. Out-of-pocket costs, co-pays, and post-transplant prescriptions are often significant. Time away from work also takes a toll on family income, with bankruptcy rates known to be higher in younger patients with leukemia and lymphoma.
To get a better handle on the complete financial impact of BMT, Ramsey and his colleagues will also use their study to gather information on costs from the patient and family perspective.
To increase participation in this part of the study, the SCCA group has created a novel web-based survey tool. The e-survey can be completed at home or on a mobile device. Expenses related to co-pays, uncovered medical bills, travel, accommodations, child care, and family caregiver time will all be probed in the survey. “This patient and family perspective has never been systematically studied in BMT,” Ramsey said.
Indeed, by evaluating the economic impacts of expanded transplant access from multiple perspectives—patients, insurers, and society—the study will provide an essential complement to new clinical outcomes coming out of the parent study.
SCCA is one of just a few centers in the United States that specializes in providing novel therapies and clinical studies for peripheral and cutaneous T-cell lymphomas. Offering collaborative efforts between research and clinical care, SCCA has had an active T-cell program since 2009 and is a member of the T-Cell Consortium, a group of lymphoma specialists from around the world working to cure this rare disease.
SCCA’s Cutaneous Lymphoma Specialty Clinic is a new multidisciplinary clinic that harnesses this expertise, bringing together a team of specialists from dermatology, pathology, oncology, and radiation oncology to comprehensively evaluate and treat cutaneous lymphoma. Treatment options depend on the kind of lymphoma, including its location and stage, as well as other factors, such as the patient’s overall health. Generally, treatment is either directed at the skin, administered systemically, or a combination of these two types of treatment is used. Cutaneous lymphoma is a chronic disease, so many patients receive multiple therapies throughout their lifetime to obtain remission and live normal lives. The new SCCA clinic works with patients over the full course of their disease.
Results from a study released at the end of January 2013 show that the combination of gemcitabine and Abraxane® is better than gemcitabine alone as therapy for pancreatic cancer. Gabriela Chiorean, MD, was one of the study’s lead investigators at SCCA. Abraxane, an injectable formulation of albumin-bound paclitaxel, is already indicated for use in metastatic breast cancer and lung cancer.
“This large international clinical trial with nanoparticle-bound paclitaxel (ie, Abraxane) combined with gemcitabine is defining a new gold standard for patients with stage IV metastatic cancer of the pancreas, by showing a significantly improved overall survival by two months compared to gemcitabine alone, and an increased chance of one-year survival from 22 percent to 35 percent,” said Chiorean.
Physicians have limited tools to fight this challenging disease, so a treatment with clinical benefits and tolerable toxicity will be welcome. An alternative treatment for this disease is FOLFIRINOX (FOL=Leucovorin Calcium (Folinic Acid), F=Fluorouracil, IRIN=Irinotecan Hydrochloride, OX=Oxaliplatin), but this has a considerable cost in patient side effects.
Read more about this study, A Randomized Phase III Study of Weekly ABI-007 (Abraxane) plus Gemcitabine (Gemzar) versus Gemcitabine Alone in Patients with Metastatic Adenocarcinoma of the Pancreas, NCT00844649.
As patients finish their treatment regimen for cancer, they will be looking to their future. However, they will likely not be worry-free. It is common for cancer patients to suffer from fear about recurrences.
Cancer survivors may also face long-lasting or late-onset effects related to cancer or its treatments. These problems may include pain, fatigue, neuropathy, lymphedema, bone loss, sexual dysfunction, cardiovascular disease, and memory issues.
The Survivorship Clinic at SCCA is designed to address the variety of problems cancer survivors may face after therapy. Our staff can support patients as they move from the acute treatment phase into day-to-day living as a cancer survivor. As patients transition from treatment to surveillance, monitoring, and routine health care needs, the Survivorship Clinic can help them focus on symptom management and leading a healthy lifestyle.
Patients can come in to the SCCA Survivorship Clinic for a one-time visit any time after they complete their acute cancer treatment, regardless of where they were treated. Patients may be on maintenance or hormone therapies, fresh off of treatment, or many years past treatment. Many of our patients need only one visit, while others find several visits helpful.
As part of their visit, each patient receives a tailored Treatment Summary and Care Plan, which outlines late- and long-term effects of treatments to be aware of, as well as lifestyle and prevention suggestions for supporting their health. This tool is shared with the patient’s oncologist and other providers. In this way, the Survivorship Clinic can help build a bridge from cancer treatment back to primary care.
The Fred Hutchinson Cancer Research Center Survivorship Program has partnered with many cancer centers and hospitals across the Pacific Northwest to offer a 12-week physical activity and healthy lifestyle program called Exercise & Thrive™, for people who have completed active cancer treatment.
Through Exercise & Thrive, survivors build muscle strength, increase flexibility and endurance, and improve their capacity to perform activities of daily living, from work to play. The program has been shown to reduce fatigue and improve physical function, strength, flexibility, musculoskeletal symptoms, and mental health. Improvements were also seen in blood pressure, weight, and waist circumference, with 70 percent of participants reporting that they continued to exercise regularly at least six months after the program.
Learn more about Exercise & Thrive and where these classes are offered across the Pacific Northwest.
The SCCA Adult Bone Marrow Transplant News is a publication presenting the latest information on bone marrow transplant research at SCCA, providing up-to-date information for all health care professionals caring for transplant patients.
Read about important outcomes research at the Fred Hutch that may benefit your patients.
Each issue of Clinical Trials Monthly highlights several of the more than 200 clinical trials that are currently recruiting patients at SCCA.
Each quarterly Leading Edge newsletter will highlight a new topic to give you the latest news on leading-edge therapies that SCCA physicians are offering.