Dupuy offers thoughts on building an interventional oncology practice

April 17, 2006

Interventional oncology is on the rise for several reasons. Cancer detection is increasing in our population as more imaging is done at an earlier stage. The technology is continuing to advance and improve.

Editor's note: Dr. Damian Dupuy, a professor of diagnostic imaging at Brown Medical School and director of tumor ablation at Rhode Island Hospital, is at the forefront of expanding tumor ablation into new organ systems and applications. He shared his experience and advice about starting and expanding an interventional oncology practice at the Society of Interventional Radiology meeting in Toronto.

Interventional oncology is on the rise for several reasons. Cancer detection is increasing in our population as more imaging is done at an earlier stage. The technology is continuing to advance and improve.

Cost efficacy plays a role and will play an even larger role in the future: We can't afford to provide healthcare for our population now, so what are we going to do in 10 years when the baby boomers reach peak cancer incidence? We're going to have to make tough decisions. We're not going to be giving patients $30,000 doses of drugs that increase survival three months. We're going to be using more cost-effective measures.

All patients with localized disease and symptoms can benefit from the new interventional oncology. Right now, we tend to treat patients who are poor surgical candidates, due to advanced age or medical comorbidities. As randomized clinical trials show benefits equivalent to surgery, maybe we'll be treating patients who are surgical candidates. We'll be saying they're interventional oncology candidates.

Treating lung cancers is probably the biggest part of my practice, followed by liver. Some of the areas where I expect to see growth are kidney, adrenal, and bone tumors. Pelvic recurrences are an area that's pretty much untouched - if you look at all the gynecological and gastrointestinal malignancies that are difficult to treat in the pelvis with conventional therapy, you can have a very large role in that patient population. Finally, there's a lot of work happening in breast cancer, and I think that's a huge area of future growth.

There are also palliative opportunities. About 50% to 70% of patients are undertreated for cancer pain. The majority of oncology is palliation. If you ask a medical oncologist what percentage of their practice they cure, they'll say about 10%. The rest is palliation. Some of the areas where we can offer palliation are the chest wall, bone metastases, and pelvis, but you can also do palliative liver procedures.

But patients just don't appear on your doorstep. You have to build a practice.

You need to get involved in those areas that are strong in your institution. For example, I do a lot of recurrent thyroid cancer in my practice, because my institution has a high-volume endocrine surgeon.

Pick the highest volume area in our institution and offer assistance for problematic cases. You don't want to pick something that doesn't have a high volume in your institution just because you have an interest. If you do, you won't develop your practice because you won't have the patients.

I can't overemphasize combination therapies. You're a member of a team, and you provide meaningful benefit to patients. You have to become a team player and provide a clinical service. Your medical and surgical oncology colleagues need to know they can rely on you. You have to educate yourself.

If that means taking some time off and learning, that's a very good thing. You come from a position of strength by asking for help to educate yourself. Going to tumor boards is very valuable. This shows that you really care about patient care and want to learn. You can learn much about what your colleagues do as they discuss a particular clinical case.

It isn't all roses. There are problems, but there are solutions. When you first start out, you'll find you're going to get the ugliest patients, with the biggest tumors that didn't respond to anything. If you treat them and have some successes, you're going to educate your team of oncologists. They'll send cases to you sooner, and pretty soon you'll be treating them together, simultaneously.