Tumor ablation practice signals shift in thinking on cancer care

Creating a successful tumor ablation practice demands that physicians change the way they approach both cancer care and the practice of radiology.

The first shift entails seeing cancer as a chronic disease that can be treated multiple times. Tumor ablation techniques such as RFA and cryoablation are making this shift more possible.

"Some people live with their cancers for many years," said Dr. Robert Suh, director of thoracic interventional services at the David Geffen School of Medicine of the University of California, Los Angeles. "You do little things here and there, and RF fits in as one of those maintenance therapies."

Dr. Damian Dupuy, professor of diagnostic imaging at Brown Medical School

That's something a physician must make sure the patient understands as well, said Dr. David S.K. Lu, a professor of abdominal imaging and interventions, also at David Geffen. Practitioners must take pains to explain to their patients that tumor ablation isn't a "cure" for cancer but a method of making cancer something they can live with.

"I always tell the patient that ablation is not a single-shot therapy," Lu said. "In order to embark on local tumor treatment, you're really embarking on a course of treatment. It's very helpful to establish upfront that the patient may be coming back because of local recurrence."

Tumor ablation fits into a continuum of cancer care, one that requires careful monitoring. Ablation methods are most effective in treating lesions no larger than approximately 4 to 5 cm. When a lesion is small, practitioners can intervene sooner, and that intervention is less punishing to the patient, said Dr. Stephen Solomon, an associate attending radiologist at Memorial Sloan-Kettering Cancer Center in New York City.

Ablation can complement more conventional cancer treatments such as chemotherapy, said Dr. Alice Gillams, a senior lecturer and consultant radiologist at University College London Medical School and Hospitals.

"One of the things you can do with RFA is take someone who's had a lot of chemotherapy, has responded to it, and buy time to make them almost chemo-naïve again and increase their response rate," Gillams said. "In some patients that we've treated, we can keep them controlled with ablation for a couple of years. Then, if they get a more aggressive tumor, they can go back into chemo - they've had two years without having any chemotherapy."

Although tumor ablation fits well with other cancer treatment protocols, surgical and radiation colleagues may not be as open at first. Interventional oncologists may have to take on a more promotional and explanatory role.

"You can't just sit by the phone and wait for it to ring," Solomon said. "It won't happen. You have to get out and explain to your referring doctors why this is a great thing to offer them. They have the patients, but they may be unaware of what you can do. You have to be there to tell them what you can do."

One of the best opportunities to introduce interventional oncology to referring physicians is through a hospital tumor board, he said. The multidisciplinary team that evaluates treatment options may be well disposed to hearing new treatment methods.

"If you invest the time to make tumor boards a regular part of your weekly schedule, you'll build a program without a doubt," Solomon said. "If you start in the lung group and the lung people aren't getting excited, maybe it's the urology group that would be excited. You have to find which tumor board seems to take to it the best and work with them."

Because tumor ablation can be a continuing treatment, radiologists who enter into an interventional oncology practice have to change they way they interact with patients.

"The number one mandate is once you take a patient on and do an ablation, it's your patient long-term, until you can't really do anything more for the patient," Suh said. "You need to direct the imaging follow-up. If you see something, you're responsible for calling them back. "

At least some of the members of an interventional oncology practice must be able to handle ongoing patient care issues, said Dr. Damian Dupuy, a professor of diagnostic imaging at Brown Medical School. It may be practical to hire a clinical colleague, such as a nurse practitioner, to handle patient care issues.

But radiologists should not let the patient care aspect keep them out of the interventional oncology field, said Dr. Peter Littrup, a professor of radiology, urology, and radiation oncology at Wayne State University School of Medicine.

"It's a heck of a lot easier for radiologists to learn how to talk to patients and act like a real doctor than it is for surgeons and others to learn all about radiology," he said.