For patients with neuroendocrine tumors that have spread, curating a liver-directed approach may make their treatment process less risky and less invasive, according to an expert.
Patients with metastatic neuroendocrine tumors (NETs) often have cancer spread to the liver, making liver-directed therapies necessary to address the metastases, especially when surgery isn’t possible.
“Most people don’t even know that (liver-directed therapies) exist,” said Dr. Emil Cohen in an interview with CURE®. “A lot of times it’s the first time that they’ve heard of it when they come and see me. So that's one of the reasons I think we're having this discussion — to get people more familiar with it. Fortunately, with the advent of web and these sorts of interactions, more and more patients know about it. In fact, some patients are flat out asking for it when they see their oncologist.”
Cohen, who is an associate professor in the Department of Radiology at MedStar Georgetown University Hospital specializing in interventional radiology, recently presented on liver-directed therapy strategies for metastatic NETs at the 12th Annual Ruesch Center Symposium.
“From the get-go, I always make sure a patient understands that what we’re going after is either palliation or cure,” Cohen said. “As you know, palliation means hopefully extending life to a significant degree. Cure is when you’re hoping to get rid of disease completely, so you don’t have to hear about it anymore.”
The Type of Liver-Directed Therapy Varies From Patient to Patient
There are a variety of options for liver-directed NET therapy, falling into ablative therapies or intra-arterial therapies. Ablative therapies include chemical (percutaneous ethanol injection), thermal (radiofrequency ablation, microwave ablation or cryoablation) and non-thermal (irreversible electroporation) options. Included among intra-arterial therapies are trans-arterial embolization, trans-arterial chemoembolization and yttrium-90 radioembolization.
“With ablative therapies, we try to overlap with surgery to try to minimize the number of tumors a patient has,” Cohen said during his presentation. “Having said that, that also means ablative therapies are basically good for patients who have very limited disease.”
The intra-arterial therapies, which are given through the arteries, are more intended for palliation, meaning they help patients live longer despite their disease remaining present.
Getting magnetic resonance imaging (MRI) can help provide more resolution to determine how many tumors a patient might have, so that the health care provider can adjust their management plan.
“We are helping the surgeons – they’re running the show as far as getting the disease under control with cutting it out,” Cohen said. “And if they can’t get to a few locations, we can certainly help an (interventional radiologist) to get that done.”
Conversely, if a patient is not a good candidate for surgery, liver-directed therapies are less invasive and are associated with fewer risks.
“A lot of our treatments, albeit something that’s been around for 20 to 30 years, have been modified to help achieve the cure,” Cohen said. “So when we talk about microwave ablation or cryoablation, or even irreversible electroporation, those treatments — if we have a small enough tumor, if we have it early enough in the course of the disease — we actually have a very high success rate almost equivalent to surgically cutting something out.”
With these treatments, patients are able to go home the same day about 90% of the time, he explained. “So you’re talking about taking something that was a big surgery (with) long recovery to getting home the same day … we in medicine who see this are frankly very grateful that we have that option for patients.”
However, this means it’s important for patients to see their providers as soon as possible. The larger a tumor gets, the lower the chances are of achieving a cure via ablative therapy.
What Patients Should Know Before Going in for Treatment
When a patient is about to begin liver-directed therapy, it’s important for them to know that the health care team consists not only of providers, but the patient’s perspective as well.
“We need to work together on stuff,” Cohen stressed. “And it may be as simple as asking all your questions so we can cut down on your anxiety before your procedure, or maybe just keeping up with which additional medications we give you, adding or subtracting them, and make us feel part of your team by trusting us.”
It’s helpful for patients to communicate openly and honestly with providers about their side effects so that they can make adjustments.
“The best thing I can tell my patients is please, please – I know sometimes when me or my family, (or) when my wife in particular goes to the doctor, she’s like, ‘Do you think I’m going to bother him if I Google this and know something about it?’ And I’m like, ‘No.’ They like that, especially if you know what kind of therapy you have,” Cohen said. “If I have a patient coming to my office saying, ‘Hey, I read about radioembolization,’ that’s fine. I actually love that, because the 20 to 30 minutes we spend can actually be spent more on the details than just starting from scratch.”
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