The Interventional Oncologist: The Fourth Musketeer of Cancer Care
- F.H. Cornelis
- Dec 9, 2017
- 7 min read
Interventional Oncology (IO) is currently one of the most active medical specialties. Alongside medical oncology, surgery, and radiotherapy, IO turns out to be the fourth pillar of cancer care. The ongoing research may even expand its scope and importance worldwide. It is time to define what an interventional oncologist is nowadays.
At first glance, the interventional oncologist is an interventional radiologist managing the cancer patient. He or she uses minimally invasive image-guided techniques to treat tumors. Originally designed for palliative rather than curative care (i.e. bland embolization or osteoplasty), these techniques are now much more specific (i.e. ablations or chemo-embolization). Depending on the skills the interventional oncologist may have and the patients referred, the physician may select to treat a certain type of tumor among others. In fact, this paradigm has to evolve since the interventional oncologist deals with many other specific problems. This requires dedicated training and environment. This shift is already observed in the United States.
The interventional oncologist in the present day is already involved in all stages of the patient's disease, from diagnosis to treatment. Likewise, he or she participates in the management of all related problems due to cancer during the follow-up. To achieve this in a time-efficient manner, the interventional oncologist must therefore have an extensive knowledge of the resources available. Journal websites, such as www.cvironline.org or www.jvir.org, are modern ways to learn or spread the latest information in IO. Attending conferences, such as ECIO (www.ecio.org) or WCIO (www.wcioevents.org), may be also an option. But most of the educational effort has to be performed at the patient's bedside with students, residents, and fellows. In anticipation of IO’s increased role in cancer care in the future, it is also necessary to conduct education at all times with any physician to diffuse IO promises to the greatest number of physicians.
The interventional oncologist has to set up a perfect organization, workflow and access to appropriate guidance tools or devices. This allows for performing the procedures safely and efficiently while being in daily practice. An example of organization that can be challenging is one encountered in basket trials [1]. The implementation of these clinical trials requires prompt performance of directed biopsies for genetic analysis before inclusion. It may strongly affect the daily activity of a hospital. Often a specific workflow has to be identified. In addition, the interventional oncologist must be able to meet the needs of his patients or guide them as best as possible during consultation with the patient. The interventional oncologist also has to be involved in all multidisciplinary team meetings, including palliative care or pain palliation. The goal is to be able to propose a solution if any, whenever possible. This is the case, for example, when, following the detection of symptomatic metastases in a patient at distance from initial treatment, a procedure has to be planned quickly for pain palliation or risk impending fracture. In short, everything must be implemented to ensure comprehensive and long-term care of the patient, beyond simple organ-specific treatment and evaluation of any initial procedure [2]. It is advisable that a thorough analysis be conducted in the near future to define the optimal conditions to practice IO. Sooner or later, the interventional oncologist will have to perform complex procedures in certified centers, following the model of neuroradiology. These centers will have to be extremely well equipped and include dedicated beds. They would be part of a network including small structures close to the patients, for simple (biopsies, port placements) or urgent procedures and consultations.
To achieve these goals and gain recognition, the interventional oncologist must be well-versed with the methods of the "dream team" (i.e. oncologists and surgeons), not only for determining the best-fit treatments but also for the evaluation of treatments. Besides consultation and participation in multidisciplinary team meetings, the interventional oncologist must be in close contact with his colleagues. He or she will thus have a complete appreciation of oncology, identifying each patient’s needs and finally cementing his or her place in the team effort involved in cancer care. IO is rarely proposed as first-line treatment but rather as an alternative in fragile patients. The current recommendations exist based on the accumulated evidence of the benefits of these procedures [3]; however, indications are neither exclusive nor definitive. It is still possible to think outside the box to enlarge them. To contribute to the further evolution of current guidelines, the interventional oncologist has to defend the minimal invasiveness of his techniques. They cause less pain, fewer side effects and shorter recovery times. Performing these procedures under local anesthesia or mild sedation on an outpatient basis may shorten the time required for treatment and hospitalization. It may even improve the quality of life of patients. It may be a wise move to promote these strengths of IO. Beyond the cost of the devices, which must evolve to be less binding, the rationale behind this is that global costs of these procedures could be less than conventional treatments. This has to be proved by setting up broad medico-economic studies. Expansion of the current indications might occur if oncologists or surgeons are involved in the process and willing to support it. But, it has to be kept in mind that the final goal of interventional oncologists is better cancer care than the mere comparison of techniques.
Hence, interventional oncologists have to be aware of the promises but also the limits of their treatments. It is essential that the interventional oncologist engages himself or herself in fundamental, transversal or clinical research to develop, improve and confirm the therapeutic armamentarium of IO. He or she has to conduct similar studies as the oncologists or surgeons, using the same method, by applying for the same grants. All this has to be conducted on good terms to create synergies and to free interventional oncologists from the devastating effects of a competitive process. The field is broad and much remains to be explored. Currently, the 4 axes of research in IO are 1) improvement of patient selection; 2) optimization of the guidance of procedures; 3) development of immediate evaluation tools; and 4) validation of treatments through patient follow-up. These axes are finally the same as those of the three other specialties. The possibilities of cooperation for an interventional oncologist are thus almost infinite. For example, the research on the immune response after ablation or embolization is promising and would improve our understanding of the mechanisms involved and identify new therapeutic strategies. Yet, to have a therapeutic impact, it has to be conducted alongside oncologists who have access to the immune therapies. Interventional oncologists have to assimilate a broad knowledge of biological effects. This would allow them to discuss the indications and perspectives of their treatments on the same level as the other leading specialties. Moreover, they must master the techniques to better select treatments and optimize the results. Thus, a long period of training is often mandatory.
A fundamental cornerstone is thus to better evaluate the treatments performed by interventional oncologists. Interventional oncologists have to convince the physicians to share patient monitoring. They have to meet regularly to discuss the medical reports. Yet, thus far IO suffers from the lack of standardization of the procedures. To render IO straightforward and better understood by all physicians, societies such as CIRSE (www.cirse.org), SIR (www.sirweb.org) or SIO (www.io-central.org) offer thorough guidelines. Among others, recommendations for percutaneous biopsies [4], ablations [5–7], or even complications [8] exist. It is of fundamental importance to put these guidelines into practice and to follow them every day. It may be necessary to adapt them nationwide to improve acceptance. All the technology available could also be used to standardize the procedures themselves. Using the strategy developed in radiation therapy, planning and guidance tools may be employed. Practices would be better homogenized and then comparable while optimized. Likewise, the introduction of standardized reports has to be explored [9,10]. Automatic extraction of data may ease the knowledge acquisition. Registries have to be encouraged to collect data. They help to address a question in a more time- and cost-efficient manner than prospective trials. The aforementioned societies promote a few registries, such as CIRT for radioembolization (clinicaltrials.gov/ NCT02305459) or ARMOR for renal ablations (clinicaltrials.gov/ NCT01888198), the SFR also through the FRI (epifri.radiologie.fr). But registries specifically built for IO have to be even more developed.
To summarize, only an interventional radiologist who has acquired detailed knowledge in oncology, developed the skills of oncologists in terms of treatment selection and evaluation strategy, and gained experience through the interaction he has with his patients and colleagues, will have developed the necessary expertise of an interventional oncologist. As cancer is a multifaceted disease, interventional oncologists can further provide innovative and effective minimally-invasive solutions to better care for the patients in a multidisciplinary team effort and thereby be recognized as the Fourth Musketeer of the cancer care.
References
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