Michael Lidsky, MD, a Surgical Oncologist at Duke University Medical Center talks about Hepatic artery infusion.
Interview conducted by Ivanhoe Broadcast News in October 2019.
Let’s start with the types of patients, the types of cancers that you see and that you treat. Are these very common cancers?
LIDSKY: Patients that are referred to us for consideration of Hepatic artery infusion most commonly have metastatic colorectal cancer to the liver. We also see patients with locally advanced intrahepatic cholangiocarcinoma, which is much less common.
Colorectal cancer commonly metastasizes to the liver. And cholangiocarcinoma is a cancer that originates in the liver.
Let’s start with colorectal. Do you know how many cases we see in the United States a year?
LIDSKY: There are nearly 140,000 patients in the United States that get diagnosed with colorectal cancer every year. About a quarter of those patients will have liver metastases at the time they initially present with their disease, and up to half of patients will ultimately develop metastases to their liver at some point during their disease course.
When these patients come to you, are they advanced? And also what are the statistics?
LIDSKY: For people that have metastatic colorectal cancer to deliver, the best opportunity for cure is to surgically remove all visible disease within the liver and combine that with effective chemotherapy. However, only about 20-25% of patients are initially resectable. The estimated five-year survival rates for patients that have surgical resection combined with chemotherapy are between 50 and 60 percent. But now that we have Hepatic Artery Infusion, we can actually increase the likelihood of survival. We are now seeing survival rates of nearly 65% 10 years after surgery when hepatic artery infusion is added, which is just as good as what we previously saw at five years after resection and standard chemotherapy alone.
Let’s talk about Hepatic Artery Infusion.
LIDSKY: The two most common scenarios that we will use Hepatic artery infusion or HAI are both for patients with metastatic colorectal cancer to the liver; the first is in the unresectable setting in which patients have advanced disease or tumors located in areas of the liver that cannot be removed. In this scenario, we use HAI to prolong life. It’s not often curative but it does prolong life by controlling the liver disease.
The other scenario that HAI is used for patients with colorectal liver metastases is in the adjuvant setting or after surgical resection. In that scenario, we’re able to surgically remove all tumors from the liver, leaving behind enough liver to compensate for the patient’s metabolic and synthetic demands. At the same time, we place the hepatic artery infusion pump to deliver chemotherapy after resection, which has a significant survival advantage.
So it can either be used before resection or after.
LIDSKY: That’s right.
Can hepatic artery infusion help get patients to resection?.
LIDSKY: That’s correct. In prospective trials that have been conducted, up to half of patients that have initially unresectable liver metastases may convert to surgical resection. And by converting to surgical resection, those patients have a significant survival advantage.
How do you decide who gets this therapy and how does it work?
LIDSKY: When we see patients in clinic and decide if they’re a candidate for this therapy, the primary thing we’re looking for is first whether or not their disease is resectable. But also we’re looking at the extent of disease – do they have disease outside of the liver and how extensive might that be. This therapy is primarily effective for patients with liver only metastatic disease. Or in some scenarios, liver dominant metastatic disease. You can imagine a scenario where we’re giving very heavy doses of chemotherapy directly to the liver, which is not treating other organs. Although this therapy is given concurrently with systemic theme chemotherapy or whole-body chemotherapy, the therapy is really focused on the liver, and patients with significant disease outside of the liver to no derive the same benefit as those with disease confined to the liver.
When we decide that the patient is a candidate for this therapy, we take them to the operating room and the pump, which is a battery-powered, motorized pump is surgically implanted into a pocket in the abdominal wall, similar to a mediport. And from that pump, a catheter is surgically placed into the artery that supplies the liver. By doing that, we’re able to give chemotherapy at very high concentrations directly to the liver. Those concentrations actually reach somewhere between three and four hundred times the concentration that we’d be able to achieve if we gave it intravenously. After the operation and once the patient has recovered, usually within two weeks, the patient comes back to clinic and they begin their hepatic artery infusion therapy at that time. So just two weeks after surgery. Two weeks after that, they come back to have their pump emptied, filled with saline, which gives their liver a break, and they initiate intravenous or whole-body chemotherapy. I think it’s important to note that this therapy, HAI, is not given in isolation; it’s given concurrently with standard of care intravenous chemotherapy. It is an adjunct to standard intravenous chemotherapy, not a replacement.
Every time.
LIDSKY: Correct.
And is it a one shot deal, doctor?
LIDSKY: The pump can only be placed once but the therapy is given in cycles with systemic chemotherapy. Patients come in and pump chemotherapy is given on alternating two-week blocks such that a single cycle is one month and that repeats six different times. This therapy coincides with the administration of intravenous chemotherapy.
Are there more side effects?
LIDSKY: Aside from the surgical risk that patients take on by having the pump placed, there is essentially no systemic toxicity related to this therapy. It’s a great benefit of this option. The only toxicity patients experience is from the intravenous chemotherapy that they would have otherwise gotten anyway.
Have patients been very open to this?
LIDSKY: Yes, we’ve had a lot of support from patients and interest from patients. Many of the patients we see have come to us after failing standard of care chemotherapy regimens. They’ve oftentimes already had the full course of first line chemotherapy, sometimes they’ve had second or third line chemotherapy, and oftentimes for several years. And they’re essentially out of other options. So this therapy does provide them with something in addition to what they would otherwise be getting.
It seems like you are seeing that it can double the survival rate. It gives people more time with their families.
LIDSKY: That’s right. The literature, which includes both randomized prospective as well as retrospective studies, would support that this therapy can double the survival for patients that have unresectable disease. So for patients who are essentially left with ineffective chemotherapy as their only remaining therapeutic option, adding Hepatic Artery Infusion can double that patient’s survival. Patients who are able to get to surgery to remove the disease and be treated with HAI are also living about twice as long as well.
Is it available everywhere? It’s relatively new?
LIDSKY: HAI is actually an old therapy. It started back in the ’80s. It’s been around for a long time, but it hasn’t become mainstream for a number of reasons. Memorial Sloan Kettering in New York is where this therapy has been pioneered. A few surgeons and oncologists who have trained at Memorial Sloan Kettering have taken on positions at other institutions have started Hepatic artery infusion programs – so Duke is one of those. And there are only a handful of HAI centers in the country.
I think you mentioned that once the patient goes through that six-month treatment, they do get the device removed.
LIDSKY: It’s not removed.
It’s never removed.
LIDSKY: It can be removed. So a lot of patients ask what happens at the end of therapy, at the end of their six months of treatment. And it depends on the scenario. But we do try to leave the pump in as long as possible. The pump can be used again in the future. So if their disease comes back or if their cancer progresses and we think they would benefit from additional HAI therapy, then we can use the pump again. Removing the pump is easy. It’s same day surgery. It’s much easier than the initial operation. But we try to leave it in at least for several years, if not longer because the majority of patients that develop recurrence of their disease will do so within the first several years after surgery.
That does make sense. Would you say this is this is changing the way that advanced colorectal cancer can be treated?
LIDSKY: I don’t know that it’s really changing the standard of care. This therapy is not right for everyone and it isn’t performed at most centers. Patients need to be fit. They need to have well-functioning livers. They need to have liver only or liver dominant disease. The other thing with this therapy is it requires quite a bit of maintenance not to mention experience and expertiese from the providers giving it. And because there are only a few select centers that use HAI, we require that our patients come to Duke to have their pump maintained. So for patients that live four or five hours from our institution, it can be challenging. We do have patients that make that sacrifice and will travel 10 hours round trip to have this therapy. But a number of patients will determine that that’s just not possible.
We hope it starts popping up in more areas, rural areas.
LIDSKY: That’s right. As we see more and more centers around the country starting programs and showing success with this therapy, I think that HAI will become more common and certainly be offered to more patients with this disease. But at this time, it’s really limited to select centers around the country with expertise and experience.
Why did you choose this area of medicine?
LIDSKY: In my clinical practice and surgical oncology, in general, there’s so much opportunity to improve therapy and to improve survival for our patients. We see a lot of patients who have been told there is no hope. And they come to us for a last opinion. When we see them and look at them as a patient and we assess their disease, oftentimes we’re able to come up with something that’s a little bit creative or potentially better than what they’ve been offered locally. So HAI is one of those therapies. Patients come to us failing the best chemotherapy we have for this disease. And rather than just giving them more of the same chemotherapy that is failing them, we’re able to add something to that, like hepatic artery infusion. And in doing that, we can restore hope for the patients. It gives them longer time with their family and ideally converts a lot of these diseases into chronic diseases, and occasionally leads to cure.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Sarah Avery, Duke Medical PR
919-660-1306
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
