Early this month, at the end of the International Liver Cancer Association (ILCA) conference in Hong Kong, journalists from Southeast Asia gathered to hear good news from doctors and executives of Sirtex Medical, the Australian-based medical device company that focuses on liver cancer treatment.
Worldwide, liver cancer is the sixth most common cancer (750,000 are diagnosed annually) and the third most common cause of death from cancer. Asia also has the highest incidence of the disease (80 percent).
During the media conference, they shared the results of a six-year study conducted among 325 people with primary liver cancer (hepatocellular carcinoma or HCC) and treated with Selective Internal Radiation Therapy (SIRT), which uses SIR-Spheres microspheres and the results confirm that the treatment is safe and effective in a range of patients with early to advanced stages of the disease.
SIR-Spheres microspheres contain radioactive Yttrium-90; they are infused through a catheter — millions of these microspheres — and carried by the bloodstream directly to the tumors in the liver, “sparing viable liver tissue and potentially increasing the patient’s survival and quality of life. Unlike other treatments, which can only be applied to limited areas of the body and in small doses to prevent organ damage, SIR-Spheres microspheres selectively irradiate the tumors and have the ability to deliver more potent doses of radiation directly to the cancer cells over a longer period of time.”
The findings were explained by a panel led by Dr. Bruno Sangro, professor of hepatology in the Liver Unit of the Clinical University of Navarra in Pamplona, Spain, and chair of the multi-center European Network on Radioembolization with Yttrium-90 Resin Microspheres (ENRY) study.
The patients were treated by teams of interventional radiologists (who administer the beads/microspheres into the patients), oncologists, and nuclear medicine physicians at eight centers in Germany, Italy, and Spain.
For patients who are inoperable (and unfortunately a large percentage are, as liver cancer is usually detected late because symptoms are often absent in the early stages), they are treated with chemotherapy, which comprises an established treatment called TACE, and radiotherapy. SIRT uses millions of tiny radioactive microspheres that are administered by an interventional radiologist.
“It is also clear from our analysis,” Dr. Sangro said, “that radio embolization may be particularly helpful in four specific patient populations. These include, firstly, patients who might otherwise be considered for TACE but may benefit more from SIR-Spheres; patients who are poor candidates for TACE due to the high number of tumor nodules or spread to both lobes of the liver; patients who have previously failed TACE; and, finally, patients who are ineligible for TACE because of portal vein occlusion. These patients have few other treatment options.”
Apart from TACE, there’s an oral medication called sorafenib, which is taken twice daily, but the ENRY study cites that it “can give side effects leading to discontinuation of the drug in more than a third of the patients (38 percent).” (SIRT and sorafenib were compared in the study.)
In Asia, a multi-center study began in July this year and it includes the Philippines where three of our hospitals — Medical City, Makati Med and St. Luke’s — are currently offering SIRT. The Asia-Pacific HCC Trials Group includes 19 cities in Asia (including Manila and Davao). Medical City has enrolled four patients in the study.
Dr. Maria Vanessa H. de Villa, surgeon and director of the Center for Liver Disease Management and Transplantation at Medical City, explains that there are several things to consider when deciding whether surgery is an option. “If we remove the tumor, will the liver left be enough in terms of the function and size? Number two, can we remove the tumor without leaving any behind? Number three, if the tumor is too big or if there are too many, and in terms of distribution — if they are in two lobes, normally we can remove only one lobe or part of a lobe, but not both, transplant na yon. Number four, if the patient’s condition would allow this major operation. If it’s too big, what we can do is to downsize it and one of the most effective ways to do that is with SIRT. I’ve seen patients with big tumors that became smaller to a degree na pwede nang operahan. It just took one treatment, that’s the advantage of SIRT. One treatment as compared with several or a lifetime of treatments with other systems.”
Dr. De Villa explains that to determine whether a patient is qualified for SIRT requires two hospital admissions. The first is for mapping or angiography (a medical imaging procedure to visualize the inside of blood vessels and organs of the body). They look at a patient’s anatomy, the vessels where the treatment should not go, whether some arteries are blocked, the tumor liver tissue, and the lungs — “because you don’t want to radiate the lungs.” This procedure lasts about four to five hours. The next admission is for the treatment itself — at Medical City they require the patient to stay overnight while in other countries it is an outpatient procedure — which lasts from an hour and a half to two hours.
It usually takes a week between the angiography and the administration of the radioactive Yttrium-90 microspheres because the hospital has to order them from Sirtex in Australia, the only plant that manufactures them.
“Age-wise any adult patient is qualified but we also have patients that are very old. One of my patients was 79 at the time she underwent SIRT in 2008. She didn’t want to be operated on and is still living to this day.”
When the liver cancer is in its early stage, one SIRT treatment is usually enough; for more advanced stages, two may be required. “By three months you will see a shrinkage, and then in six months a bit more, and up to eight to 10 months it will continue shrinking,” says De Villa.
Can the treatment eradicate the tumor?
“It depends on the original size. Normally it applies to tumors that are very big, but we have seen it applied to a tumor that is small and it disappeared.”
How expensive is the treatment? “The cost varies from country to country,” says Dr. De Villa. “You have to factor in three things: the hospital cost, the beads or microspheres themselves, and the doctors’ fees. The beads are very expensive, costing from P450,000 to P500,000. If you do the other treatments (like sorafenid) it is also quite expensive. And we have people who go abroad for treatments, but now that SIRT is available here, I would say the cost is comparable.”
Liver cancer is one of the most difficult cancers to treat, as the treatment not only has to attack the cancer cells but also preserve the function of the liver. In Asia the leading cause of liver cancer is hepatitis B; alcoholism may also be a contributing factor.
Now, liver cancer patients have new hope for survival and better chances of living a quality life.