Hello and welcome to Patient Power sponsored by UW Medicine Health System. I'm Andrew Schorr

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1 Advanced Techniques for Treating Liver Tumors Webcast James O. Park, M.D. Veena Shankaran, M.D. Raymond S.W. Yeung, M.D., FRCS(C), FACS Derek Epps November 28, 2011 Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion with your own doctor, that s how you ll get care that s most appropriate for you. Derek s Story If someone is diagnosed with a cancer tumor on their liver, whether it started in their colon or started in the liver, it's serious business, and coordinated care can make a huge difference. Hear more about it next on Patient Power. Hello and welcome to Patient Power sponsored by UW Medicine Health System. I'm Andrew Schorr Well, if someone has more advanced colon cancer, and of course colon cancer is the thing we recommend so often you have regular colonoscopy for, certainly if you're 50 or older. I do. But if it has spread, it can spread to your liver, so it can metastasize. And there are other people who can develop cancer in their liver itself, and unfortunately that's been increasing with the incidence of hepatitis C, which is an epidemic actually in the United States. In either case, it calls for specialized care. And at the Seattle Cancer Care Alliance they have that, where they have the various specialists who have approaches that can come together to treat that, all working together for the benefit of the patient. We're going to talk about that as an example of coordinated care for liver cancer or metastatic cancer that's spread to the liver as--as it can make such a difference for people. And one person who has been affected in a very positive way by that is Derek Epps, who is 39 years old. He's an attorney and he lives in McCleary, Washington, which is west of the capital in Olympia, and Derek is recovering now from robotic surgery that he had. He's working, and he's been working throughout, but he has had various procedures. Derek, it all started several months ago when they thought you had an inflamed appendix, right? 1

2 That's correct. I was diagnosed with appendicitis in February of And so they take out your appendix, but they still think something is not right. You have further diagnostic tests, and they then do a colonoscopy. Something is not right, and based on that they referred you for specialized care at the University of Washington and Seattle Cancer Care Alliance, right. They wanted--and you wanted that second opinion. That's correct. I wanted a second opinion. I had been diagnosed with a mass in my colon, but it wasn't positively identified as cancer at the time. Well, it certainly is a scary event no matter what not--not knowing what's going on. So you had another colonoscopy and other exams, and what did they say it was? At that stage they thought it looked like cancer although they didn't do any more biopsies on the--on the tumor itself, on the mass, but recommended me for surgery with Dr. Sinanan. At the University of Washington. So you had surgery, and how much of your colon and digestive track was removed? They took out about a foot of my colon and ilium including the ileocecal valve. Wow. Wow. Long way from having just an appendicitis. So there was a concern, I understand, that there had been a spread to your liver. Yes, there was. And so that connects you with one of our other guests today, and that is Dr. Veena Shankaran. She's a medical oncologist. She's an assistant professor of medical oncology at the University of Washington School of Medicine. She's a specialist in this area of gastrointestinal cancer. So, Dr. Shankaran, when you did all the exams what did you believe had happened with the liver? Was it as I described earlier, that cancer from the colon can spread 2

3 and in this case had? Yeah, when--you know, when I first met Derek it was after his two surgeries on the colon, so first the appendix surgery and then the subsequent colon surgery, and around that time we had attained a CT scan to do staging basically to look for any evidence of spread outside the colon. And the liver is one of the most common sites for colon cancer to spread, and there was a single spot that was noted on that CAT scan that was suspicious for colon cancer spread to the liver. So--and I know I kind of lived this years ago. This happened exactly to my mother, although I think it had spread more than that. So different modalities can come together, so would an approach here be part chemotherapy or drug therapy and if possible some approach, some surgical approach? Yes, it's a little bit of an obviously complex situation because there are many treatments that you can use, and sequencing those treatments obviously require some discussion. But essentially when I met Derek, we knew he had a stage III colon cancer at the least and then soon found out later he was a stage IV with this liver lesion. And certainly many studies have shown that chemotherapy is indicated in controlling disease and preventing spread of disease, so we immediately initiated that. But there was concern that this liver lesion needed to be addressed, and it was preferable for us to address this sooner rather than later so that's when we got the liver clinic involved, and Derek saw them shortly after he initiated chemotherapy to discuss this. We're going to talk about the liver tumor clinic and its unique capabilities in just a minute, but I want to bring the surgeon involved. And so this is Dr. James Park, surgical oncologist. He's an assistant professor and he's in the hepatobiliary area of surgical oncology at the University of Washington and Seattle Cancer Care Alliance. So, Dr. Park, I understand in Derek's case your approach that you all discussed with him was to do a robotic surgery, so sort of minimally invasive, to try to take out as you call that lesion. So talk about that for a minute, what you're able to do in a minimally invasive way now. And I find it so incredible when I think about the liver, a lot of people don't realize it, is that you can take part of the liver out and the liver can grow. Dr. Park: That's right. So, actually, Derek's case was discussed in a different conference in a multidisciplinary pancreas cancer clinic that we have at the SCCA, and Veena and I just happened to be there at the same time, and she pulled me aside and consulted 3

4 me about the possibility of going ahead with chemotherapy versus performing surgery to the liver first. And we looked at his scan together, and the lesion or the tumor in question was in a very favorable location for Derek to undergo minimally invasive robotic-assisted surgery, and that would give us an opportunity to get him recovered quickly to get back to Dr. Shankaran to get more chemotherapy for the both the adjuvant therapy for the colon primary but also adjuvant therapy for the liver metastasis. So you're absolutely correct. The liver is unique, with the exception of the central nervous system. It has a remarkable ability to regenerate, and in a case such as Derek's where he had taken good care of his liver, one can remove up to 75, 80 percent of the liver and the remainder would grow back. Certainly, his case, the tumor was quite small, it measured about 2 centimeters, and it was peripherally located, so we were capitalizing on that favorable location to try to provide him with a minimally invasive approach. Normally this operation would have required an incision that's about maybe three or four inches in size. It would require a three-to-four week recovery before he would be able to get back to a medical oncologist such as Dr. Shankaran to get chemotherapy, but he really outpaced everyone and has done remarkably well. And, Derek, you told me that you had been working throughout this whole procedure, right? I mean, you had the robotic approach. You've been working as an attorney. I understand you work for a shellfish company as an in-house counsel, so it's like a company that has farms for geoducks and other shellfish, interesting work. But you've been able to do that through much of this, right? Oh, absolutely. With the liver surgery I was probably--it affected me the least of any of the three to some degree. I was up and walking around and doing--trying to do physical activity within 24 hours of the surgery. Wow. But as well, I had my laptop computer with me so--i work from home a lot too at times, and working from the hospital room wasn't that much different. It just had a little more comfortable bed with some better options. The Team Approach to Treatment Let's put all this in perspective. So the director of the liver tumor clinic that Dr. Shankaran referred to at UW Medical Center in Seattle is Dr. Raymond Yeung, and 4

5 he's a professor in the surgery department at the UW School of Medicine. Dr. Yeung, I understand when we talk about cancer that's spread to the liver there are different modalities, and Dr. Shankaran used the word sequencing that come into play, it can be pretty complicated. And so you have this clinic to bring these smart minds together to see what's right for the patient. Tell me about that a little bit, because that's not on every corner. That is correct. I think we saw a very good example of this type of patient that we see in our liver tumor clinic in which the diagnosis in itself is very devastating, and often the treatment options are, like you said, very complex. So we believe that the best way to provide the optimal treatment plan for patients is to not have one person dictate the treatment course but to bring a group of people together who are dedicated to treatment of liver cancer. So at our liver tumor clinic, which was started about 14 years ago, we bring together seven specialties all together in one room, discuss the situation, and basically to leave no stone unturned, to then come up with a consensus recommendation that we all agree with that we think would be best for the patient taking into consideration not only the medical evidence but importantly the patient's desire and goal. And I think with that approach we usually can have a fairly solid plan for the patient, and all that can be done within one visit to our clinic. Dr. Shankaran, help us understand how this can work. So Derek comes to see you or someone is diagnosed. What other doctors get involved and might be involved with someone with a case like this, and how does that work as far as everybody putting their heads together? Well, I think that the nice thing is we all see each other quite often in the context of various clinics and meetings and tumor boards, so all of us have access to each other to discuss cases like Dr. Park and I did in Derek's case. And it's fairly--fairly easy to refer patients in a timely fashion to a liver tumor clinic. They are seen very quickly, and then their care coordinated back to the SCCA is very smooth. So in Derek's case we actually saw him back in clinic very shortly. I think he only missed--his chemotherapy was--usually, you know, after a major liver surgery chemotherapy can be delayed by several weeks. He was back on chemotherapy almost right on schedule, maybe a week delay, so that whole coordination of care through the liver clinic was fairly smooth. So, Dr. Yeung, so the idea is that a lot of smart minds and even the latest research can come together for the benefit of the patient. The patient can have some confidence that everything that's available now has been considered and offered to them but as you said according to their wishes. 5

6 That is correct. We're uniquely positioned being at a university setting to provide cutting-edge treatment. For example the robotic-assisted liver surgery that Dr. Park performed is the first experience in this area. Wow. So let me ask you about that, Derek, from your perspective. How--what would be some adjectives you'd use for how the care was with everybody working together for you? It seemed incredibly efficient, well organized. Even with someone like myself that--who traveled for some distances everyone would see--that was able to get their kind of schedules together so not only would I see potentially Dr. Park in a visit I'd also see Dr. Shankaran at the same time when I was in town. So very efficient, well organized. And from part of getting my colon removed as well as the liver surgeries the doctors in Olympia had estimated that I'd be, you know, out of work and kind of in the hospital for almost six weeks with a large incision. And then all of the different surgeries that I had instead was--i missed work maybe a week to 10 days to two weeks. Wow. How are you doing now? Right now, I feel really good. I'm trying to exercise more, although getting towards the end of the chemotherapy my energy levels are still dwindling. But, you know, I'm trying to have a more active lifestyle and ride bikes. I'd been riding as much as five hours a week, and I'm down to one or two now, but hopefully that will rebound again. Well, I hope so. So everybody wants their best shot at beating cancer. Do you feel with these folks who have helped you and continue to help you that that has been giving you the best shot? Absolutely. Yeah, the best thing I ever did was come there for the second opinion. Advances in Treating Liver Tumors Dr. Shankaran, just a word about liver cancer. All these modalities are coming along, and I'm going to ask the surgeons as well. From your point of view, though, are you hopeful? So whether it's drug therapies or a combination of drug therapies and different surgical approaches or chemo delivered directly to the liver, and we'll learn 6

7 more about that, are you hopeful that things can be improving? Are you hopeful? Yes, absolutely, I'm very hopeful. We're actually working on opening a few trials that are looking at sequencing chemotherapy along with liver-directed therapy for liver cancer and for colon cancer, so I think it's a very exciting area, and I'm extremely hopeful that we'll make progress. Well, thank you for that. Dr. Park, so I want to ask you, when we think of surgery, so robotics is really cool and that you're able to apply it in this way. There are some other approaches that maybe you do, as well, related to surgery and then you have colleagues who do. I know I've heard of heating tumors, cooling them, or as we talked about, applying chemotherapy in a variety of ways right to the liver. All that is possible at the UW? Dr. Park: That's right. As Dr. Yeung was mentioning, we truly have a multidisciplinary approach, and for liver-directed therapy not only are there surgeons that are doing these radiofrequency ablation techniques that you mentioned but also the interventional radiologists are quite active, and they have catheter-based modalities such as transarterial chemoembolization or radioembolization where they deliver beads that contain either chemotherapy or radiation to treat both colon cancer and primary liver cancers is all available at the UW and SCCA. So, Dr. Yeung, tell me how unique that is that all--where we are now both with technology, wisdom in treating these illnesses, clinical trials. I asked you earlier whether it was available in every neighborhood, and I guess not, but it sounds like that's a big commitment that the UW has made over many years for this. That is--that is right. I think it is all about the patient at the end, and I think we are very fortunate to have this group of people dedicated and really pushing the envelope forward and making significant progress, I have to say, even within my short career here. Dr. Shankaran, just one more question for you. And that is it sounds like this multimodality approach is in liver cancer, metastatic cancer in this case, maybe what's called for, that if you just did chemo or you just did surgery for many patients that wouldn't be enough, and so you-- you need to kind of be going on all cylinders, if you will, to bring together different specialties in a coordinated way. Yes, that's--i mean, that's absolutely true. We have made a lot of progress in terms 7

8 of chemotherapy. There are many new agents that have been introduced since the early 2000s, but in the setting of metastatic disease, cancer that has spread to the liver or the lung potentially, there is very--chemotherapy is limited in that you cannot eradicate the disease completely. And so when somebody who has limited disease is fit and can undergo surgery that's obviously something that we would want to add to the treatment. Well, I want to thank you for what you do. Dr. Yeung, so I want to talk about pioneering in medicine. So when new developments happen is it a place like UW and your clinic where it happens in this area? I mean, where does medical progress come from, and for patients in a region or if people come from a distance can they feel like they are plugged into that pioneering? Do you know what I mean? A couple of thoughts on that. There are continuing new development from the technology standpoint, and us being a relatively high-volume center we do attract companies to offer us these new devices. For example, in addition to the robot, we recently acquired a new ablation technology known as NanoKnife which is different from the radiofrequency ablation where it doesn't cause heat, and you don't get the heat-related damage. So things like that are being studied at this point. And then we have a whole infrastructure from the university standpoint whereby basic science investigators and engineers are putting together new tools to detect cancer earlier, to treat it in a more minimally invasive way, in a more accurate way. So all those things are filtering up to the clinics, and we are very privileged to have the opportunity to investigate those. Dr. Park, so in surgical approaches, you referred to it earlier, there are--that you may have another specialist working right alongside you, so it's not just about getting access to where the cancer is and for you to cut it out, if you will, but there may be other approaches that are used in concert. Dr. Park: Yes, and I think that's the strength of the liver tumor clinic and the SCCA working in conjunction with each other is because we have all these options. If you are a hammer you tend to look for nails, and you know what to do with them or do to them, but by having all these options available you really can focus on the patient and what the patient needs. So by having peers that can do different types of treatment and make those opportunities available to you, you have a much greater armamentarium just by having your colleagues be available. And the liver tumor clinic is quite unique in that way that the patient can see all of those providers in one single visit. So, Dr. Shankaran, clinical trials, you mentioned. And so I just want to ask you, that 8

9 is how people have access to them at a place like UW and that's also how we, I like to say, move the ball forward, to help themselves perhaps but to help other patients as well, right? Absolutely. And so any patient that walks through our door we will want to think about if they would be eligible for any of the number of clinical trials we have available. Certainly, you know, there's opportunities to receive newer interesting drugs, then the benefits in a larger sense in terms of our understanding of the disease is another goal of clinical trials in general. Closing Thoughts Dr. Yeung, how proud are you of this group and what you're doing, your whole group related to liver tumor clinic? I can't say enough about the people I work with, people like Dr. Park, Dr. Shankaran and many others in the group over such a long period of time, they are the ones that make it happen, and at the end I hope the patients are the ones that will benefit most. Well, let's give the last word to a patient. So, Derek, you've been listening, but you've been living it as well. So how grateful are you in the care you've received through the University of Washington? Incredibly grateful. It's hard to even put it into words, really. When we found out that we had the disease one of the things that I learned was researching through SCCA's website before we'd even decided to go the to the University of Washington, and how it had said that, you know, the first attempt to addressing the cancer is the most important one. And so with taking that to heart we looked around even nationally to look at other hospitals like the facilities in Baltimore and different national hospitals that treated cancer. And we came to the determination that we'd probably get the best treatment that we could right here in our own back yard, which was incredibly nice in the fact that it was convenient to us, but more important was the fact I was trying to get this addressed and get it addressed the first time around. Do you feel that they've at this point given you your life back? I could probably answer that question better in five years. 9

10 Right. But, yeah, I mean, to be honest, I felt like whether or not I got my life back I feel like I've had the smallest amount of interruption to my life than I would have thought even possible. When someone kind of tells you have cancer for the first time, that really sets you back. So with that comes all those things, you know. How long am I going to be in treatment for? Am I going to end up on disability? Can I do--you know, what's going to happen? What are the next steps? You know, all those things flood through your minds. So in that sense, yeah. I mean, they gave me that kind of the hope at the end of the day as well but also helped me keep my life together as much as possible as well during the process. Well said. So what would you say to other patients? If they are diagnosed with a serious illness, a cancer, a cancer that's spread or maybe it's started where it can be so serious, in the liver, what would you say to them as far as how to seek out the best care? Unfortunately, I've already had experience with that. One of the employees that works for my company was diagnosed with stage II thyroid cancer. She's under 30. And she's been kind of going around to different doctors in the area and kind of getting pushed in between these different facilities if you go in a sense--and different opinions. And, you know when I sat down and talked with her I--telling her that, you know, whatever you do, get a second opinion. If you can't go to UW, go to the SCCA for it if you can, or there are a lot of other facilities out there as well. But I told her about my experiences and how much I thought they had helped me and how much I felt I got the right diagnosis and, you know, the best treatment that was available. Dr. Yeung, you're the head of the liver tumor clinic. When you hear that testimony how does it make you feel? I'm very happy that we're doing our job. Well said. Well, I think the points of all this is how experts in different related fields coming together for cancer and coordinated cancer treatment often with different approaches that can work together may be called for, as we said, for some of these diagnoses, that's what you want. I want to thank all our guests for being with us. Derek Epps, I wish you all the best and a long life, Derek. Appreciate it, Andrew. 10

11 And keep working with those shellfish. I'll think of you every time I take a bite. And Dr. James Park, thank you for being with us and the amazing things you've been doing in pioneering in surgery, thank you, sir. Dr. Park: Thank you. And Dr. Veena Shankaran has been with us, medical oncologist, we thank her for all she does. And Dr. Raymond Yeung, director of the liver tumor clinic at the UW Medical Center at the University of Washington, thank you for your leadership in this field, sir. As you hear, it can make a real difference. Thank you so much for the opportunity. This is what we do on Patient Power is connect you with leading experts and in this case really the leading edge of medicine, but not just to be leading edge but to make a difference for patients as it has for Derek Epps. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion with your own doctor, that s how you ll get care that s most appropriate for you. 11