PMP Pals serves as a source of information to patients about centers of expertise for treating PMP and appendix cancer. In this blog, we focus on Dr. Edward Levine, a surgeon who has treated this form of cancer for 20 years. Dr. Levine is Chief of Surgical Oncology of the Comprehensive Cancer Center at Wake Forest Baptist Medical Center, where approximately 100 surgeries with HIPEC are performed annually. We spoke to him in January about a range of topics.
First, we are interested in how you came to be involved in treating appendix cancer patients.
My first case was in 1996. I became interested in focusing on this cancer because I saw that patients coming back to our clinic for check-ups were experiencing improved outcomes from the newer protocols being used – cytoreductive surgery with HIPEC. The older forms of treatment and protocols had much shorter survival for these patients. It was so encouraged to see this improvement in outcome that I expanded my efforts for potential HIPEC patients.
What is your longest surgery for PMP/appendix cancer? Is that your most memorable case?
My longest HIPEC was 19 hours. The good news is that the average length of surgery is coming down – for us, it currently is 9 hours. And, more importantly, the complication rates are coming down. Now, nearly half the patients undergoing surgery with HIPEC do not need to spend any time in the intensive care unit.
There is no one particular case that stands out as most memorable for me. What stays with me is seeing the long-term survivors’ photos of their grandchildren, their travels, and their active hobbies like kayaking. This is what makes an impression on me – seeing my patients able to enjoy these kinds of moments.
Are you currently involved in any research trials?
Yes, at Wake Forest we have several on-going studies in different areas. First, we have performed the largest quality of life study worldwide to date for patients undergoing HIPEC. We are looking at more than 600 patients in this study. We will present this study at the March 2016 meeting of the Society of Surgical Oncology. We are following up that study with one looking at caregivers for HIPEC patients. Additionally, we have a long term study on patient outcomes, looking at response to surgery survival after HIPEC.
We also are studying what makes tumors tick – looking at the genomics and genetics of tumor development from a scientific standpoint. And finally, we have a first ever Phase II clinical trial looking at the chemotherapy agents used in HIPEC for appendiceal cancers. I am serving as the principal investigator; we are working with the University of Pittsburgh and the MD Anderson Cancer Centers on this study, which is in the follow up phase now. We expect to be able to compile the results by the end of the year.
To patients I would say that even though your type of tumors is rare (only about 3,000 new cases per year), don’t feel alone. There is active research taking place for this type of cancer. And, groups like PMP Pals provide an important source of support to patients and caregivers.
What advice do you have for patients who are approaching CRS and HIPEC treatment?
That’s a good question. First, I would say to take time to prepare yourself well before the surgery. Come to this treatment in the best possible shape. By that I mean not just physiologically and nutritionally, but also your mental state and spiritual state – all of these are important. The better the shape you are in, the better the outcome.
Then, around the time of your surgery, prepare for things that will improve your quality of life in those weeks. Get to know your surgeon, talk about what to expect, get to know the hospital you will be spending time in. Both the patients and caregivers need to know their surroundings and their surgeon in order to keep stress in check and to take care of themselves as well as possible while going through surgery.
After surgery, your recovery is like a marathon, not a sprint. Often it can take 3 to 6 months for full recovery, and the surgery can be life changing. Patients need to be prepared for this and plan for adequate time and support to recover.
Let’s talk about chemotherapy. We find there is a lot of confusion about when systemic chemo is recommended for PMP tumors. Can you clarify this for patients?
For appendiceal cancer tumors of the low grade kind, with no nodal metastases, there is no evidence of benefit from systemic chemo. For high grade tumors, based on the genetics involved, we do offer systemic chemo. For high grade tumors, we see response rates that are similar to response rates for chemo for treating colon cancer. These high grade tumors respond to the same drugs used for colon cancer – specifically, oxaliplatin-based chemo drug regimens (often referred to as FOLFOX) are the best first line systemic chemo treatment. By contrast, the genes in low grade tumors are very different from those in both colon cancer tumors and high grade appendiceal cancer tumors. The low grade tumors are slow growing, and we do not see the same kind of impact from systemic chemo.
Dr. Levine, thank you for sharing your time with PMP Pals. We appreciate all you do to treat your patients as well as to improve medical treatment of appendiceal cancer and PMP in general.
You’re welcome. Likewise, I appreciate the ongoing effort and expanding role of PMP Pals. I have been involved with PMP Pals for many years and am glad to see the organization still here to provide support. Finding support from a group like PMP Pals is so important to patients and caregivers.