Prof Peter Naredi - Umea University, Sweden
Optimal treatment for colorectal cancer patients with liver metastases
Peter, you’re the President of the European Society of Surgical Oncology. You had a superb meeting quite recently and I know that a topic of great importance is this question of surgical resection of liver cancer metastases. Can you tell us what’s happening in your work and why you are interested to be here at ESMO.
Yes, the main reason is that treating liver metastasis, it’s really a multi-disciplinary approach that you need to have. So with better systemic treatments today, like chemotherapy with biological treatment, you get a very high response rate of liver tumours. And surgery for liver tumours, and especially those from colorectal cancer, for the patient, it’s not giving the patient many complications, it’s actually rather rare, and it has hardly any mortality. So if we can take the tumours away, we have a very good chance of curing or having the patient in a state where they can live for five or ten years. So the combination of surgery and chemotherapy makes it really worthwhile to find these metastases and then do everything to treat them.
What are the techniques, then, for combining this multi-disciplinary approach?
When you’ve found them, you have to take the decision whether you should, if there is a chance for surgery, for a liver resection, in that case you go for a rather tough systemic drug treatment so that they shrink as fast as possible. They should not disappear, but they should shrink so that we don’t need to take that much of the liver. We can take away 70% of the liver volume; the liver is like skin, it can actually grow out again, which is fascinating. So we can do surgery in the liver, once, twice, two times, three times, four times, as long as we have enough liver volume left after our surgery. And this is a way to keep patients alive with this metastatic disease.
What’s the downside of doing this, then, because it’s not universally accepted yet, is it?
I would say for the last three or four years, it has become universally accepted. But on the other hand if you look on a population-based level, some sites are more aware of it, and are more prone to do this surgery than other hospitals are. But I think today that you can say that this multi-disciplinary approach is universally accepted.
Can you give me some idea of just how successful it can be? You did mention the word ‘cure.’
When we talk about systemic treatments, chemotherapy and biological, we have talked about a median increase in survival from seven months to 24 months, but earlier we really talked about five year survival. And now with the best treatments, maybe we have 5-9%. With liver surgery, already before we had the systemic therapy to add on, we had 30% five year survival – one out of three patients who went through surgery lived after five years, and now with this addition of systemic therapy we have 40-50%, and also in small, selected groups 60% of patients living after five years.
What about patient selection, though, because not all patients are suitable?
No, because if you take something away, you have to be sure they don’t have metastases of other sites, it’s when they are in the liver. But this is what’s so fascinating with colorectal cancer - it seems like these metastases more often go to the liver than any other site in the body. Why, we really don’t know; we talk about seed and soil, that the liver might have properties that make the cancer cells more prone to stop in the liver, but anyhow, today about one out of five patients with liver metastasis can go through surgery, and what we hope in the future is that this will be increased to one out of three or even more.
And what we know is that this is the way you can actually… the gain you do actually can be shown for the whole population of patients with colorectal cancer. So the fewer you operate, it changes the chance for the whole population to survive longer. It’s not a rare incidence that patients have liver metastases.
Does it seem as though you’re actually fighting the disease itself, and stopping it in its tracks for this minority of patients?
No. We fight the disease for each individual, but there are so many of these individuals that it actually makes a difference for the whole population of patients with colorectal cancer. Somewhere between 30 and 40% of patients with colorectal cancer will develop liver metastasis. So this is why it makes a difference.
And the bottom line for surgeons treating patients with liver mets, and also for cancer doctors, what would that be?
Today I think, even if I wasn’t optimistic and said people are aware of it, I think it’s very important that everybody gets aware that the patient should be evaluated by the specialists: the medical oncologist and the liver surgeon, who can actually make a decision whether there’s a chance to do a liver section with curative intent, so you actually put the state of the art treatment up front for that patient. Now maybe a patient will go through a less intensive treatment and never get that chance, so I agree it’s still marketing that has to be done, but it’s more accepted than before.
Peter thank you very much for joining us here on ecancer.tv, here in the town of Milan, and I hope you continue to enjoy this wonderful meeting.