The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskLisa@Sunnybrook.ca
The Question: My wife has colon cancer that has metastasized to her liver. She has been receiving cancer treatments in Winnipeg since June 2012. I understand from Biocompatibles Inc. that Ontario hospitals may offer Debiri treatments with respect to the liver. I would be grateful if you could let me know if these treatments are available and how I might be able to access them. Thank you very much for your assistance.
The Answer: I am sorry to hear that your wife’s colorectal cancer has spread. And I can understand why you are looking at different options outside of standard chemotherapy. Sunnybrook has been offering the DEBIRI treatment (intra-arterial infusion of irinotecan-loaded drug-eluting beads) for about two years and while it extends survival significantly, it is not a cure. On average, the Sunnybrook team performs this procedure once or twice a month.
Eligible patients are those with cancer that has spread to the liver that is not surgically operable and has not responded to at least two standard systemic chemotherapy drugs. Typically, these patients have diffuse tumours on their liver – sometimes in a rain shower pattern – making surgical removal impossible.
With DEBIRI, also known as liver chemoembolization, beads are threaded through a small catheter line from the blood vessel into the artery, located in the groin, that supplies blood to the liver. These tiny beads contain a very highly concentrated dose of the chemotherapy drug irinotecan. With this treatment, the blood vessels are partly blocked with the beads, starving the tumor of its blood supply, while concentrating chemotherapy in high doses to the tumours. This devastating “one-two punch” slows, and in some cases, even halts tumor growth.
A small, single institution phase III of a clinical trial of 74 patients randomly assigned to receive DEBIRI (36) versus systemic irinotecan, fluorouracil and leucovorin (FOLFIRI, 38), found a survival advantage for patients who use the treatment, compared to those who use standard intravenous therapy, according to a 2012 study published in the journal, Anticancer Research. The study, while limited, demonstrates the potential DEBIRI has in the treatment of metastatic colorectal cancer.
“It is hard for me to say whether she is a candidate or not without more details,” said Calvin Law, head of the cancer surgery program at Sunnybrook. “We really think that DEBIRI should be examined on a case-by-case basis.”
A team that includes a radiologist, medical oncologist, radiation oncologist and surgical oncologist select what patients would benefit from the treatment.
“If we all agree,” said Dr. Law, “then the interventional radiologist will look at the picture and tell us if they can put the beads in the right place.”
If the treatment is recommended, it takes place in two sessions, usually weeks apart. Each time, the patient is in hospital for two nights and three days. Return to work is widely variable – from as low to a week to a month or longer.
“Typically, there is more than one treatment and occasionally, there are more than three treatments,” said Dr. Law.
Having said all that, the main issue may be whether the Manitoba provincial health plan will pay for the treatment. Generally speaking, medical treatment will be funded from one province to the next, as part of the Canada Health Act, which provides equal access to medical care. However, this may be a little different: critical to the funding will be whether DEBIRI s considered the standard of care in your province. You will also need to get your wife’s oncologist on side with the approach, as she will undoubtedly need to recommend it.
To that end, I would suggest your wife’s oncologist contact Dr. Law, who said he would be happy to discuss the treatment.
Lisa Priest is Sunnybrook’s Manager of Community Engagement & Patient Navigation. Her blog Personal Health Navigator provides advice and answers questions from patients and their families, relying heavily on medical and health experts. Her blog is reprinted on healthydebate.ca with the kind permission of Sunnybrook Health Sciences Centre. Send questions to AskLisa@sunnybrook.ca.
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This is an interesting navigation case involving multiple stakeholders – industry, specialists, payers, jurisdictions.
It raises an important issue regarding equity of treatment in a “universal” health care system. As the standards of care can be different from province to province, is the principle of “equal” access to treatment applied equally across the country? Your article brings this point into question. The duty to equity is still an issue in debate.