Dr Zinner is the CEO and Executive Medical Director at Miami Cancer Institute. He spoke with IO Learning about the role of interventional oncology at the Miami Cancer Institute.
Tell us about interventional oncology at the Miami Cancer Institute.
Interventional oncology plays a complementary role for virtually every solid tumor we talk about. The potential for either diagnostic or therapeutic interventional oncology is complementary to what we do. I think for us, interventional oncology is a very integral part of what we do for solid tumors.
How is interventional oncology involved with the tumor board?
Particularly around gastrointestinal (GI), and to some degree some the other areas, like prostate and lung, interventional oncology plays an integral role in the tumor board. For example, they have a role in either making the diagnosis or following a patient who has a recurrence, whether or not they should be treated with radiation, chemotherapy, interventional oncology, or all three.
How is interventional oncology perceived at your institution?
Where I came from, it was the same as interventional radiology. Interventional oncology wasn’t distinguishable, and in Miami, there really is a defined group of interventional oncologists, which I have come to appreciate even more. They are doing new and innovative things that we did not do at my previous institution.
The Miami Cardiac & Vascular Institute (MCVI) has been so forward-thinking in terms of their interventional radiology and how they matured over time. I think the compliment really goes to Barry Katzen, MD, who had the idea 20 or 30 years ago to develop interventional radiology into what it is today, and the eventual result from that included interventional oncology.
How can other institutions work to bring interventional radiology more to the forefront?
I’d say think about developing either a division, department, or recruitment, and it has to do with personnel. It’s basically sub-specialization, and you have to be prepared. The same interventional radiologists who are doing transcatheter aortic valve replacement (TAVR) probably shouldn’t be the same interventional radiologists who will be doing irreversible electroporation (IRE). These are different skillsets. I think in most places, however, they overlap.
It’s the concept of being a generalist. Yes, it’s resources and cost. You can have a house full of generalists or you can have a house full of sub-specialists, but you need to have the volume for both.
Are there any areas in which interventional oncology is potentially under-utilized that you see as an area of potential growth?
For us, we’re just learning how to take advantage of what Govindarajan Narayanan, MD, has brought to us in terms of IRE. We’re just learning how to take advantage of IRE as a complement to ablation, cryo, RFA, or any other form of energy ablation. I had never heard of IRE before I came to MCVI. I attended a couple of lectures by Dr. Narayanan and was fascinated by this new way of delivering tumor ablation.
How would you describe IRE?
It’s not thermal-related. I’m used to either heat or freezing, which are both thermal-related energy ablation for tumors, but IRE provides a third, non-thermal-related method, which means the surrounding tissue is not involved. You can get very close to blood vessels, which has been the rate-limiting step for every surgeon, with every solid tumor. How close is it to a critical blood vessel in terms of your ability to get an R0 resection with no tumor left behind? That’s a critical part of what we now have to offer, and there aren’t a lot of places that have that.
To be fair, I think IRE is so early in its development that we don’t know what the long-term outcomes are going to be, but it’s still enough to convince me to begin to think about using it.
Relating to the tumor board question, for example, if a patient has recurrent or unresectable pancreatic cancer, what is the therapy we would use? Well, we would probably use chemotherapy, but do we use radiation therapy? We now have MR-Linac (Elekta Unity), which, again, narrows the spectrum between the therapeutic index for a killing dose, versus a surrounding tissue dose that injures normal tissue versus something like IRE or radiofrequency ablation or cryoablation. If it’s close to a blood vessel, IRE is a good choice.
Do you have advice for interventional radiologists working in IO and their attendance at tumor boards?
I think if you have a mature interventional oncology group, interventional radiologists should attend all of the GI tumor boards and possibly thoracic and genitourinary boards.
In your CIO presentation, you mentioned there were ten pillars of cancer care. Is that an extension of the traditional pillars?
Correct. If you look at that, there is supportive care that is associated with clinical trials. For us, all of those pillars are what drive us. There are traditionally four pillars — radiation, surgery, chemotherapy, and whether you want to add interventional oncology or immunotherapy, either one of those. But we feel that we have very robust patient support services, which includes complementary medicine, and this is not part of interventional oncology necessarily, but complementary medicine, with psychosocial support, nutrition support, and exercise therapy.