Implants buy liver cancer patients some time
BY MARIKA SBOROS: 18 MAY 2016, 17:49
More cancer patients in SA with inoperable liver tumours may now have access to a one-off radiation treatment option paid for by medical aid — at a cost of up to R 250,000 — to extend their lives by a few months.
Local oncologists believe that in a best-case scenario, new research shows that SIR-Spheres Y-90 resin microspheres, a permanent, single-use, implanted medical device used in selective internal radiation therapy, could shrink liver tumours sufficiently to make surgery an option, even a cure.
The device was developed by Australian company Sirtex Medical.
The Discovery Health Medical Scheme has indicated it may approve more reimbursements in “appropriately selected patients” after reviewing the evidence.
Fedhealth said it would review funding of the treatment method “on a case-by-case basis, and then make a reimbursement decision”.
The treatment is now available at more than 950 sites globally including more than 300 centres in the US. In SA, its use has been limited by a high rate (80%) of medical-aid reimbursement rejection. The Steve Biko Academic Hospital at the University of Pretoria was the first in SA to treat liver tumours with SIR-Spheres microspheres in 2012.
The procedure is now available only at the Wits Donald Gordon Medical Centre in Johannesburg, the Rondebosch Oncology Centre in Cape Town, and the Life Entabeni Hospital and Rainbow Oncology Centre in Durban.
Some cancer specialists welcomed Discovery Health’s move, saying it gives more patients access to a technology that can prolong life and has “great potential in management of other cancers involving the liver”. They hope other schemes will follow.
The move comes after Minister of Health Aaron Motsoaledi’s budget vote speech in Parliament in which he referred to the “exploding prevalence of cancer around the world and in our country”.
Motsoaledi lambasted pharmaceutical companies for making cancer drugs “devilishly unaffordable today”.
If no drastic action were taken to make cancer treatment more affordable, Motsoaledi said, “we are going to be counting body bags, like we are at war”. There are concerns in medical circles that the high cost of SIR-Spheres may do little more than contribute to those “devilishly unaffordable” drug and treatment options for cancer, and stratospheric health-care costs.
IN SA, primary liver cancer is a leading cause of death. It is diagnosed in about 3,500 patients annually, according to the University of Pretoria’s department of nuclear medicine website.
The university reported that about 85% of these cases will be inoperable.
More than 5,000 patients are diagnosed with colorectal cancer annually, the university says. In more than 40% of colorectal cancer patients, the disease spreads to the liver and cannot be removed surgically.
If colorectal cancer spreads, research shows it most often spreads to the liver, and inoperable liver tumours usually cause speedy death. SIR Spheres Y-90 resin microspheres are a form of selective internal radiation therapy (Sirt) or radioembolisation.
Radioembolisation is a minimally invasive procedure that combines embolisation and radiation therapy to treat liver cancer.
Medical embolisation is the insertion of a particle into the blood stream to block a blood vessel and restrict blood supply to a tumour.
Sirt is a nonsurgical method of treating malignant liver tumours that originate from the liver (primary liver cancer) or have spread to the liver from elsewhere in the body.
The procedure takes 60-90 minutes and is usually out-patient. It allows a radiologist to deliver millions of tiny resin “beads” that are known as radioactive microspheres directly into an artery that feeds liver tumours, by using a catheter through an incision in the patient’s groin.
These microspheres are small enough to be delivered straight into the tumours, but big enough to become trapped in the small vessels that keep tumours alive. The treatment delivers high-dose beta radiation aimed directly at the tumour, without affecting surrounding organs.
Patients can receive and tolerate much higher radiation doses than are possible with conventional external beam radiation. This helps to starve the tumour of oxygen by cutting off blood supply, resulting in fewer and milder side effects.
Durban interventional radiologist Gareth Bydawell has treated about 30 patients with SIR-Spheres at Entabeni Hospital and says costs vary, depending on “the amount of consumables during the process”.
The radioembolisation particles cost about R 140,000, he says. Additional products and procedural cost add R 50,000 – R 100,000.
Because treatment is one-off, the cost is “comparable to certain chemotherapy medications which are required on a regular basis”.
However, because SIR-Spheres can shrink tumours, patients with previously inoperable tumours may “well become eligible for surgery in some cases”. The risk profile is “very small, with careful work-up before the treatment and with safe technique” and the risk of systemic side effects is reduced.
“Being able to offer a patient more time is priceless.”
DISCOVERY Health CEO Jonathan Broomberg says the decision to reimburse was taken after a review showing evidence “sufficient to demonstrate positive net health benefits in carefully selected patients who may undergo treatment in specialised hepato-biliary centres”.
Evidence suggests SIR-Spheres can add “significant and meaningful value to patients who would otherwise have no other treatment option at this stage of their disease”.
Broomberg says in one cancer type, treatment may increase life expectancy up to 22 months instead of untreated patients dying within six months.
Dr Waldemar Szpak, radiation oncologist at Rainbow Oncology Centre in Durban, says the Si-flox trial, published in the Journal of Clinical Oncology in late 2015, shows that the treatment keeps liver tumours in check for almost eight months longer than regular chemotherapy alone when used early in patients with metastatic colorectal cancer that has spread only or mainly to the liver.
Bydawell says suitability for treatment all depends on the patient’s particular disease profile.
There are contra-indications. Bydawell says he would not prescribe SIR-Spheres for patients with malignant disease outside the liver, or if liver function were compromised significantly.
Patients with a blood clot blocking or narrowing the portal vein that brings blood to the liver from the intestines, or who have “abnormal vascular anatomy” that would result in significant reflux of hepatic arterial blood to the stomach, pancreas, or bowel, are “not ideal candidates”.
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