Reading Room: RFA Effectiveness Review & Talking to Your Doctor about Liver Mets

C3 Advocates Contribute to RFA Effectiveness Review

Posted: 16 Feb 2010 10:16 AM PST

Written by Kate Murphy.

How useful is radiofrequency ablation (RFA) in treating liver metastases from colorectal cancer?

To answer that question, American Society for Clinical Oncology scientists included two C3 advocates, Rob Michelson and Dr. Andrew Guisti, on an expert panel looking at published RFA research.

In appreciation, the panel dedicated their Clinical Evidence Review to Michelson who died in January, 2008.

The Expert Panel wishes to dedicate this Clinical Evidence Review to Rob Michelson, who served as the patient representative at the Panel meeting in October 2007 and passed away early in 2008. His contributions at the meeting and as a reviewer of the first draft were substantive and thought provoking.


While the panel could not find sufficient evidence to establish an evidence-based practice guideline for RFA to treat cancer that had spread to the liver from the colon or rectum, they did complete a review of existing studies and called for more research into the usefulness of RFA to improve outcomes for patients with liver metastases from colorectal cancer.

In reviewing existing medical literature, the panel focused on three important questions:

The effectiveness of RFA versus surgical resection for those tumors that could be surgically removed (resectable).
The usefulness of RFA to treat tumors that could not be surgically removed (unresectable).
RFA approaches (open, laparoscopic, or percutaneous).
Radiofrequency ablation uses metal probes and low frequency electric current to heat and destroy tumor tissue. Radiofrequency also seals small blood vessels to reduce bleeding risk. Because heat is confined to the cancerous tissue, patients don’t feel it and normal liver tissue is protected.

RFA can be performed during an open surgery, laparoscopically, or through the skin percutaneously. During all treatments, good imaging is critical to be able to see the tumor being ablated. CT scans, MRI, or ultrasound can be used during percutaneous RFA, but intraoperative ultrasound is used during an open or laparoscopic operation.

Postablation syndrome occurs in about 30 to 40 percent of patients, usually beginning three days after an RFA procedure and lasting about five days. Patients experience low-grade fever, chills, malaise, achiness, pain, and nausea and vomiting. It is more common when large tumor volumes are treated and is probably due to inflammation as treated tissues die.

Other complications from RFA were relatively low and were more common in open as opposed to percutaneous methods. There were fewer complications among more experienced doctors and in hospitals with more RFA experience.

The Expert Panel included an Appendix to help doctors discuss options with patients to manage liver metastases from colorectal cancer.

Panel members concluded,

There is a compelling need for more research to determine the efficacy and utility of RFA to increase local recurrence-free, progression-free, and disease-free survival as well as overall survival for patients with colorectal hepatic metastases. Clinical trials have established that hepatic resection can improve overall survival for patients with resectable colorectal hepatic metastases.

SOURCE: Wong et al., Journal of Clinical Oncology, Volume 28, Number 3, pages 493-508, January 20, 2010.



Talking to Your Doctor about Liver Mets

Posted: 16 Feb 2010 10:08 AM PST

Written by Kate Murphy.

What should you and your doctor talk about if your colon or rectal cancer has spread to your liver?

Deciding on the best way to manage liver metastases from colorectal cancer isn’t easy. It’s best done with the involvement of multidisciplinary team of doctors and thoughtful discussion with the patient.

In developing the ASCO 2009 Clinical Evidence Review on Radiofrequency Ablation of Hepatic Metastases From Colorectal Cancer, the Expert Panel developed points for patients and physicians to consider during an office visit to learn about treatment options.

In an Appendix to their Evidence Review, the Panel wrote the following for physicians meeting with patients:

Discussion Points Between the Patient and Physician: Hepatic Resection and/or Other Treatment Options (eg, Radiofrequency Ablation) for Hepatic Metastases From Colorectal Cancer

State that the goal of the appointment is to make sure the patient understands all the treatment options and has all the information needed to make a choice. Ask the patient, “What are your goals for this visit?”
Ask the patient how much prognostic information he/she wishes to hear during the discussion and whether he/she prefers to hear risk and benefits estimates conveyed as numbers (eg, 30%) or as words (eg, very small). It is important to understand the patient’s perceptions of risks and benefits and to discuss other patient/family issues that might influence decision making.
Tell the patient that treatment for hepatic metastases from colorectal cancer is often performed in stages and may be ongoing.
Discuss the role chemotherapy may play in determining if and when hepatic resection is recommended and/or if radiofrequency ablation (RFA) or other treatment is considered.
Tell patients with resectable tumors that hepatic resection is recommended and the prognosis is good (5-year survival for 40% of patients and 10-year survival for 20% of patients). There are differences in survival for patients with single versus many tumors and small versus large tumors.
If RFA is considered for unresectable tumors, discuss which method (open, laparoscopic, or percutaneous) is indicated and whether the RFA procedure will be performed alone or at the same time as hepatic resection. Discuss imaging, surgery, anesthesia, hospital stay, and recovery issues. Consider patient preferences.
Any comorbidities and/or patient preferences should be discussed in detail and placed in perspective as to their effect on potential benefit of therapy versus potential risk.
Discuss possible complications.
Tell the patient about the importance of high-quality, up-to-date preprocedural imaging as well as the importance of follow-up computed tomography or magnetic resonance imaging scans according to the recommended schedule after the procedure to determine whether the tumor was completely ablated and to plan for additional treatments as necessary. Explain how the appointments will be scheduled.
Additional potential prognostic and predictive markers should be discussed (eg, carcinoembryonic antigen).
Talk to the patient about colorectal cancer surveillance and the importance of all follow-up appointments, tests, and scans. Encourage the patient to use the American Society of Clinical Oncology Colorectal Cancer Surveillance Flow Sheets to keep track of follow-up appointments.
SOURCE: Wong et al., Journal of Clinical Oncology, Volume 28, Number 3, January 20, 2010.