An Emerging Discipline

Interventional oncology is poised to advance cancer treatment options for hospitals.

As the second leading killer in the United States, cancer obviously commands the attention of the entire medical community. Nearly 1.5 million patients will be diagnosed with cancer this year alone, with the dis-ease claiming approximately 560,000 American lives. To beat these grim odds, cancer patients rely on a multidisciplinary team of physicians. Interven-tional radiology has long been an active part of this team, and under its umbrella, an emerging field known as interventional oncology is beginning to take a larger role in the effort to treat cancer.

Interventional oncology moves beyond traditional oncology treatments, such as systemic chemotherapy and radiation treatments. Often, interventional oncologists—a term increasingly used to describe interventional radiologists who specialize in oncology—treat patients who cannot sustain further chemotherapy or radiation. “Interventional oncology is exciting because it is directed therapy to patients‘ tumors, it’s less invasive, and the recovery time is faster,” said Sean Tutton, MD, FSIR, an interventional oncologist and associate professor at the Medical College of Wisconsin, Milwaukee. “It offers opportunities for patients who have run out of options.”

Overall costs associated with cancer accounted for an estimated $206.3 billion last year. With such high demand, providing high-quality treatment for cancer patients has become a highly competitive area for the nation’s hospitals. “They have to distinguish themselves as a place where cancer is treated and treated well,” Tutton said. “Interventional oncology gives the opportunity to distinguish a hospital as unique relative to its competitors in the market, and it also allows for the opportunity to bring new patients into the system.”

Exciting Advances

For most of the nation’s larger institutions, the groundwork for interventional oncology is already laid in their existing interventional radiology programs. “If you have an interventional lab, the capital expense is not huge,” Tutton said. Most of the equipment needed, such as CT units, is already in place, although hospitals may need to upgrade to state-of-the-art ultrasound systems and ablation units in some cases.

Because large academic institutions already have the equipment, investing in an interventional oncology program often makes sense. Smaller hospitals may not have access to the same resources, and, in some cases, it could be futile to compete with larger local institutions. “It may be more reasonable to ally yourself with one of those big cancer centers, if it’s feasible,” Tutton said.

However, some smaller hospitals successfully offer these services to their communities. For example, Charles Nutting, DO, FSIR, performs interventional oncology procedures at the Swedish Medical Center, Denver, and Skyridge Medical Center, Lone Tree, Colo—both 200- to 300-bed hospitals. “I think even smaller institutions can treat a large number of patients if there’s infrastructure to support the physician as well as the drive to bring patients in,” he said. “One of my specialties is radioembolization. Even as a little 200-bed hospital, we did the most cases in the whole United States last year with this type of procedure.”

Interventional oncology builds on many of the therapies used in interventional radiology, such as embolization, which has long been used to stop the bleeding in inoperable tumors, for example. “Now we’re using embolization therapy to actually treat the tumors,” Tutton said. “One of the treatments that we use is called transarterial chemoembolization (TACE), which is frequently used to treat patients who have a primary liver tumor, or have metastatic disease to the liver from

colorectal cancer, breast cancer, or other cancers commonly known to go to the liver.” TACE combines embolization technology with direct chemo delivery to these tumors.

“One of the other mainstays of interventional oncology is ablation therapy,” Tutton adds. With radiofrequency ablation or cryoablation, interventional oncologists target tumors with heat or extreme cold.

Most treatments are performed in conjunction with traditional methods, such as systemic chemotherapy, but there are also advances unique to interventional oncology. “There are new and improved burning techniques that can be performed using CT or ultrasound guidance,” Nutting said. “There are new drug-delivery systems that can be administered angiographically.”

One of the main benefits for both hospitals and patients is that the majority of these procedures can be performed on an outpatient basis. “In most of what we do, the patients go home, usually within a couple of hours, but almost all the time within 23 hours,” Nutting said.

Clinical Care

While most interventional oncology procedures fall under the purview of hospital radiology departments, the scope of these treatments is much different from traditional diagnostic radiology. Interventional oncologists admit patients, consult with patients in the clinic, provide the treatment, and conduct follow-up appointments.

“We are much closer to surgery at every level than we are to radiology,” said Jeff Geschwind, MD, associate professor of radiology, surgery, and oncology, and director of vascular and interventional radiology at Johns Hopkins University School of Medicine, Baltimore. “The thing that keeps us within radiology is the fact that we use image guidance to do our procedures.”

Most interventional radiology departments already have the equipment in place to support an interventional oncology program—but the main investment for hospitals is personnel. “You have to provide cohesive, coordinated care,” Tutton said. “A hospital has to approach it in a programmatic way.”

This means hiring receptionists to coordinate scheduling and administrative tasks as well as knowledgeable nurses, nurse practitioners, and physician assistants, who can provide the support that allows the interventional oncologist to focus on delivering high-quality patient care. “In order to provide interventional oncology services, you actually have to function as a clinical entity, so just doing the procedures is not enough,” Tutton said. “The most expensive part of this whole undertaking is devoting the human resources.”

Johns Hopkins uses funding from clinical trials as well as from professional fees to help pay for the needed personnel, according to Geschwind. For academic institutions, clinical research is an attractive option that can ultimately improve revenue, but it also means an additional personnel expense. “If you are involved in clinical trials, you need research nurses who can handle the enormous bureaucracy that has now become the norm for running any kind of clinical trial,” Geschwind said.

While personnel costs can be steep, favorable reimbursement rates can make the investment worthwhile, and being on the cutting edge of cancer therapy can attract more research opportunities to an institution as well. “The investment that a hospital and a group needs to make is significant,” Tutton said. “But fortunately, the reimbursements are reasonable, and I think hospitals find it financially favorable to offer interventional oncology services.”

Reputation Building

Although interventional oncology is a growing field, gaining the acceptance of the medical community is no easy task. Convincing clinical oncologists and other specialists of the value of these services—which may overlap with their own expertise—requires constant communication with these disciplines to present hard evidence of the procedures’ worth.

“You need a dedicated interventional radiologist and staff, who are willing to give the extra effort to build a program,” Nutting said. “You have to go out and build it.”

The first step is gaining recognition within one’s own facility. Already, interventional oncologists have regular meetings with oncology and work very closely with other disciplines, but they must take additional steps to prove their value. “The tumor boards have really become an important vehicle for communication between physicians,” Geschwind said. “So, the interventional radiologists need to attend those.”

In addition to hard clinical data, it is also crucial to provide hard numbers showing the increased revenue these procedures provide for hospitals so that the program secures the funding it needs. “You need to explain to the hospital that there’s a direct link between a single procedural patient you capture and revenue to the hospital,” Geschwind said.

By constantly bringing this information to the hospital’s attention, Geschwind said he is starting to see more investment in interventional oncology services at Johns Hopkins. “We bring an enormous amount of money to the hospital, and they are finally understanding that they need to provide us with the support that they provide to other clinical groups,” he said.

Just as radiation oncology has become a separate entity at Johns Hopkins, Geschwind hopes to develop an independent interventional oncology center at Johns Hopkins. But for the time being, the services remain part of the interventional radiology program. “The problem in academic medicine in general is that it’s not that easy to have people cross departments,” Geschwind said. By encouraging recognition of the field, he hopes the transition will become easier.

It is also important to reach out to the greater community. Many interventional oncologists give national lectures or local talks to educate referring physicians about the benefits of the specialty. “With most of the cancers that people develop, we have a role in either improving their pain, so palliation, or improving their survival,” Tutton said.

Because cancer treatment is an interdisciplinary undertaking, interventional oncologists must build support from their clinical peers in order to be accepted. “If they accept what we do and they consider us as peers, then I think the future is bright,” Geschwind said.

Next Steps

As cancer awareness and the demand for cutting-edge care continue to increase, hospitals will likely invest more resources in providing cancer treatment. “It’s a disease that has the attention of the entire world,” Geschwind said.

Naturally, curiosity about the benefits of interventional oncology is also on the rise. Nutting has already experienced increased interest from patients themselves, who often find his services through the Internet. “I get a fair number of patients just from the Internet alone,” he said. “They tend to surf the Internet to become as educated as possible and will seek out the physicians who are providing these services.”

Advances in technology will continue to make interventional oncology an exciting field—and an attractive option for hospitals looking to expand their cancer-treatment offerings. “The next generation is going to be doing immunologic or biologic active therapies—injecting agents that turn the body’s immune system against the tumor, or that turn off the tumor’s ability to replicate to stop the tumor from growing,” said Tutton, noting that nanotechnology advances also may have exciting implications for interventional oncology.

Although most interventional oncology efforts are housed within interventional radiology programs, Geschwind believes that interventional oncology will eventually become an independent field. “The future of interventional radiology is oncology,” he said.

Ann H. Carlson is a contributing writer for Axis Imaging News. For more information, contact