Ensuring a Voice for Interventional Oncology in Cancer Care

The team concept of multispecialty disease management for oncology has existed since the 1950s.¹ Charles Dotter first proposed the concept of interventional radiology (IR) in 1963. In the ensuing 60 years, cancer care has become increasingly complex, and the practice of IR has evolved beyond being a room in the basement where procedures or “specials” were performed. Interventional radiologists have pioneered treatments that have transformed into locoregional therapy alternatives to surgery and radiation for patients with cancer. In the United States, IR is now a primary medical specialty where one can enter the residency training pathway directly from medical school to complete a curriculum designed around clinical care, image interpretation, and image-guided intervention. Today, interventional oncology (IO) is considered a subspecialty of IR, dedicated to the diagnosis, treatment, and palliation of cancer and its sequelae, and its practitioners (interventional oncologists) are akin to surgical or radiation oncologists. Thus, many have argued that IO is the fourth pillar of oncology.

In the October 2022 issue of Endovascular Today, three leading interventional oncologists were asked to assess whether IO has established itself as the fourth pillar of oncology and came to consensus that it is an “ongoing process.”² Among the three leaders, a common theme of the need for effective communication of the value of IO stood out—with “written reports alone [being] inadequate,” interventional radiologists who “spoke up” in multidisciplinary conferences, those who got “the word out,” and those who helped add IO therapies into guidelines “moved the field forward.” Recognizing that voice is a key medium for communication, if we are to continue toward the fourth pillar goal of being recognized as an equal partner in cancer care, the IO community must turn its attention to how it can amplify its voice and make the message resonate.

LOCAL ENGAGEMENT

Amplification starts with local engagement. The Commission on Cancer, an accrediting organization, has deemed the use of multidisciplinary tumor boards (MTBs) a quality standard, requiring at least 15% of all new cancer cases at an institution to be presented at MTBs.³ This is also common internationally, as 86% of members of the American Society of Clinical Oncology practicing outside of the United States report access to MTBs at their institutions.⁴ An MTB is a cross-functional team made up of members with differing expertise working toward the common goal of achieving the best outcome for the patient. It is essential for interventional oncologists to be part of the MTB; otherwise, the team is incomplete.

Once on the team, the interventional oncologist must use their voice to bring the benefits and risks of interventional therapies into the discussion. Although it may be difficult and even uncomfortable to navigate the often-hierarchical dynamics of MTBs and it is “not for the faint of heart,”² it nevertheless must be done. It is only through advocacy in the local setting of individual MTBs that we will advance IO therapies from being an afterthought of salvage or palliation to being an equal consideration as a local therapy option. As we enter the era in which the management of oligometastases is taking prominence, we have an opportunity to use the MTB forum to expand our role in the delivery of cancer care by developing locoregional therapies for multiple organ sites and histologies.

NATIONAL REPRESENTATION

Amplification of IO’s voice at the national level requires inclusion and adequate representation. The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of 32 leading cancer centers that develops resources for cancer care delivery, including algorithmic treatment guidelines by cancer type.⁵ There are 62 treatment guidelines: 39 pertaining to solid tumors, 18 to liquid tumors, and five to pediatric cancers. IO is represented on 11 out of 39 solid tumor guidelines; however, only two guidelines (anal carcinoma and hepatobiliary cancers) have more than one interventional oncologist as a member of the panel. Considering the median size of a guidelines panel is 36 members, interventional oncologists are underrepresented. In fact, the entire specialty of IO is represented across the NCCN guidelines by only eight interventional oncologists. Guideline panels for uveal melanoma and extremity sarcoma, which include IO treatments in the cancer care algorithms, function without representation of an interventional oncologist, ostensibly the specialist with the most expertise as to how these treatments should be best applied. One could argue that not only are some NCCN treatment guidelines panels incomplete but their composition should be reexamined to ensure parity in representation. Often, a lone voice may often not be sufficient to challenge conformity.

MESSAGING THAT MATTERS

A clear and concise message is one that cannot be lost in translation. In the oncology world, the common language and most valued form of communication is data. To have IO resonate with a broader group of stakeholders, including other oncology specialties, patients, industry, and the Centers for Medicare & Medicaid Services, we need more data. IO will need to embrace a culture change where research and clinical care are equally valued. This will require investing in the development of a robust research infrastructure and the training of a savvy research pipeline and workforce. Only through the results of basic and translational research along with clinical trials will IO treatments become established as equivalent options for local therapy in cancer.

SUMMARY

Like fingerprints and facial patterns, voices are unique, and IO has one of the more distinctive ones. It’s time we used it.

1. Kesson EM, Allardice GM, George WD, et al. Effects of a multidisciplinary team working on breast cancer survival. BMJ. 2012;344:e2718. doi: 10.1136/bmj.e2718

2. Ganguli S, Brown K, Salem R, et al. Roundtable discussion: has interventional oncology established itself as the fourth pillar of oncology? Endovasc Today. 2022;21:81-85. https://evtoday.com/articles/2022-oct/roundtable-discussion-has-interventional-oncology-established-itself-as-the-fourth-pillar-of-oncology

3. Rocque G, Wheeler S, Williams GR. The missing voice in multidisciplinary tumor boards. J Geriatr Oncol. 2021;12:1157-1158. doi: 10.1016/j.jgo.2021.03.004

4. El Saghir NS, Charara RN, Kreidieh RY, et al. Global practice and efficiency of multi-disciplinary tumor boards: results of an American Society of Clinical Oncology international survey. J Glob Oncol. 2015;1:57-64. doi: 10.1200/JGO.2015.000158

5. National Comprehensive Cancer Network. NCCN guidelines. Accessed November 15, 2022. http://www.nccn.org/guidelines/category_1.