Surgery is one of the oldest forms of treatment for cancer and offers the greatest chance for diagnosis and cure. Cancer surgery is generally considered complex surgery and studies have shown that hospitals, like City of Hope, that employ surgeons with high volumes and experience in specific operations result in more effective and accurate tumor removal, smaller incisions, shorter recovery times and improved overall patient outcomes.
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Listen in as Dr. Vijay Trisal, medical director of City of Hope's community practice locations and staff surgeon in the Division of Surgical Oncology, discusses how City of Hope's surgical experts often have access to newer approaches and/or clinical trials to offer patients the best care possible.
Transforming the Future of Cancer Surgery
Featured Speaker:
Vijay Trisal, M.D.
Vijay Trisal, M.D., is a surgical oncology expert in the field of skin and breast cancers. His research interests are focused on the patients with malignant melanoma, as well as the study of novel genes that may help in early detection and treatment of melanoma and the use of isolated limb infusion delivering high dose chemotherapy to treat locally recurrent disease. He is a member of the National Comprehensive Cancer Network committee that helps formulate guidelines for the treatment of melanoma both nationally and internationally. Transcription:
Transforming the Future of Cancer Surgery
Melanie Cole (Host): Studies show that cancer patients treated by specialists have better outcomes. City of Hope's Department of Surgery is at the forefront of surgical advances and specializes in the latest minimally invasive and laparoscopic procedures and is a world leader in robotic-assisted techniques. My guest today is Dr. Vijay Trisal. He's an associate clinical professor in the Division of Surgical Oncology and the medical director of Community Practices at City of Hope Medical Foundation. Welcome to the show, Dr. Trisal. Please tell us, what is surgical oncology?
Dr. Vijay Trisal (Guest): Thank you for having me, Melanie. Surgical oncology is an additional layer on top of basic general surgery. As you know, surgeons train in a residency program where they go through five, sometimes even seven years, of doing general surgery where they can do operations on every part of the body. But oncology, having become such a specialized field, not only understanding the surgical aspect but understanding the biology of the disease, how the cells behave, what new medications there are, adds another layer of training on top of the surgery. You have anywhere from two to four years of additional training with where there’s designated ACGME-approved programs in this country, which impart that training for two to four years’ time and mainly focusing on cancer surgery. When fellows come here and they ask about what this additional training does to them, it really concentrates, in my mind, 15 to 20 years of experience in this two to four years’ time, where what you would do and understand, let us say gastric cancer or breast cancer, by doing it yourself and learning, you would get that experience in two to four years’ time. That puts you at a level where you can really discern between the different complexities. So, like I was talking about gastric cancer last week, some gastric cancers are closer to breast cancers. Lung cancers are closer to melanoma, and no two lung cancers may be the same. There may be one lung cancer that is closer to melanoma as compared to another lung cancer. To understand that, this additional training, I think, is very critical.
Melanie: Dr. Trisal, why is it important for patients to see an oncology surgeon for cancer as opposed to a general surgeon?
Dr. Trisal: First of all, I don't think all cancers need to be seen by a surgical oncologist, although there clearly is more evidence, as you are aware of, that in complex cases, if you see a specialist, the outcomes are better. If you have a simple right-sided colon cancer, I don't think there is the huge difference in whether it is seen by a general surgeon or oncologist. But for the complex cases, whether it is esophageal cancer, whether it is pancreatic cancer, whether it is rectal cancer, whether it is a tumor called sarcoma or complex melanoma, the understanding of the disease and how you can tailor an approach to each patient, that additional training is A critical. There is data that has come out by looking at not just centers that have surgical oncologists but high-volume centers. So, pancreatic cancer surgery is complex surgery. If you're not doing a certain number every year, you do not have the understanding of which are the zebras in these, which are the ones where you may need to approach it differently first, where you may need to do chemotherapy first. So surgeons are trained to operate, and that is the first thing that has gotten, as one of my program directors used to say, that if you have a hammer, everything looks like a nail. And if you're a surgeon, you think of "Okay, can I cut this out or not cut this out?" But that approach in oncology is actually harmful sometimes because you may need to do chemotherapy first, you may need to shrink down the tumour and use radiation as one of your other hammers to see whether it comes off of critical structures where you have better chances of getting a negative margin. That understanding, I think, is better in surgical oncology, because of additional training, because of understanding the biology, because of what I think is more important is this interdisciplinary care. That means not only are you seeing the surgical oncologist but that surgical oncologist presents this case in an interdisciplinary setting with a medical oncologist, with the social worker, with the radiation oncologist, with the radiologist, and what you do get is you get 200 years of concentrated experience between the 10 of them that can guide you towards even an incremental better outcome.
Melanie: And what are some of the new cancer fighting medicines and technologies that are used by the specialists at City of Hope?
Dr. Trisal: Oh, we will have to have a half-day session for that. But for, let's say two or three diseases as a part of my passion and where my recent interests are, in melanoma for example, we have a huge deluge of new drugs that have really transformed how melanoma is treated. Ten years back when we looked at melanoma, we had one drug, one medication which was called Interferon, which used to basically be used in patients who had higher risks of recurrence. But what we have done is looked at the molecular targeting of these patients. We've seen that these cells evade the body's immune system. They say that the dumbest cancer cell is smarter than the smart oncologist, and these cancer cells are actually so smart that as soon as your body tries to fight it, it coats itself in a different envelop telling the body's immune system that "oh, it's its own friend, it's not a foe." What the newer drugs have done is they have done one of two things: One is, on one side, they have taken the brakes off of the immune system; that means where there was an order regulation of the immune system. So, if I get a bad cold and I have an allergy to something, that is when your immune system overreacts. But there's a balance in the system; you don't want the immune system to overreact, whereas when you have melanoma, you do want the immune system to overreact. So some of these drugs take the brakes off of the immune system and let our own cancer-fighting cells fight the cancer. Those are drugs like CTLA-4 blockers, which is called Ipilimumab. These are new drugs. The group of drugs that have come are called basically immune mediator drugs. On the other side, what we have also done is accelerated the immune process. So not only are you taking the brakes off of these cars so that it runs faster but you also put your foot on the accelerator. So, some of these drugs which are called PD1 or PD1 ligand blockers—those are called programmed deaths; PD stands for programmed death—what they do is, the cancer cells have this receptor, like an antenna on top that tells the body's immune system not to eat it, in simple words. But what these PD1 ligands do is they block that receptor and basically get this car to race faster so that the immune system can be up regulated. Similarly, let us talk about lung cancer or sarcomas. We are more and more looking at individual biomarkers, what are called targeted therapies or small molecule fighters. What they do is they look at uniqueness in these cancer cells. So, if one cancer cell has an antenna that is dissimilar than your body's own cancer cell, you can just target that. When we used to use chemotherapy, it is like a poison, rampant poison, it goes to the whole body and you think that all cells that are fast-dividing will die from this before the slow-dividing cells die. As you know, cancer cells are fast dividing so you feel that they will be killed first. But with this targeted therapy, they're pretty much honed and on to the cancer cells. So the antennas on top of the cancer cell will be the only one that picks up this molecule, and through a process that is a big cascade of reactions that happens, the cancer cell would die. That is where the focus on, whether that is colon cancer, whether that is breast cancer, whether that is melanoma or that is lung cancer or a prostate cancer, that is where the field is going.
Melanie: Dr. Trisal, in just the last minute or so, why is it so important for patients to come see a specialist at City of Hope?
Dr. Trisal: City of Hope is one of the most remarkable places in this country in the sense that you have a group of 230 physicians that just focus on oncology. There is camaraderie between the physicians that really percolates and translates into better patient care. And I think the focus is really on the patient. You get the group of people who formulate guidelines in this country, so we’re an NCI- designated cancer center, all the guidelines and system guidelines, there is a representative at City of Hope. That really gets the education not only to the group of people that are together but in this multidisciplinary setting you have different disciplines that coordinate with each other very well. You really have to see City of Hope to believe it, even right from the time you enter into the gate, from the person who takes your car to the person who greets you, the focus is really on the patient. When I came from Michigan, I really realized that it's not just another cancer center; it is elevated five notches above anything else I have seen.
Melanie: Thank you so much, Dr. Vijay Trisal. You're listening to City of Hope Radio. For more information, you can go to cityofhope.org. That's cityofhope.org. This is Melanie Cole. Thanks so much for listening. Have a great day.
Transforming the Future of Cancer Surgery
Melanie Cole (Host): Studies show that cancer patients treated by specialists have better outcomes. City of Hope's Department of Surgery is at the forefront of surgical advances and specializes in the latest minimally invasive and laparoscopic procedures and is a world leader in robotic-assisted techniques. My guest today is Dr. Vijay Trisal. He's an associate clinical professor in the Division of Surgical Oncology and the medical director of Community Practices at City of Hope Medical Foundation. Welcome to the show, Dr. Trisal. Please tell us, what is surgical oncology?
Dr. Vijay Trisal (Guest): Thank you for having me, Melanie. Surgical oncology is an additional layer on top of basic general surgery. As you know, surgeons train in a residency program where they go through five, sometimes even seven years, of doing general surgery where they can do operations on every part of the body. But oncology, having become such a specialized field, not only understanding the surgical aspect but understanding the biology of the disease, how the cells behave, what new medications there are, adds another layer of training on top of the surgery. You have anywhere from two to four years of additional training with where there’s designated ACGME-approved programs in this country, which impart that training for two to four years’ time and mainly focusing on cancer surgery. When fellows come here and they ask about what this additional training does to them, it really concentrates, in my mind, 15 to 20 years of experience in this two to four years’ time, where what you would do and understand, let us say gastric cancer or breast cancer, by doing it yourself and learning, you would get that experience in two to four years’ time. That puts you at a level where you can really discern between the different complexities. So, like I was talking about gastric cancer last week, some gastric cancers are closer to breast cancers. Lung cancers are closer to melanoma, and no two lung cancers may be the same. There may be one lung cancer that is closer to melanoma as compared to another lung cancer. To understand that, this additional training, I think, is very critical.
Melanie: Dr. Trisal, why is it important for patients to see an oncology surgeon for cancer as opposed to a general surgeon?
Dr. Trisal: First of all, I don't think all cancers need to be seen by a surgical oncologist, although there clearly is more evidence, as you are aware of, that in complex cases, if you see a specialist, the outcomes are better. If you have a simple right-sided colon cancer, I don't think there is the huge difference in whether it is seen by a general surgeon or oncologist. But for the complex cases, whether it is esophageal cancer, whether it is pancreatic cancer, whether it is rectal cancer, whether it is a tumor called sarcoma or complex melanoma, the understanding of the disease and how you can tailor an approach to each patient, that additional training is A critical. There is data that has come out by looking at not just centers that have surgical oncologists but high-volume centers. So, pancreatic cancer surgery is complex surgery. If you're not doing a certain number every year, you do not have the understanding of which are the zebras in these, which are the ones where you may need to approach it differently first, where you may need to do chemotherapy first. So surgeons are trained to operate, and that is the first thing that has gotten, as one of my program directors used to say, that if you have a hammer, everything looks like a nail. And if you're a surgeon, you think of "Okay, can I cut this out or not cut this out?" But that approach in oncology is actually harmful sometimes because you may need to do chemotherapy first, you may need to shrink down the tumour and use radiation as one of your other hammers to see whether it comes off of critical structures where you have better chances of getting a negative margin. That understanding, I think, is better in surgical oncology, because of additional training, because of understanding the biology, because of what I think is more important is this interdisciplinary care. That means not only are you seeing the surgical oncologist but that surgical oncologist presents this case in an interdisciplinary setting with a medical oncologist, with the social worker, with the radiation oncologist, with the radiologist, and what you do get is you get 200 years of concentrated experience between the 10 of them that can guide you towards even an incremental better outcome.
Melanie: And what are some of the new cancer fighting medicines and technologies that are used by the specialists at City of Hope?
Dr. Trisal: Oh, we will have to have a half-day session for that. But for, let's say two or three diseases as a part of my passion and where my recent interests are, in melanoma for example, we have a huge deluge of new drugs that have really transformed how melanoma is treated. Ten years back when we looked at melanoma, we had one drug, one medication which was called Interferon, which used to basically be used in patients who had higher risks of recurrence. But what we have done is looked at the molecular targeting of these patients. We've seen that these cells evade the body's immune system. They say that the dumbest cancer cell is smarter than the smart oncologist, and these cancer cells are actually so smart that as soon as your body tries to fight it, it coats itself in a different envelop telling the body's immune system that "oh, it's its own friend, it's not a foe." What the newer drugs have done is they have done one of two things: One is, on one side, they have taken the brakes off of the immune system; that means where there was an order regulation of the immune system. So, if I get a bad cold and I have an allergy to something, that is when your immune system overreacts. But there's a balance in the system; you don't want the immune system to overreact, whereas when you have melanoma, you do want the immune system to overreact. So some of these drugs take the brakes off of the immune system and let our own cancer-fighting cells fight the cancer. Those are drugs like CTLA-4 blockers, which is called Ipilimumab. These are new drugs. The group of drugs that have come are called basically immune mediator drugs. On the other side, what we have also done is accelerated the immune process. So not only are you taking the brakes off of these cars so that it runs faster but you also put your foot on the accelerator. So, some of these drugs which are called PD1 or PD1 ligand blockers—those are called programmed deaths; PD stands for programmed death—what they do is, the cancer cells have this receptor, like an antenna on top that tells the body's immune system not to eat it, in simple words. But what these PD1 ligands do is they block that receptor and basically get this car to race faster so that the immune system can be up regulated. Similarly, let us talk about lung cancer or sarcomas. We are more and more looking at individual biomarkers, what are called targeted therapies or small molecule fighters. What they do is they look at uniqueness in these cancer cells. So, if one cancer cell has an antenna that is dissimilar than your body's own cancer cell, you can just target that. When we used to use chemotherapy, it is like a poison, rampant poison, it goes to the whole body and you think that all cells that are fast-dividing will die from this before the slow-dividing cells die. As you know, cancer cells are fast dividing so you feel that they will be killed first. But with this targeted therapy, they're pretty much honed and on to the cancer cells. So the antennas on top of the cancer cell will be the only one that picks up this molecule, and through a process that is a big cascade of reactions that happens, the cancer cell would die. That is where the focus on, whether that is colon cancer, whether that is breast cancer, whether that is melanoma or that is lung cancer or a prostate cancer, that is where the field is going.
Melanie: Dr. Trisal, in just the last minute or so, why is it so important for patients to come see a specialist at City of Hope?
Dr. Trisal: City of Hope is one of the most remarkable places in this country in the sense that you have a group of 230 physicians that just focus on oncology. There is camaraderie between the physicians that really percolates and translates into better patient care. And I think the focus is really on the patient. You get the group of people who formulate guidelines in this country, so we’re an NCI- designated cancer center, all the guidelines and system guidelines, there is a representative at City of Hope. That really gets the education not only to the group of people that are together but in this multidisciplinary setting you have different disciplines that coordinate with each other very well. You really have to see City of Hope to believe it, even right from the time you enter into the gate, from the person who takes your car to the person who greets you, the focus is really on the patient. When I came from Michigan, I really realized that it's not just another cancer center; it is elevated five notches above anything else I have seen.
Melanie: Thank you so much, Dr. Vijay Trisal. You're listening to City of Hope Radio. For more information, you can go to cityofhope.org. That's cityofhope.org. This is Melanie Cole. Thanks so much for listening. Have a great day.