Sprinting towards better outcomes for rare cancers

"The first thing that you need to do is convince people of the need for a comprehensive peritoneal disease centre, just as you have done here," said eminent peritoneal disease expert, Professor Beate Rau, Head of Special Surgical Oncology, Charite Medical University of Berlin at the keynote lecture at the first SingHealth Peritoneal Surface Oncology Conference held in August.

Professor Rau was referring to the Department of Sarcoma, Peritoneal and Rare Tumours or SPRinT in the Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre Singapore (NCCS),  headed by Associate Professor Claramae Chia.  SPRinT is a one-stop centre for sarcoma, peritoneal, melanoma and rare tumours, significantly changing how these rare diseases are managed to improve patient outcomes.

 

Up until a decade ago, peritoneal surface malignancies were considered rare and had poor prognoses. Since then understanding of the origin and incidence of the disease had improved significantly. We now know that the majority of peritoneal surface malignancies arise from tumours in the abdomen, ovaries and liver, and not just from the peritoneum. Continuous innovation in treatment and management has meant that these patients now live longer with better quality of life.

 

In 2019, SPRinT was formed as a dedicated surgical oncology service to manage peritoneal carcinomatosis, soft tissue sarcoma, melanoma and rare tumours at varying stages of disease, regardless of tumour origin. In most hospitals worldwide, treatment for these cancers are organ-centric with complex surgeries performed in low volumes by surgeons in different subspecialties. Because of this there is often a lack of standardised care and there is a risk of either under or over treating patients.

SPRinT seeks to address these gaps by managing a relatively high volume of an average of 600 cases a year with outcomes comparable to other high-volume centres around the world. Surgeons lead the team and collaborate with a multidisciplinary team of oncologists, radiologists, scientists and nurses. The SPRinT team performs an average of 50 cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) procedures each year and have completed more than 65 pressurised intraperitoneal aerosolised chemotherapy (PIPAC) procedures in the past 18 months.

 

Research is key to improving patient outcomes and is crucial to SPRinT's mission. Headed by SPRinT Senior Consultant, Assistant Professor Johnny Ong, the Laboratory of Applied Human Genetics at NCCS found that ascites, the excess fluid build-up in the abdomen of peritoneal disease patients, could be made an inhospitable environment for cancer and inhibit its growth. By interrogating the proteins in ascites, the team identified PAI-1 (plasminogen activator inhibitor 1), a key paracrine factor, to be a reliable marker of response to direct inhibition and curb cancer cell proliferation.

The team published the results of their paradigm shifting study in Cell Reports Medicine earlier this year and filed a patent that is recognised in Singapore, the United States, Europe and China. Working with partners, and collaborators in Singapore and internationally to exploit this discovery, they are now conducting studies and developing therapeutics to treat peritoneal and various other cancers in the future.

The SPRinT team is also studying current treatment modalities and their effect on patients' quality of life. One study followed 150 patients who had undergone CRS and HIPEC at NCCS from 2012 to 2017 and found that certain aspects of quality of life had improved, especially emotional functioning. A separate study of peritoneal metastasis patients who had undergone PIPAC showed the procedure reduced symptoms and also improved quality of life. The findings also showed that these treatments do not adversely impact patients' quality of life, something that clinicians carefully consider when recommending and planning treatment for each patient.

 

 

Building on its forward momentum, SPRinT organised the inaugural SingHealth Peritoneal Surface Oncology Conference, a hybrid event held in August 2022. The meeting marked the first collaborative effort between SingHealth, the Peritoneal Surface Oncology Group International and the European Society of Surgical Oncology. A total of 141 local and overseas delegates, 10 chairpersons and 10 distinguished speakers participated.

"To continue pushing the boundaries of clinical care, we must keep up to date with the latest studies, treatment modalities and expert recommendations on how to deal with the debilitating disease," said Assoc Prof Chia, who was also one of the Conference Chairpersons.

Experts at the Conference included Professor Paul Sugarbaker, Director of the Program in Peritoneal Surface Malignancy, Washington Cancer Institute, widely known as the father of the HIPEC procedure. During his key plenary lecture at the Conference, he shared that HIPEC, the procedure he pioneered, needed updating. He challenged attendees to innovate how chemotherapy is delivered, improve drug selection and continue to find ways to improve outcomes for patients with peritoneal disease.

It is in this spirit of fearlessness and putting patients first that SPRinT continues to race ahead to find better ways of treating this group of rare cancers.