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Comment by kogus | Hacker News Reader

This part confuses me:

  Twelve days after he was given the immunotherapy
  drugs, Professor Scolyer had surgery to have
  the bulk of his tumour removed.

If they were able to remove the tumor, was it incurable?

Afterwards, they were able to analyze the tissue in the (now removed) tumor to establish that the immunotherapy drug had performed far above anyone's expectations.

That is fantastic news, but it is not my impression from the article that the drug enabled the removal. So by "incurable" did they mean "only treatable by surgery", or am I missing something?

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> If they were able to remove the tumor, was it incurable?

I think with the glioblastomas, you remove 99% of it, and the 1% of tissue that can't be scalpeled out just regrows the whole thing. But if I'm wrong, then the other possibility is that the 1% metastasizes. Either way.

OK, so is it like this:

BEFORE: We remove 99%, the other 1% metastasizes, you live for six months

AFTER: We remove 99%, this medicine stops the other 1% in its tracks, you live out the course of your life

Solid tumors that can be removed in a big chunk by surgery, are in a sense curable.

The problem is individual cells might fall off and those cells will grow into new tumors in other spots.

Immunotherapy will kill those cells. But if you tried immunotherapy to kill a big chunk of tumor the side effects might kill the patient - think never-ending fever and inflammation.

See you do both, you do surgery to remove the bulk of the tumor, and immunotherapy to vacuum up any lone cells.

That'll still be poor outcomes for brain tumors whose position makes surgery impossible.

If I'm not mistaken, also there are even a few that are just nearly impossible to cut... remember reading an account of one such that dulled a few dozen scalpels. The introduction of some new cutting tool at the time was encouraging.

its more:

BEFORE: we remove 99% by surgery, try and get the rest by radiation. outcome poor.

AFTER: we have proved that the immune system is attacking the tumour, this might remove the need for surgery, or means that they don't need to section as much around the tumour to be successful. Or it means that the brain gets attacked by the immune system.

What's weird about this article (and maybe about its reception on HN, although it does further some popular narratives on this site) is that if you have ever known someone diagnosed with a glioblastoma you will be familiar with some very positive initial results after surgery, followed within a year by recurrence, 2 or three other experimental treatments, and very likely death within 2-3 years. That's the thing that is incurable, and while I hope for the best for the doctor, there's nothing about this article that suggests something substantially different in outcome from the immunotherapy. I would think we would have to wait maybe a year to really see anything outside the prevailing expectations - he was diagnosed in June.

I didn't get the impression that they were pushing the immunotherapy like a miracle cure, just that when the tutor was removed and biopsied they found evidence that it had done something when the traditional belief seems to be that the blood-brain barrier would have render it useless.

"10-fold increase in the immune cells in the tumour, that they were activated against the cancer" seems outside the prevailing expectations.

Cancerous tumours will continue to grow if any cancer cells are left - surgery is usually necessary but won't cure it. Glioblastoma are some of the most aggressive brain tumours on top of that.

Some context is that Profs Scolyer and Long have recently had a lot of success with immunotherapy for melanoma used as a neo-adjuvant - that is, before surgery. Start the patient on immuno asap and then excise so the immune system is triggered to potentially clean up anything that has spread.

Surgery being undertaken doesn’t mean there’s an intent or expectation to cure: this is your point of confusion. Incurable doesn’t mean “we’ll never do anything to try and help”.

1) Some tumors (brain being one example) cause problems due to the space they take up and the pressure they exert on nearby organs. Removing a large part of the tumor stops this happening, until the tumour regrows. This hopefully means that majority of the patient’s remaining life is mostly free of these problems.

2) Debulking can also help with subsequent treatment, as there’s less tumor to have to be treated.

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