nanoknife IRE for pancreatic cancer

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RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Sun Aug 19, 2018 07:17 PM

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Liver Metastases
Embolization vs Ablation

Dear Caseyzson,
          You asked whether chemo-embolization or direct ablation is the better means to manage liver metastases.  Here are the studies you referenced: " target="_blank" rel="nofollow"> " target="_blank" rel="nofollow"> " target="_blank" rel="nofollow"> /pubmed/29221632 " target="_blank" rel="nofollow"> " target="_blank" rel="nofollow"> " target="_blank" rel="nofollow"> /pubmed/21975434 " target="_blank" rel="nofollow"> " target="_blank" rel="nofollow"> " target="_blank" rel="nofollow"> /pubmed/28099930
          Regarding the 3 abstracts you cite, the two German reports come from some of the same researchers, dated 2011 (small group n=32) and 2018 (large group n=112).  The reports even use the same sentence structure.  They report Response Rates of 9.4% and 11.6%, respectively, in the liver tumors, while the patients are receiving chemo-embolization and also likely receiving systemic chemotherapy.
          In the small 2017 Chinese study (n=27) a 55.6% response rate is claimed.  However, a third (9) of the patients were pancreatic NET victims, not adenocarcinoma victims.  NET’s patients survive much longer (witness Steve Jobs and Aretha Franklin).  In the Chinese research Overall Survival was 50 months for pancreatic NET patients, and 9 months for adenocarcinoma.
          The Response Rate is the key here.  For the liver metastases the Response Rate was perhaps 9-56% from the best chemo-embolization practitioners, but the Response Rate is 100% for the best IRE practitioners (and some other ablation systems).
          Embolization is very difficult to achieve, since there are often multiple blood supplies to a given tumor.  It takes a lot of work to close them without damaging other healthy organ tissue.
          In the Chinese study for example “the 27 patients underwent TACE for a total of 52 times (1–7 times each), including eight treatments with drug-eluting beads (DEB) and 44 treatments with iodinated oil.”  That’s a lot of intrusion, a lot of work and modest results.
          Embolization MIGHT have a role for very weak patients.  But, if the patient is strong and the metastases are few, then true ablation is preferable.  And, of course, make sure that systemic chemotherapy will continue without delay, since micrometastases are likely present at many sites.
          You should be commended for your tireless pursuit of the best treatment for your mother.  Other pancreatic victims would love to have such a committed and imaginative Care Manager.
          Now, you know more about how to approach published research with skepticism.
          This is the type of hard work you need to do – Or you could spend more time studying
          Keep going back to EndPC, where new items are regularly added.  And, do not neglect the possible role of bacteria in pancreatic cancer.

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Wed Aug 22, 2018 05:08 PM

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NCCN 2.2018 Guidelines & New IRE Trial
How to Study the Guidelines, and Trial Features

          First, a new IRE trial is available at Holy Name Medical Center, Teaneck, New Jersey.  Enrollment will be limited to 30 participants suffering from unresectable Locally Advanced disease.  Metastatic patients are not eligible.
          It appears that the electrodes will be positioned during laparotomy, rather than during open surgery or percutaneous procedure.  Clinical trial details are available here:

          In addition, the new 2.2018 NCCN guidelines are now available, released in July 2018.  They contain several noteworthy changes:
>> All of the text beginning on Page 44, and continuing for 100 pages, has been revised.
>> Genetic testing and counseling are encouraged as part of the oncologist’s workup.
>> Neoadjuvant chemotherapy is now an option for those “high-risk patients” who are eligible for immediate surgical resection.  This recognizes the new Neoadjuvant-First vs Surgery-First debate.
>> Radiation (SBRT) has been added as an option for locally advanced disease, if the primary site (pancreas) is the sole site of disease progression.
>> Irreversible Electroporation (IRE) has been addressed for the second year.  Refer to the Footnote for more on NCCN’s IRE opinion.
          The new NCCN guidelines can be downloaded here:

How to Use the NCCN Guidelines
          NCCN guidelines are used by medical oncologists to make treatment decisions.  However, more than half of all treating physicians ignore these guidelines.  Read about the detrimental consequences to patients here:
          These guidelines (link above) will allow you to determine whether your physician is applying the best available therapy.  It takes a few days of real work to study them, but they reduce suffering in the long run.
          Every care manager MUST study the document carefully (and study the last two years of posts on this website).
          The following is a list of NCCN features by page number.  You should study the guide in the following order:
> Pg-4: The new Evidence Block system.
> Pg-43: The ranking of chemo regimens using Evidence Blocks.  Focus on the far-left column: Efficacy.
> Pg-47: Staging code.  Coding to this detail should appear in the overall-condition and biopsy reports.
> Pg-48: Discussion of the disease and therapies.  And, note well the Categories of Evidence and Consensus, upper left, Page 48.  Using this code the authors rank the reliability of therapies.  Category-1 is, of course, the best.
> Pg 103: Genetic Syndromes and Risk.
> Pg-104: Indications for Various Therapies.
> Pg-111: References.  Here you will find research leaders AND physicians you may wish to seek for treatment.
> Pg-2: Oncology leaders who authored this guideline.  They are physicians you may wish to consult for treatment.
> Pg-6: Physician decision tree.  With the exception of IRE, your physicians should be following this decision tool.
          Be sure to study my new website EndPC, which offers guidance on all pancreatic cancer topics, including the latest therapy, care management and clinical trials. 
There is also a new Decision Guide, which will help guide you to the proper therapy.  Both are located here:

Footnote.  The NCCN panel irrationally recommends against IRE for locally advanced disease “due to concerns about complications and technical expertise.”
          NCCN bases its absurd recommendation on the 2016 musings of several non-IRE practitioners – statements selectively chosen by freelance writer Susan Jenks.  Those physicians never address IRE’s unique application: The removal of tumors which encase blood vessels and ducts, thus making surgical resection (and cure) possible.
          NCCN’s unfounded concern about “complications” is based on the first 10 IRE patients at the inexperienced Roswell Park Cancer Institute.  In 2016 Roswell’s Steven Hochwald said: “What’s unclear is whether IRE really makes a difference in patient outcomes.” 
          Now, two years and only 15 patients later, a still-inexperienced Roswell Park thinks differently, insisting: “We have had some success in extending survival using IRE.”  Yet, NCCN keeps it irresponsible recommendation.  See the 2018 Roswell statement here:
          And the 2-page 2016 interview which nixed a favorable IRE recommendation is downloadable here:

RE: nanoknife IRE for pancreatic cancer

by Baloo on Sat Sep 08, 2018 05:11 PM

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I'd like to share my story. Unfortunately it's not very good news, so this post probably won't help too many people but  just in case it does I thought I'd post it. I would like to thank those of you who have shared your experiences both positive and negative. Thanks in particular to PhilipJax for his outstanding contributions.

I was diagnosed when I was 57, in the fall of 2016, following a long period of the "usual" symptoms- elevated blood glucose levels a year earlier, strange emotional experiences including panic attacks and depression, weight loss, stomach pain, and back pain near the left kidney. I have always been healthy and active  although overweight- female, at 5'3 and 168 lbs.  I never smoked and rarely drunk alcohol. Initialy I was treated for excess stomach acid and given a proton pump inhibitor drug which did nothing so I discontinued it. Symptoms worsened, the pain was bad, so an ultrasound was scheduled. It detected a tumor in the pancreas and CT, MRI and a biopsy confirmed pancreatic adenocarcinoma in the body/tail,  unresectable, ineligible for radiation, stage 4 with 3 metastases, 2 to the liver and one to the soft tissue in the umbilicus. I was started on Folfiriox at 100% on Feb. of 2017. The mass on the pancreas at its largest was 5.3 x 6.5 cm. I was not able to tolerate Folfirinox at the 100% rate for no more than a few treatments  so the rate was decreased. I lost a lot of weight and at my lowest was 98 pounds. I have been given 70% of the dose (except Leucovorin, 100%) since then and my weight stabilized at around 120 pounds which is a healthy weight.  The tumor did respond partially to the folfirinox, at it's smallest it was 3.3 x 1.5 cm - but it has grown back since then. (The doctors consider the tumor "stable" but that allows for a growth rate of 10% between CT scans.). All the metastases, however, disappeared.

Because the nanoknife procedure is not available in Canada I decided that the only option for me was to go to Germany. I sent my medical information to Dr. Birth, who reviewed the scans and agreed to do the surgery. I discontinued Folfirinox in March of 2018, and had the surgery in early May. By this time I had recovered from the chemo and weighed approximately 125 pounds.  The hospital in Stralsund is excellent and the care I was given was exemplary. The cost of everything including airline tickets was approximately 25,000 Euros. We flew into Hamburg and took the subway and trains- a 3.5 hour trip-  to Stralsund.

Surgery took 3 hours. I was given a spinal anesthetic (not as bad as I'd feared) along with the gas. I had a six inch incision, and no complications whatsoever from the surgery which involved both the nanoknife treatment and the removal of the pancreatic tail. Dr. Birth's recommendations were for further stereotactic radiation. We stayed 2 weeks in Germany- which I'd recommend as the minimum if you are going there. It takes that much time to recover from the surgery. I was told not to lift more than 5 kilos (about 10 pounds) for 3 months following the surgery- you'll need a luggage sherpa- to avoid the possibility of a hernia but there were no other restrictions. A followup CT scan was recommended 3 months after the surgery.

I recovered quite quickly, felt much better and was eating normally. But things went south in a hurry. A couple of weeks before the CT scan on August 13th 2018 my appetite started to lessen and I lost weight. A week later, solid food was not staying down, and very quickly liquids weren't either. I spent a lot of time in emergency getting rehydrated. My weight dropped down to 108 pounds. The CT scan showed the possibility of the tumor pressing on the small bowel, the size was larger than when I'd had the nanoknife surgery, and enlargement of the lymph nodes surrounding it but no other obvious metastases. A few days later I was in surgery again getting an 11 cm stent put in for a complete bowel obstruction. The stent was a life saver and I'm back in the world of the living. I'm still not able to eat normally, but it's improving.

Bloodwork showed an elevated CA-19-9 level of 441- the highest it's ever been. It had dropped to a low of 16 during the Folfirinox treatments before the surgery. What's frightening is the rapid regrowth of the tumor and I am concerned that it will soon close the stent again. I had a round of Folfirinox last week which seems to have helped reduce the pressure in my gut so the quality of my life has improved at least for now.

In hindsight, I would have done things a little differently- I should have pursued the nanoknife treatement when my tumor just started to regrow, shortly after it had reduced in size to 1.5 x 3 cm. but I was mislead by the term "stable" and thought that perhaps it would disappear with just the folfirinox. Also, waiting 3 months after the nanoknife for the next CT scan was too long. I had assumed I would have time to recover from the nanoknife surgery before pursuing sterotactic radiation- I'd have to go back to Germany for that - and possibly That would have saved me from the misery of the blocked bowel, and avoided the necessity for the stent (although I'm sure it would have been needed later, anyway).

At this point I have no more options. Since it's metastasized to the lymph nodes stereotactic radiation is probably pointless- even though gold marker beads were put in by Dr. Birth. I can refuse further folfirinox treatment, suffer from the effects of the cancer, and die quickly, or continue on it and  suffer from the effects of the chemo and die more slowly. Not very palatable.

Here in Canada we do not have the option of changing chemo drugs, and if the second line fails, going back to the first. The protocol is to keep hammering away with one therapy until it fails or there's unacceptable toxicity, then trying the next line of drugs, and so on. I cannot try Gemcitibane/Abraxane and if that fails go back to Folfirinox. There's no way to even pay for it on my own, just to see.If anyone has any advice for me on what to try, (and I've tried all the supplements/ snake oil stuff) I'd love to hear it. I'm not a believer in a "God" who will heal me although I do believe in the placebo effect.

Anyhow I'm lucky to still be standing and still in relatively good health, almost two years after diagnosis. That's much better than what most metastatic pancreatic cancer patients get.

I'm hopeful for a new technology called an iontophoretic device which delivers chemotherapy drugs directly to the tumor rather than intravenously, avoiding the toxicity to other tissues.  But I do not think this will be available in time for me. Inital animal trials using Folfirinox have been promising. As PhilipJax says, try to stay alive for as long as possible, explore all options, do not delay making those decisions-  until the next hopeful treatment comes along!

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Tue Sep 11, 2018 09:20 AM

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PAXG Better in Stage 4 & Stage 3
Cisplatin & Capecitabine Added To Nab-Paclitaxel / Gemcitabine

Dear Baloo,
         Just now I noticed your post. I will take a look and get back to you soon.

         PAXG will be a minor breakthrough, if future Phase 3 trials confirms the following Phase 2 results.

Stage 4 Metastatic.  For metastatic patients Italian researchers report good response to PAXG – the addition of Cisplatin and Capecitabine to the standard Nab-Paclitaxel plus Gemcitabine regimen.
          Their Phase 2 trial NCT01730222 evaluated 83 metastatic chemo-naïve patients, 42 randomized to receive the PAXG regimen and 41 to receive the Nab-Paclitaxel plus Gemcitibine (AG) regimen.  More details in this 2018 report
          The outcome:
1. The Response Rate was 50% in the PAXG group, and 29% in the AG grouip.
2. Median Progression Free Survival was 8.3 months in the PAXG group vs 6.1 months in the AG group, 36% longer.
3. Median Overall Survival was 14.4 months for the PAXG group and 10.7 months for the AB group, 35% longer.
4. The 1-year Overall Survival was 62% for the PAXG group and 44% for the AB group
5. The 2-year Overall Survival was 24% (12–39) for the PAXG group and 12% (2–26) for the AB group.

Stage 3 Locally Advanced.  For Locally Advanced, Borderline-Resectable patients the same researchers evaluated PAXG in Phase 2 trial NCT01730222.
          The trial randomized 54 chemo-naïve patients, 26 to the PAXG arm and 28 to the AG arm.  Details are found in this 2918 report.
          The outcome:
1. The Response Rate was 50% in the PAXG arm vs 36% in the AG arm.
2. Median Progression Free Survival was 12.5 months in the PAXG arm vs 9.9 months in the AG arm.
3. The Median Overall Survival was 20.7 months for the PAXG group vs 19.1 months for the AG group.
4. The 18-month (1.5 year) Survival rate was 69% for the PAXG group vs 54% for the AG group.
5. Regimens had little impact on rate of surgical resection. Eight patients (31%) in the PAXG arm and nine (32%) in the AG arm underwent resection.

Actions.  A patient does NOT have to join a trial to undertake the PAXG regimen – all of the agents are readily available.
          Note that, in the case of Cisplatin, hydration will be necessary.  So, be sure to read this caution on the use of saline.  “Balanced crystalloid fluids” may be preferable.  See
          Commonly, oncologists wait until the close of Phase 3 with its large enrollment size before adopting new chemo regimens like PAGX.  However, current pancreatic patients can’t wait that long.  The PAXG group size wasn’t vast, but it wasn’t small either – good enough for those who cannot wait.

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Wed Sep 12, 2018 03:32 PM

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Canadian Health System, The Limitations

Dear Baloo

Missing information.  There were several things I could not determine from your letter.  I assume the following:
1. That no organ currently has metastases except the lymph system.  That is good news.
2. That you have not undertaken radiation.  If Dr Birth’s work was meticulously thorough, radiation should not have been recommended, because IRE should be used (among other tasks) to achieve excellent surgical margins.  Thus, systemic chemotherapy, not localized (radiation) therapy, should be used thereafter, because there is a multitude of unseen micro-metastases – the bowel tumor being an outcome.  (Radiation itself can cause bowel obstruction)
3. That there was no systemic chemotherapy (neither adjuvant nor maintenance therapy) for months after the IRE / surgery. This was an error by Dr Birth and your home oncologists.

What to do now.  As you note, what you face now is the plight of Canadian socialized medicine (the calamity that Mr Obama wanted for the USA).
          I assume you have studied my Decision Guide, available at
          If you have been tested for Microsatellite Instability (MSI) or for BRCA, that would guide your treatment, MSI being somewhat treatable and BRCA being hindered by Cisplatin and Oxaliplatin.
          Some things you might want to try very swiftly.
1. Option 1.  Seek care at another, independent Canadian institution.  You MIGHT get a different interpretation of the nationally-imposed protocol.  If FOLFIRINOX has stopped working, you might try the PAXG regimen mentioned on this forum page.  If toxicity will release you from a failing FOLFIRINOX, CLAIM the symptoms that will achieve that.
2. Option 2.  During a pause in chemotherapy, move to a USA city which has a major university-linked cancer center, like MD Anderson.  Enter treatment via the emergency room due to a “pain attack,” saying you cannot return to Canada (due to some carefully planned reason).
          University systems have large resources and may arrange a form of time-payment.  And, they are more likely to consider an innovative chemo regimen.
          National laws in the US mandate emergency room plus other care needed to “stabilize” the patient.  But, that may not translate into long-term therapy.  See
          The accursed “sanctuary cities” in the US might be more likely to treat you for little or no cost.  They include New York, Chicago, San Francisco, probably Los Angeles and others – all of which have large cancer centers.  Leading oncologist Margaret Tempero is located at a California university.  The New York policy is explained here
          Or you could try the healthcare system of another “medically liberal” nation.
          The US state of Arizona encourages “Canadian Cross-Border” healthcare, so you might get ideas from the state promotion program.  Mayo Clinic Phoenix (Arizona) is home to Tanios Bekaii-Saab, an oncologist of world stature.
          Unfortunately, Canada and the UK do not have reciprocal health programs.
          There are nongovernmental agencies (like Lutheran Family Services) in major US cities which aid refugees.  They will know how to “game” the system.  Contact them long in advance using your carefully-planned story.
          You might also purchase traveling health insurance.  Some CLAIM to cover pre-existing conditions, and could cover at lease some medical expenses.  Such insurance is frequently used by Canadian Snowbirds wintering in the US.  An example making such claims is the following
          You might stay at a long-term hotel (and research inexpensive rental apartments)
          If you fail, your costs are limited to travel and some hotel expenses, and you can always return to the unworkable Canadian system.
          Since you have nearly accepted cessation of all therapy, then you are willing to pursue all other avenues.  So, these options are possibilities and will take only several days of hard work to investigate.  You can probably think of more options that I.
          I wish I had more imaginative strategies – I have too little knowledge of the Canadian health system.  Let us know what happens.  You are healthy enough to fight this longer.

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Wed Sep 12, 2018 10:06 PM

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US Healthcare for Non-Citizens
Obamacare: Canadians & Others Might Be Eligible

Dear Baloo & Everyone:
          In a previous post on USA healthcare for non-citizens I failed to address the possibility of Obamacare, which MIGHT be acquired in a few months.
          US ACA Affordable Care Act (ObamaCare) claims to ignore preexisting conditions, so existing pancreatic cancer should be covered.
          Further, ACA is available to aliens who possess “nonimmigrant visas” and who are “lawfully present” in the US.
          Recent federal rules may have reduced the number of geographic areas where ACA is reasonably-priced or active.  Nevertheless, this is a strategy that should be considered earnestly.
          Details on how to qualify are here:
          Applications for nonimmigrant visas can be made online at these sites.
          And, frequently asked questions are here.
          Also, this non-government site offers some insights which should be verified at the government sites.
          ObamaCare’s open enrollment period begins in November.  However, there may be exceptions, allowing Special Enrollment at other times.  See
          So, in a few months a non-citizen might be treated in the US.
          It would be prudent to pursue the visa and Obamacare plan, even if you are uncertain whether you will use them.  This is part of the “contingency planning” and the “irons in the fire” which every pancreatic patient must practice at all times.
          Before selecting a specific insurance plan, make sure your preferred US medical institutions will accept it.
          Let us know your experience, so that we know whether this approach is workable.

PS: Tumor infusion devices, like iontophoretic, have been tried before without success. Besides, you need systemic chemotherapy due to hidden micrometastases.

RE: nanoknife IRE for pancreatic cancer

by Caretakerformom on Thu Sep 13, 2018 07:23 PM

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Hi there.  For Stage 4 patients, would this type of treatment be used after Nanoknife or instead of.  I am the caretaker for my mom who was diagnosed with Advanced Adenocarcinoma in April with a 6 cm tumor incolving celiac trunk and sma artery, unresectable.  Scans showed stage 3, biopsy showed 5mm peretonial involvment.  She is seeing Dr. Mark Truty at the Mayo Clinic, however, he doesn't do surgery resections on "stage 4" patients. 

1.  With research I have done she is oglio, correct?

2.  she has had 6 Fulfirinox treatments, couldn't tolerate the last 2, so switched to Gemzar/Abraxane, and she just finished her second treatment. Scans in July showed tumor shrunk from 6.1 to 5.7 with no further Met showing up on Pet.  Was talked about that we should have HIPEC and radiation next with Dr. Truty, however, we have recently learned about the Nanoknife and know someone who is 5 years out from having it. How do we know for sure if we should take the risk and have the surgery when one physician who performs it is saying she's good and she should while other patients with the same disease and tumor type are being told it's too risky and they should have radiation first. 

I don't know where to go next.  I am the caretaker, her life is on the line, and it all falls on ME.  HELP!!!!!!!!!!  I have done hours and days of reserach and keep ending up back at square one. 

RE: nanoknife IRE for pancreatic cancer

by PhilipJax on Fri Sep 14, 2018 09:01 AM

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What Chemotherapy & IRE vs Radiation
A Decision Guide to Sort Things Out & Stop Wasting Time

Dear Care
          This reply will be delayed several days due to its internal weblinks.
          IRE, if performed by a highly skilled practitioner as part of open surgery, will do what radiation hopes to achieve.  But IRE will do it with greater precision and greater likelihood of success (and with fewer Adverse Events).  In addition, early radiation will make IRE more difficult.
          Further, radiation is a focal therapy, and your mother has a systemic disease, so a systemic therapy is needed for now.  So consider delaying radiation.  Read Abstract e16257 here:,6312
          Study my Decision Guide carefully, which will take 2-4 days of hard work.  The outcome will structure your education and put an end to your wheel-spinning.  Download the Guide here:
         You have not described your mother’s physical condition, that is, ECOG status.  Assuming it is 0-1, she can endure a lot, so must tough it out.  Some things to consider:
1. She should be tested for BRCA mutation and Microsatellite Instability.  Mayo is capable of doing that.
2. Press the oncologists to add Cisplatin to Nab-Paclitaxel + Gemcitabine (which will be especially helpful if she is BRCA-ish.  Push hard – you are not making a suggestion but a request.  Download the 2018 PAXG report, to present as part of your argument – after you have studied it thoroughly.  Dr Tanios Bekaii-Saab of Mayo-Phoenix would certainly consider your request.
3. Make inquiries about HIPEC, to the specialists who are most skilled.  You will find that info at the following link.  This assumes she is ECOG 0-1 and well-insured.  See Abstract P-137 here
4. Make initial inquiries to U Louisville and JHopkins about intraoperative IRE (IRE as part of open surgery), explaining your systemic and peritoneal plans, asking whether she would be accepted for surgery upon reduction of primary and peritoneal tumors (this is indeed oligo).
          You will find other guidance in the Guide.
          Finally, get a laptop (or tablet with keyboard), so you can prepare letters that are properly structured with correct format and spelling.  Letters you send to physicians must be readable.
          Act swiftly, and get tough.  Keep us posted.
          And be sure to study my website at

RE: nanoknife IRE for pancreatic cancer

by Baloo on Mon Sep 17, 2018 09:37 PM

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Philipjax, thank you for your detailed reply. I will be able to read this carefully tomorrow and respond properly, there is a lot of information in it. Thanks again.

I do have an appointment/bloodwork on Thursday. If all goes well I will have another Folfirinox treatment on Friday. I'll have a lot of questions for my oncologist.

RE: nanoknife IRE for pancreatic cancer

by Caretakerformom on Tue Sep 18, 2018 12:07 AM

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I'm on it! I have a phone conference tomorrow with Dr. Donoway.  What are your thoughts on him? 

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