raig daniels
Wow, I sound like a douchebag. My high school self would punch me in the face just for using the word "aforementioned" — let alone using it alongside Metallica. I'm sure Kaiser will do me the honor next time we meet. First word that popped into my head. I'm sticking with it.
Before treatment started, I met with my oncologist to review bloodwork and the treatment plan. Here's where things stand.
Liver Enzymes
My liver enzymes are still elevated but showing a mixed trend:| Marker | Feb 10 | Mar 10 | Trend |
|---|---|---|---|
| AST | 47 | 52 | ↑ slight |
| ALT | 125 | 116 | ↓ |
| GGT | 118 | 143 | ↑ |
| ALP | 209 | 190 | ↓ |
ALT and ALP — two of the more clinically significant markers here — are both moving in the right direction. AST is essentially flat. GGT is up, which isn't good, but the overall picture is a mixed stress pattern rather than a clear deterioration.
Inflammation
CRP dropped from 3.10 to 2.81 mg/dL. Elevated, but trending slightly down.What We Discussed
Imaging: The next scan is scheduled after treatment cycle 8.PCI score: I asked whether a Peritoneal Cancer Index score had been calculated from my previous imaging. She didn't give a number, and that's actually the correct answer — PCI from imaging alone is unreliable. The most accurate way to determine PCI is through diagnostic laparoscopy: a minimally invasive surgical procedure in which a camera is inserted into the abdomen to directly assess the extent of disease. That's the standard.
For context, PCI is the primary metric surgeons use to determine whether CRS surgery is feasible. High-volume centers vary their cutoffs depending on the cancer type and their own outcome data — there's no single universal number. My PCI will be a critical decision point.
Will chemo eliminate the cancer entirely? I asked directly. The answer: possible, but very unlikely. I expected this — the research supports it. Surgery remains the primary path forward if I'm a candidate.
Medical records: My oncologist has requested a CD of all prior imaging (MRI, PET, CT scans) so I can share them with other surgical centers I'm evaluating. I still need to track down a CD reader.
Champalimaud surgical history: I asked for data on the number of CRS procedures performed here. She's scheduling a meeting with the head surgeon to answer that directly.
What Is Diagnostic Laparoscopy
Since this procedure is likely in my near future, here's what it involves:1. General anesthesia
2. A small incision (~1 cm) near the belly button
3. CO₂ gas inflates the abdomen to create visibility
4. A camera (laparoscope) is inserted
5. 1–3 additional small ports may be placed as needed
6. The surgeon visually inspects all abdominal regions
7. Biopsies may be taken
Typical duration is 30–60 minutes. Most patients go home the same day or after one overnight stay. Recovery is generally 2–5 days of mild soreness.
Evaluating Surgical Centers
CRS surgery outcomes are heavily volume-dependent. The difference between a low-volume and high-volume center can be the difference between incomplete cytoreduction — which significantly worsens prognosis — and a successful surgery. I'm currently identifying centers to evaluate. None has been vetted yet; this is the candidate list.The five questions every center needs to answer:
1. How many CRS procedures do you perform per year?
2. What is your CC-0 cytoreduction rate?
3. What PCI cutoff do you use for colorectal cancer?
4. What are your major complications and 30-day mortality rates?
5. What long-term survival outcomes have your patients achieved?
If those answers hold up, the conversation goes deeper. These next questions are where you separate a center that performs CRS from one that has genuinely mastered it. Volume matters, but so does case mix, surgical judgment, and honest tracking of outcomes. A center that can't answer these questions — or deflects — is telling you something.
If the first five pass, ask these:
- How many CRS procedures have you personally performed in your career?
- What percentage of your cases are colorectal peritoneal metastases specifically?
- What is your CC-0 cytoreduction rate for colorectal cases?
- How do you determine preoperatively whether CC-0 is achievable?
- How do you evaluate small bowel involvement?
- What is your 30-day mortality rate?
- What is your major complication rate (Clavien-Dindo Grade III or higher)?
- What are the average ICU and total hospital stay lengths?
- What is your median survival for colorectal CRS patients?
- What 5-year survival rates have you observed?
Red flags in any answer:
- "Almost everyone is a candidate."
- No tracked survival statistics
- Vague or evasive answers on PCI or CC-0
Europe — CRS-HIPEC Centers
Institut Gustave Roussy — Villejuif (Paris), France- One of the largest peritoneal cancer programs in Europe
- Surgeons involved in development of modern CRS-HIPEC protocols
- Extensive experience treating colorectal peritoneal metastases
Netherlands Cancer Institute (NKI-AVL) — Amsterdam, Netherlands
- Major European referral center for peritoneal metastases
- Longstanding colorectal CRS-HIPEC surgical program
UZ Leuven — Leuven, Belgium
- Strong surgical oncology program
- Multidisciplinary treatment of peritoneal surface malignancies
Charité – Universitätsmedizin Berlin — Berlin, Germany
- Large academic medical center
- Advanced surgical oncology programs including peritoneal malignancies
United States — CRS-HIPEC Centers
MD Anderson Cancer Center — Houston, Texas- One of the highest-volume peritoneal malignancy programs globally
- Extensive experience performing CRS-HIPEC for colorectal cancer
Memorial Sloan Kettering Cancer Center — New York, New York
- Major surgical oncology program
- Strong expertise in colorectal cancer and peritoneal metastases
UPMC Hillman Cancer Center — Pittsburgh, Pennsylvania
- Longstanding CRS-HIPEC program
- Historically influential in peritoneal surface oncology research
Wake Forest Baptist — Winston-Salem, North Carolina
- Major CRS-HIPEC referral center in the United States
- Experienced multidisciplinary surgical oncology team
Moffitt Cancer Center — Tampa, Florida
- Dedicated CRS-HIPEC surgical program
- High-volume NCI-designated comprehensive cancer center
Johns Hopkins Sidney Kimmel — Baltimore, Maryland
- Specialized peritoneal surface malignancy program
- Strong integration of surgical oncology and research
Mayo Clinic — Rochester, Minnesota
- Major tertiary referral center with complex surgical oncology expertise
- Multidisciplinary management of peritoneal malignancies including HIPEC
More to come after the surgeon meeting at Champalimaud and as I work through the evaluation process.