Gaziantep is a small city with a big resume that doesn't quite connect. The arid dusty landscape that makes the sky appear almost beige during the day, the grit that coats everything; hair, clothes, the inside of the nose, the corner of the eyes along with the over 100 degree temperatures are in stark contrast to the slick advertisements. Glossy tourist brochures and state-sponsored websites denote it's fame as one of the oldest continuously inhabited cities in the world, but they don't talk about the dust. Guidebooks gush eloquence over regional cuisine, particularly Baklava but they don't mention block after block of squat, drab, cement apartment buildings that appear Soviet-inspired, with lines of dust covered laundry.
Hot in the city
But it's August, and it has been heating up here in Gaziantep this month, so it may be an unfair assessment. The border with Syria lies just an hour south, and United Nations vehicles cruise the streets at odd intervals. A group of students arrive from George Mason University to assist in humanitarian aid for the Syrian refugee problem which, in some ways, mirrors our own crisis at home.
As the dust cloud which obscured our arrival dissipates, more of this ancient city is revealed; a thoroughly modern tram, tree-lined streets, grassy parks with ample shade and video displays, a brand new mall. Gaziantep has more than one face to show visitors.
A biblical place
Little remains of the ancient biblical city of Antiochia ad Taurum. All of the antiquity has been erased to make space for modern buildings, roads and 21st century life. But not all the charms of Gaziantep have been eradicated; Kale castle, the old bazaar and a section of winding and cobbled streets with storefronts displaying the traditional wares, spices, copper, pistachios still exist. Nights are cool and breezy; young families with strollers enjoy evenings in the park while coffeehouses and open air restaurants host native singers and a relaxing ambiance. It is in a large contrast to the CNN reporters in the lobby of my hotel reporting on the Islamic militants advance on Aleppo, or the crowded hallways of the university hospital.
But I am not here as a tourist, a political journalist or for a humanitarian mission. I bring nothing to Gaziantep; no media crew, no medical or relief supplies. Just a handful of notes about a locally known surgeon and copies of his published work. I am not here to teach, to offer aid or to help. I am here to learn. But this is not Pulitzer prize writing, and this is not the New York Times. I am not a writer but a nurse that writes. It is an important distinction, in a city is teaming with professional journalists, United Nations officials, and a large displaced population.
Dr. Ahmet Feridun Işık , Thoracic Surgery
Dr. Ahmet Işık is a genial, compassionate and kind surgeon from the coastal region of Turkey. During my visit, we meet several of his peers in the hallways of the hospital. They seem surprised that a nurse would travel half-way across the world to speak with this humble surgeon until they are reminded of his recent publications. His affable nature belies the extent of his research achievements. He has managed to do what very few physicians have done; to extend and improve the quality of life of patients with metastatic mesothelioma and other advanced pleural based cancers. His original thirteen patients are a testament to his success, just like the man in his office.
The man in his office is a fit-appearing man in his mid-sixties. His face is tanned and weather-worn, wreathed in a smile and framed with thick graying hair. He is happy to speak with a visitor, and does so in clear, if hesitant English. “I feel good,” he states, 18 months after undergoing HITHOC with Dr. Işık. Equally important, his most recent PET/CT scan shows no recurrence of disease. He has already outlived his prognosis.
Survival measured in months, not years
Pleural Mesothelioma is a cruel and devastating disease with life expectancy measured in months, not years. Most patients already have advanced disease by the time they develop symptoms such as malignant pleural effusions, pleuritic chest pain, loss of appetite/ unintended weight loss and /or chronic cough. There is no five-year survival; the grim prognosis usually carries a six to eight month sentence which is often marked by pain, dwindling strength and shortness of breath.
In the United States, mesothelioma is mainly associated with occupational exposures; in navy shipyards, textile processing and mineral mining. But in rural regions of Turkey, entire communities have been exposed to asbestos through environmental exposures. In these areas, asbestos is a naturally occurring particle in the soil. It contaminates the soil, the surroundings and the very air that residents breathe. This, along with endemic tobacco use contributes to a high incidence of mesothelioma and lung cancers in Turkey.
But Dr. Işık's patients are exceeding the timetables after undergoing an experimental procedure called intra-operative Hyperthermic intrathoracic perfusion chemotherapy (HITHOC). Like it's better known abdominal counterpart, HIPEC, this procedure involves surgically removing cancerous tissue, followed by a high temperature (42 degrees centigrade) lavage of a cancer fighting medication. This heated chemotherapy “bath” kills any of the microscopic cancer cells that can't be seen in the operating room. These are the cells that are often left behind despite doctors' best efforts during traditional surgery. These cells then grow and spread in a process called 'seeding.' With an aggressive cancer like mesothelioma, these seeds spread cancer like wildfire. By the time these cancer seeds have grown large enough to be detected, it is often too late for any further treatments to be effective.
Current treatment regimens are largely ineffective and often palliative in nature. In 2013, Dr. Işık published the study that led to this journey to Gaziantep. In this retrospective study; Dr. Işık compared the outcomes of patients from 2009 - 2011 who underwent HITHOC with patients undergoing the standard treatment (pleural decortication) and palliative treatment (pleurodesis). In a bleak testament to the gravity of the disease, none of the original subjects is alive today. The median survival of the patients in the standard and palliative treatment groups was 6 to 8 months. But, of the original 14 patients in the HITHOC treatment group, all but one demonstrated long-term symptom-free survival, living from 24 to 36 months after the procedure.
Despite the promising preliminary results, Dr. Işık is hesitant to attribute all of the positive results to this experimental treatment. "We need a large prospective study before we can attribute our results to HITHOC.” His current study utilizes retrospective review, which is a lower form of evidence. But, right now, it's the best data he can obtain.
Government bureaucracy stymies research efforts
While Dr. Işık is cautiously optimistic about the effects of HITHOC on his patients, he is much less sanguine about his chances of expanding his research despite the large numbers of eligible patients in southeastern Turkey. Due to Turkish governmental reimbursement regulations, Dr. Işık and his team won't receive any funding for performing experimental treatments on patients in a prospective style study, even if preliminary results show clear benefits over the existing treatments. This means that Dr. Işık will have to find third-party sponsors such as private organizations or pharmaceutical companies to help pay for his research. But even this may prove problematic; since most of his research and that of his predecessors (Dr. David Sugarbaker) have been based on first-generation platinum-based chemotherapy drugs. Unfortunately, there is not much incentive for pharmaceutical companies to support research on older, less expensive medications when even modest results in very limited samples can lead to billions of dollars in sales of newer, more costly medications.
Casualties of War
One of today's patients is a casualty of the on-going Syrian civil war which has brought over 1 million refugees inside Turkey's borders. The patient is a young Syrian girl who was severely injured in an explosion, which she narrowly survived. After spending over four months in the intensive care unit on life support, she developed complications from endotracheal intubation. As her trachea became scarred and stenosed, Dr. Işık placed a endobronchial stent to help keep her airway open. On her follow-up visit today, the chest x-ray shows that the stent has migrated down into the right main bronchus.
She is tearful and afraid as she is being prepped for bronchoscopy. Dr. Işık needs to look in her airways and determine whether the stent can be re-positioned, replaced or removed entirely. He reassures her in a gentle voice before she is sedated for the procedure. She remains tearful but looks relieved to see his familiar face.
The procedure goes well, but the results aren't good. The stent must be removed entirely and the trachea is extensively scarred. It's a long scarred area, which means tracheal resection is not an option. Another stent may buy her some time, but she will eventually need a tracheal transplant, a dangerous and difficult procedure.
Elsewhere in the hospital, we see patients with lung infections, lung cancers and more of the usual fare for a hospital that draws patients from a large surrounding area. Dr. Işık confides that patient- provider communications and relations have been tense since the killing of a thoracic surgery resident a few years ago. The doctors remain wary of unexpected violence from their patients and families and this casts a shadow over Dr. Işık's face and his work. Dr. Işık is surprised to learn that violence against healthcare providers is epidemic in the United States as well. It makes for an interesting conversation.
University of Gaziantep
Dr. Levent Elbeyli is the senior surgeon and chief of thoracic surgery at the University of Gaziantep. The hospital is large with 900 beds, 20 operating rooms and 24 specialty surgical ICU beds. The Department of Thoracic Surgery boasts four staff surgeons including Dr. Işık and four thoracic surgery fellows. They perform on average, 15 to 20 surgeries per week. They treat the full range of thoracic (lung and pleural cancers, esophageal and medistinal) disease and conditions such as empyemas, hydatid cysts as well as a large amount of thoracic trauma and war-related injuries.