principles of surgical oncology · effect of operative volume on morbidity, mortality, and hospital...
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Principles of
Surgical
Oncology
Prof. Riccardo A. Audisio, MD, FRCS
Consultant Surgical Oncologist University of Liverpool - UK
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Although there are many
kinds of cancers, they all
start because of out-of-
control growth of
abnormal cells.
Cancer cells can form a
mass of tissue commonly referred to as a tumour.
Cancer is a disease of the
cell
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Surgical Oncologists deal with
the removal of “tumours”
How?
When? Why?
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Sub-specialities Organ Based
• Thoracic oncologists
• Urological oncologists
• Gynaecologic oncologists
• Breast oncologists
• Orthopaedic oncologists
• GI oncologists
Patient-Type Based
•Paediatric oncologists
•Geriatric oncologists
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New Techniques
• Chemoperfusion: sarcomas
melanomas
liver + Breast? Pancreas?
• Hyperthermia: peritoneal malignancies
• Minimal Access:
laparoscopy/thoracoscopy
NOTES - TEMS
• Nd:YAG Laser: endoscopy
trans-cutaneous
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Areas of interest
• radical removal of cancer
(locoregional)
• cosmetic & functional outcomes
• emergency setting (timing)
• early diagnosis & screening
• staging
• follow-up
• palliation & symptom control
• resection of metastases
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Surgical Oncology
1. Representation of Surgical Oncologists
2. Promoting multidisciplinary approach
3. Providing education & training
4. Promoting clinical & translational
research
5. Facilitating career development
6. Promoting public policy
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Surgical Oncology
BASO was founded in 1973 as a forum for
British surgeons interested in the subject of
malignant disease.
It works closely with affiliated cancer-
specific subspeciality groups, particularly
in respect of cancers of the Breast,
Gastrointestinal Tract, Head & Neck,
Endocrine System and Skin.
It aims to provide a united voice on
relevant professional issues.
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Surgical Oncology
ESSO “was founded in 1981 to advance the art, science and
practice of surgery in the treatment
of cancer”
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National Societies
There are several national
societies of Surgical Oncology
There is no consistent training in
Surgical Oncology
There is no “qualification” in Surgical Oncology (apart from the
Netherlands)
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National Societies
There are several national
societies of Surgical Oncology
There is no consistent training in
Surgical Oncology
There is no “qualification” in Surgical Oncology (apart from the
Netherlands)
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No pan-European Training Programme
in Surgical Oncology and no standard
form of accreditation for Surgical
Oncologists in Europe.
Surgical Oncology is not recognised
as a specialist discipline in most
European countries.
Most European Member states have
their own professional bodies, which
regulate surgical training and
accreditation.
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The European Union of Medical Specialists
(UEMS) and the European Board of Surgery Qualification (EBSQ)
The UEMS was established in 1958 to promote
the free movement of medical specialists
within Europe and to ensure the highest
standards of medical care.
It contains 37 specialist sections, representing
35 countries and includes the European
Board of Surgery (EBS).
EBS runs a number of Specialist Examinations
once or twice per year.
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What you need to do to become
a surgical oncologist ?
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what we were trained for
will soon become obsolete
learn to adapt
learn the method
(not the procedure)
Education
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Miller JD. Effect of surgical experience on results of esophagectomy for
esophageal carcinoma. J Surg Oncol 1997
Oesophagectomy is associated with substantial morbidity/mortality
A retrospective review of oesophagectomies for cancer:
74 pts - 20 surgeons
3 surgeons >6 oesoph’mies/year 42 pts 7% leaks 0% mort.
17 surgeons <6 oesoph’mies/year 32 pts 22% leaks 22% mort.
CONCLUSIONS: Oesophagectomy for cancer should
be performed by experienced oesophageal surgeons
with sufficient volume of procedures to maintain
competence.
Oesophageal cancer
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Swisher SG. Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer. J Thor Cardiov Surg 2000
1994-1996: 13 cancer institutions & 88 community
hospitals/US
complications & hospital stay/charges mortality
were assessed according to:
hospital size (>600 beds vs <600 beds)
cancer institute vs community hospital)
operative volume
CONCLUSIONS: Improved outcomes and decreased
hospital stay where a large number of
oesophagectomies is performed
Oesophageal cancer
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Bokey EL. Factors affecting survival after excision of the rectum for cancer: a multivariate analysis. Dis Colon Rectum1997
709 patients who underwent colorectal surgery 23-year
period
CONCLUSIONS:
survival was poor for those who had postoperative
complications (cardiovascular or respiratory)
&
for those who did not undergo surgery by a colorectal
specialist
The nature of the operation performed had no independent effect on survival
Colorectal cancer
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McArdle CS. Outcome following surgery for colorectal cancer.
Br Med Bull 2002
Audits were undertaken in a single institution between
1974-1979 & 1991-1994
There is evidence to suggest that survival following
surgery for colorectal cancer is improving:
earlier diagnosis? better surgery?
This analysis confirmed that there has been a substantial
improvement in survival following surgery for colorectal
cancer
This improvement was largely due to better surgery
rather than earlier presentation
Colorectal cancer
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Guller U. WJSO 2006
Women treated at low-volume hospitals
have a 3-fold increase in risk of dying of
Breast Ca.
Breast cancer
10-year survival is 8-15% higher in pts treated by
specialised surgeons Gillis CR BMJ 1996
Stefoski MJ. BJ Cancer 2003
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Pancreatic cancer
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Surgical Oncologists are better...
better survival: tailored surgery &
multidisciplinary management
better QoL: cosmetic & functional outcomes
better interaction with patient & relatives:
“breaking bad news”
better understanding of legal & regulatory
issues
better coping with grief & depression
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tissue based treatment
tissue diagnosis
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genetically informed oncology
molecular diagnosis
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pattern of growth & invasiveness
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Impersonal
High toxicity Small benefits
Tissue based treatment
Pathway driven treatment
Personalised
High benefits Low toxicity
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Risk assessment councillor
Diagnostician
Locoregional Treatment Director
Multidisciplinary Team Leader
Survivorship Advocate
Salvage Surgeon
Educator
Surgical Oncologist
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Risk Assessment Councillor
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HRT – alcohol consumption – BMI
physical exercise - pollution
Risk assessment councillor
Family history: BRAC1-BRAC2
Gail model
Claus model
Tyrer-Cuzick
Chemoprevention
220,000 BC mutations in the US
only 5% identified !!!
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200 genes associated with
cancer (18 with BC)
Risk assessment councillor
Genes associated with
metastatic spread
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CHEK2: low-penetrance tumour
suppressor gene in BC
bilateral BC
few family members
CRC
prostate cancer
Risk assessment councillor
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Cancer is a genomic disease
associated with a plethora of gene
mutations resulting in a loss of control
over vital cellular functions:
• driver genes linked to
oncogenesis
• passenger genes are thought to
be irrelevant for cancer development
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Large-scale genomic datasets
(MAXDRIVER) allow integrating
these genomic data to identify
driver genes from aberration
regions of cancer genomes, thus
becoming an important goal of
cancer genome analysis
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Diagnostician
New technologies developed
at a high pace:
• imaging techniques
• methylation & microRNA biomarkers
• microfluidic chip based analysis
• LOC (lab-on-a-chip)
• liquid biopsy
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Liquid biopsy
Circulating tumour DNA (ctDNA) as a
biomarker for:
•monitoring treatment response
•disease progression in patients with
metastatic disease
breast – ovarian – prostate – lung -
pancreatic cancer
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Locoregional treatment director
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Locoregional treatment director
MDT
Pathologist
Radiologist
Radiation oncologist
Medical oncologist & all other relevant
specialists
I. Patient
new
complaint
II. GP or
screening
Initia
l refe
rral
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personalised treatment
=
biologically targeted
multimodal management
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Neoadjuvant treatment
Intraoperative RT
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Neo-adjuvant CT Targeted surgery
Cyberknife
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Terminator
Orchestrator
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Patients have a right to say
(with a very powerful voice)
Survivorship advocate
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side effects – lymphoedema
side effects of CT & RT
palliation – terminal care
carers – family – children
follow-up (personalised on
genomics?)
depression – ostheoporosis
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non responders to CT/RT
M+: brain
liver
lungs
skeletal
local recurrence: breast/axilla
chest cage
axilla
pelvis
bone/soft tissue
Salvage surgery
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Surgical Oncologists are better...
•better survival: tailored surgery &
multidisciplinary management
•better QoL: cosmetic & functional
outcomes
•better interaction with patient & relatives:
“breaking bad news”
•better understanding of legal &
regulatory issues
•better coping with grief & depression
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… and the future is…
• Regenerating tissues and organs
•New ways of visualising tissues
(fluorescence)
• From minimally-invasive to non-invasive
•Nanotech for direct surgical interaction
• Patient-oriented & patient-driven surgery
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surgery
cancer
aging
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Surgery for older
cancer patients !!!
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Surgery is NOT finger
gymnastics
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Multidisciplinarity
Pre-operative care
neoadjuvant – PET – stenting –
nutrition - assessment &
preabilitation
No bowel preparation
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Per-operative care
anaesthetic care
fluid balance
minimal blood los
function-sparing surgery
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Post-operative care
enhanced recovery
nutritional support (fluids)
delirium
prompt mobilisation
early discharge
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Targets ???
Prolong survival
Quality of Life
Preserved functionality
Return to normal life
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Patient’s aims
Communication free/informed choice
misinformation & misconception may:
•limit treatment options
•impact on survival
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Consent
Surgical Procedure...
Possible risks…
Intended benefits…
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Functional status
Comorbidity
Cognitive status
Depression Nutrition
Polypharmacy
Socio-economics issues
Geriatric syndromes
DOMAINS ASSESSMENT SCALE
Geriatric Multidimensional Assessment Tool
PS, ADL, IADL
CIRS,
Charlson Comorbity scale
MMS
GDS
MNA
Multifarmacoterapia
Living conditions, Caregiver,
Income, access to trasportation Demenza, Delirium, Depression,
I Level
Total Clinician’Time:
30¹- 40¹
II Level
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Frailty Assessment
Lengthy procedure
“new tool”
Lack of a unique tool
Unproven advantages
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Definition of frailty is crucial in:
Designing Clinical Studies/Trials
Consenting patient
Individualising treatment
Predicting outcome
Comparing series
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“”real world” prospective
registry (fase IV trial)
preoperative assessment
surgery
1 – 3 – 12 months
outcomes
correlation with preop assessment
improved assessment
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EORTC & ESSO supportive
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Cancer
Registries
Plea for original research
Clinical input
EURECCA
Networking
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Geographical Variations 1995-2005 Stage I-II
NO surgery
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Geographical Variations
NO axillary surgery
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Geographical Variations
relative survival
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NO surgery
Less surgery in the Netherland over the
last 15 years
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NO surgery
More PET in the Netherland over the
last 15 years
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NO surgery
No decreased overall- and relative-
survival
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Avoid the emergency setting
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Pre-abilitation:
Neo-adjuvant CT/RT
Anaemia
Salts & fluid balance
Malnourishment
Depression
Physiotherapy
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Enhance awareness
National BC Campaign >70
2014 enhanced awareness 82%
BC recalled 39% pre – 57% post
symptom awareness 19% to 26%
67% increase in breast referrals
25% increase in BC diagnosis
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What is right for Y pts might not be appropriate for E pts
Cancer Registry Data: 1,508pt >75yrs
Rutten HJT. Lancet Onc 2008
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geriatric patients ARE different
cognitive impairment 50%
incontinence 47%
need help with feeding 49%
need major help with transfer 44%
delirium 27%
major depression 24%
delusions 8%
agitated/aggressive 9%
BMJ 2012;344:12
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Many thanks for assisting your
surgeons appreciating
the specific needs of
older patients