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Where are we going wrong? The story behind unneccessary deaths and suffering Renée Otter, MD, PhD….. Sequences in oncological care Early detection diagnosis staging Treatment A Treatment B rehabilitation Palliative care • Patients’ pathway (journey) Sequences in oncological care Treatment B Early detection diagnosis staging Treatment A Treatment C rehabilitation Palliative care • Patients’ pathway (journey) Sequences in oncological care Treatment B Early detection diagnosis staging Treatment A Re-staging rehabilitation Palliative care • Patients’ pathway (journey) Treatment C Patients’ pathway (journey) Early detection diagnosis staging Treatment A Treatment B rehabilitation Early detection • Reason for this: tackle precursor situations to cancer or cancer in an early stage as « the earlier the cancer is detected, the better survival » Early detection • Not all precursor stages of cancer (dysplasia) lead to cancer • If precursor stages of cancer (dysplasia) lead to cancer, the real lead time is unknown (vary from some years to >20) • overtreatment? Undertreatment! Early detection • Reason for this: tackle precursor situations to cancer or cancer in an early stage as « the earlier the cancer is detected, the better survival » • Individual (PSA) • Organised (screening programme) • Participation depends on a.o. the public awareness of symptoms (and the character of the person), the knowledge of the GPs • knowlegde of how to do the tests (based on what?? • by whom • where to go if ever the results are not « within the norms » • The health system should stimulate participation and knowledge Sequences in oncological care Treatment B Early detection diagnosis staging Treatment A Treatment C rehabilitation Palliative care • Patients’ pathway (journey) Diagnosis and staging • Once screening or symptoms (rare find by chance) • Diagnosis needs: – Knowledge on the 150 different types and subtypes of malignancies: Cancer is NOT 1 disease – physical examination – Radiology (+ nuclear medicine) – Pathology – synthesis : diagnosis AND stage – Stage necessary to plan the right treatments Diagnosis and staging • Where are we going wrong – Knowlegde of the GP to whom to refer – Knowledge of the medical specialist: if not a cancer specialist (but vice versa is true too!!) – Availability of diagnostic equipments ( financial position of a country) AND • trained radiologists!!! • Trained pathologists intra – and intervariabilitypanels – Availablility of dedicated MDT ( different disciplines of medical specialists) – Knowledge and availability of evidence based guidelines and staging classifications (TNM) Diagnosis and staging • Where can we get information? – On delay on diagnosis and staging – On minimal imaging technics for that cancer – On Quality of the radiologist and pathologist?? • Will this information of any help? To whom? • Sensation and loss of confidence for nothing!! thats where we are going wrong. • Second opinion: is it independant?! Sequences in oncological care Treatment B Early detection diagnosis staging Treatment A Treatment C rehabilitation Palliative care • MDT Multidisciplinary teams • Who are they: • Combination of diagnosic and treatment specialists – Trained – Experienced – Integrated • Shares responsabilities in taking decisions concerning treatment plan Multidisciplinary teams • Where are we going wrong? • Trained?!Are there special training programmes, are some specialisations recognised like onco-urologists?! NO EU decisions • Experienced: what does this mean: volume? Outcome? % of complications? What about a small country??what about rare cancers? Variation among EU is huge • Integrated in a dedicated team : requests trust and confidence!!! • How to measure what is right and wrong? Complication rates?? survival?? Patients experiences?? • Financial position of medical specialists in a private versus public sector • Who/ what will & can take the decisions concerning which team is dedicated?! Medical Treatment • Where are we going wrong? – How to measure what is right and wrong? – Are evidence based guidelines always providing the right treatment opportunities for every one?? Individual/personalized medicine??? – Availability of new or expensive drugs? Be careful as drugs only have a small impact on the survival Treatment according to guidelines No « changes » in stage over 10 years • More stage I breast cancer because of the change of TNM classification • Increase in stage I prostate cancer because of PSA • No change in stage in colon cancers; in rectal cancers less stage I & II because of procedures: endo-echo, MRI, Pet scan • More stage IV lung cancer because of PET scan Sequences in oncological care Treatment B Early detection diagnosis staging Treatment A Treatment C rehabilitation Palliative care Supportive care Rehabilitation • Support patients to go back to the society • Huge problem the more patients become (ex) patients increase survivorship • Are there GLs? Trained professionals?? • No impact on survival but on Quality of life • « LIVING NOT SURVIVING » From the OECD • Differences in cancer survival – half of it may be explained by the available resources (imaging techniques ,infrastructure, new drugs, NHE) – ¼ by process quality of delivery of care(early detection, access,optimal treatment) – ¼ by governance (NCCP, coordination….) • Where are we going wrong? • Do we treat survival or quality of life?????