Download Pancreatic Cancer

Why a Cancer Center
Murray F. Brennan, M.D.
Why a Cancer Center?
 Is cancer going to be a problem?
Estimated Global Incidence Rate
All Cancers – by Age
Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004.
Predicted Cancer Incidence
Developing vs Industrialized Countries
Kanavos P, Ann Oncol 17:vii15-vii23, 2006.
Increase in Cancer Mortality
1990-2020
SubSaharan Africa
China
The World
Established
Market Economies
0%
50%
100%
Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004.
150%
200%
Incidence & Mortality for Most Common Cancers
in Less Developed & More Developed Countries
Kanavos P, Ann Oncol 17:vii15-vii23, 2006.
Why a Cancer Center
Premise
Cancer Care is disease based
not discipline based
Why a Cancer Center
Premise
When you focus your activities
you improve outcome
Table of Contents
Why a Cancer Center
 Improve cancer care
 outcome, quality of life
 Focus resources and people
 Provide direction for others
 Maximize use of resources
 Maintain and retain staff
 Educate
 Research
Why a Cancer Center
Outcome Measures
Improve Survival
Improve Quality of Life
Why a Cancer Center
Improve Survival:
 Prevention
 Accurate diagnosis
 Early Diagnosis
 Improved treatment
 Improved quality of life
 Improved Care
Why a Cancer Center
Improve Survival:
 Prevention
• Smoking cessation
Deaths from Tobacco Smoking
Of everyone alive today
500,000,000
Will eventually be killed by tobacco
Past & future
7
Million
projected
Annual Deaths due to tobacco estimated
worldwide
3
1950-2030 projected
1.3
million
0.3
million
1975
2.1
million
2000
Million
projected
2025
to
2030
1950
2.1
million
0.2
negligible million
1950
industrialized countries
2025
to
2030
2000
1975
developing countries
Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Smoking Rate for Men & Women Combined
49%
Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
The Demographics of Tobacco
Kenya
Population (thousands)
30,669
Adult smoking
male
female
total
66.8%
31.9%
49.4%
Youth smoking
male
female
total
16%
10%
13%
Youth exposed to passive smoking at home
--
Cigarette consumption (annual per person)
200
Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
A Hard Day’s Smoke
Nairobi, Kenya
Minutes of labour worked to purchase 20 cigarettes
Minutes worked
180
158
150
120
92
90
60
30
0
Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
International
brand
Local brand
The Business of Tobacco
Kenya
Growing tobacco
land devoted to tobacco (hectares)
agricultural land devoted to tobacco (% of total)
tobacco produced (metric tons)
4,500
0.19%
7,000
Tobacco trade
cigarettes exports (millions)
cigarettes imports (millions)
tobacco leaf exports (metric tons)
tobacco leaf imports (metric tons)
550
50
4,423
50
Manufacturing
number of workers
cigarettes manufactured (millions)
1,701
--
Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Uganda
Why a Cancer Center
Screening & Early Diagnosis Improve Outcome
Cancer Control Programs in Brazil
Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004.
 TIS n = 21
◄T0 n =42
 T1 n = 416
 T2 n = 550
 T3 n = 750
 T4 n = 42
Gastric Adenocarcioma
RO Resections by Time




MSKCC 7/1/85 – 6/30/05 n = 1705
1985-1989
1990-1994
1995-1999
2000-2004
p < 0.001
n = 347
n = 411
n = 380
n = 567
Why a Cancer Center
Improve Survival:
 Improved Care
 Patient
 Accurate diagnosis
 Appropriate first treatment
 Volume & outcome
 Surgeon
 Volume vs outcome
 Institution
 Efficiency of scale
 Resource utilization
Why a Cancer Center
Accurate Diagnosis:
 Centralized referral
 accuracy
 efficient use of resources
 standard for the nation
Soft Tissue Sarcoma
Histopathology
Liposarcoma
19%
Leiomyosarcoma
15%
1309
1037
1104
2758
406
184
204
Other
38%
MPNT
3%
MSKCC 7/1/82 – 6/30/06 n = 7002
MFH
16%
Synovial
6%
Fibrosarcoma
3%
Non ”EWS family” gene fusions in sarcomas
SSX1
SYT
SSX2
35%
SSX4
<1%
PAX3
75%
FKHR
PAX7
COL1A1
PDGFB
ETV6
NTRK3
(multiple)
ALK
ASPL
65%
TFE3
Synovial sarcoma
Alveolar rhabdomyosarcoma
10%
99%
Dermatofibrosarcoma
protuberans (DFSP)
99%
Congenital fibrosarcoma
50%?
Inflammatory myofibroblastic
tumor
99%?
Alveolar soft part sarcoma
Sarcomas Presenting in Unusual Primary Sites
Confirmed by Translocation Data
Sarcoma type
Primary Sites
Ewing Sarcoma
Kidney
Skin
Lung
Desmoplastic Small
Round Cell Tumor
(DSRCT)
Brain
Parotid
Hand
Synovial sarcoma
Prostate
Lung
Heart
Ovary
Pancreas
Meninges
Peritoneum
Kidney
Tongue
Cervix
Breast
“Pediatric” Sarcomas Confirmed in Older Adults (>50)
by Translocation Data
Sarcoma type
Typical
age range
Oldest
confirmed case
Ewing Sarcoma
10-30
72
DSRCT
10-30
67
Alveolar
Rhabdomyosarcoma
10-20
68
Why a Cancer Center
Does centralization make a difference?
If it does, how do we measure success?
Does volume matter?
Why a Cancer Center
Questions:
 Does volume matter?
 surgeon volume?
 institutional volume?
 Does surgical specialization / training
matter?
Why a Cancer Center
Outcome vs Volume
 Operative survival
 Long term survival
Why a Cancer Center
Perioperative Mortality
Gastrectomy
Mortality Rates by Surgeon Volume
Surgeon
Volume
# of Surgeons
(%)
# of Patients
(%)
Mortality
Rate
1-2
698 (63)
929 (25)
8.8%
3-4
216 (19)
733 (20)
7.9%
5 - 11
159 (14)
1106 (30)
5.7%
> 12
41 (4)
943 (25)
2.8%
NY State 1994 - 97
Operative Mortality by Hospital Volume
Esophagectomy
% 30-Day Mortality
20
17.3
15
10
3.9
5
3.4
0
1-5
6-10
Volume
>11
n = 503
p = 0.001
Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998.
In-Hospital Mortality
Hospital and Surgeon Volume
Increase in Mortality
compared to high volume surgeon, in high volume hospital
Hospital Surgeon
Colectomy
Lung
lobectomy
Gastrectomy
High
Low
0.7%
1.5%
2.0%
Low
High
1.2%
1.8%
4.2%
Low
Low
2.3%
1.3%
6.0%
Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002.
Why a Cancer Center
Volume does matter in perioperative
mortality / morbidity
 What other factors influence outcome




Sex
Race
Age
Socioeconomic
Hospital Volume vs Colon Cancer
Hospital Volume 1991-1996
1-57
58-112
n hospitals
440
89
51
31
n patients
6837
7105
6947
7097
Mortality
5.5
5.0
4.4
3.5
SEER – Medicare n = 27,986
Schrag D. JAMA 284:3028-3035, 2000.
113-165 166-383
p <0.001
Why a Cancer Center
Volume matters for operative mortality
 what about operative morbidity
 length of stay
Adenocarcinoma of the Pancreas - Resected
Median Length of Stay (days)
30
26 26 25 25
24
24 23
25
20
16 18
15
14 13 13
11 11 10 10 10
9 10 9 9 8 8
10
5
MSKCC 1984 - 2006
Year
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
0
Why a Cancer Center
If volume matters, how much is enough?
Why a Cancer Center
Volume levels have to be
procedure / disease specific
Hospital Volume
Variation in Volume Loads
Quantiles Procedures/year
Very low
Medium
Very high
Colectomy
<33
57-84
>124
Gastrectomy
<5
9-13
>21
Pancreatectomy
<1
3-5
>16
Medicare 1994-1999
Birkmeyer JD. N Engl J Med 346:1128-1137, 2002.
Why a Cancer Center
Measures of ‘success’
 perioperative mortality
 length of stay
 cost
 long term survival
Why a Cancer Center
Volume matters in perioperative outcome,
but does it matter in long-term survival?
Why a Cancer Center
Does specialization matter?
Outcome and Specialization
Colorectal Cancer
Specialist vs Non-specialist
Postop mortality
0.67 (0.53 – 0.84)
Anastomotic leak
0.46 (0.31 – 0.66)
Local recurrence free
0.56 (0.44 – 0.7)
Long term survival
0.76 (0.71 – 0.83)
n = 5173
Smith JAE, et al. Br J Surg 90:583-592, 2003.
Colorectal Cancer
Five Year Survival – Specialist vs Non-specialist by Site
n = 5173
Smith JAE, et al. Br J Surg 90:583-592, 2003.
Breast Cancer - Specialist vs Non-Specialist
Relative Failure Rate vs Volume
Surgeon Volume / Annum
Hospital Volume
<5
6-10
11-15
>15
Overall
1
0.95
0.9
0.84
<35
1
0.90
0.87
0.72
36-70
0.89
0.87
0.80
0.74
71-125
0.74
0.70
0.67
0.68
>125
0.69
0.74
0.73
0.61
n = 29,666
Skinner KA. Ann Surg Oncol 10:606-615, 2003.
Breast Cancer - Specialist vs Non-Specialist
Overall Survival
n = 29,666
Skinner KA. Ann Surg Oncol 10:606-615, 2003.
Why a Cancer Center
 Conclusions
 volume matters, both institutional and surgeon
 specialization matters
 Specialist centers and specialist surgeons doing
increasing volume will increase
 Challenges
 how much volume
 how much specialization
 how to train the specialist and the non-specialist
Why a Cancer Center
If institutional and surgical volume
and specialist status matters,
can society afford high volume, specialist centers?
Why a Cancer Center
Has anything changed?
Operative Mortality
Improvement with Time or Volume
1994
1995
1996
1997
1998
1999
Pancreatectomy:
Op mortality
% in >16/yr hosp
10.8
17
11.3
19
12.6
18
11.5
23
10.5
22
10.2
24
Gastrectomy:
Op Mortality
% in >21/yr hosp
10.7
18
11.8
19
12.0
19
10.9
20
11.3
21
11.8
21
16.5
16
15.4
18
17.0
19
15.1
19
15.0
18
15.1
21
Esophagectomy:
Op mortality
% in >18/yr hosp
1994-1999 Medicare
Goodney PP et al. J Am Coll Surg 195:219-227, 2002.
Why a Cancer Center
Improved Treatment
Table of Contents
Why a Cancer Center
 Improve cancer care
 Focus resources and people
 Provide direction for others
 Maximize use of resources
 Maintain and retain staff
 Educate
 Research
Why a Cancer Center
Focus Resources and People
Distribution of Health Workforce by Cadre
Kenya
African Region
Physicians
Nurses &
midwives
Dentists
Pharmacists
Public health
workers
Lab technicians
Other health
workers
Community
health workers
Administrative
WHO AFRO 2006.
Why a Cancer Center
Premise:
The future of a Department, Institution ,
or Country lies in their commitment to
the young
Why a Cancer Center
Educate and retain the Next Generation
- EDUCATE=
Educate the Next Generation
University of Nairobi,
School of Medicine
1967-68
Moi University,
School of Medicine
1988-90
Focus Resources & People
Kenya
Kenya
AFRO
Density/1000 Density/1000
Physicians
4506
0.139
0.217
Midwives
37113
1.145
1.175
WHO AFRO 2006.
Why a Cancer Center
Educate and retain the Next Generation
-RETAIN-
ECFMG 1958-2005
New Applicants vs Number Certified
Note: The availability of exam results for some examinees from 2004 was delayed until
early 2005; as a result, the number of certificates issues in 2004 is lower due to this delay.
Hollock JA. Acad Med 81:S7-16, 2006.
Number & Source of Physicians
Entering Training in 2003
(23,681* entered in training 2003)
US IMGs
5%
Non-US Citizen
IMGs
20%
US Osteopathic
Graduates
11%
Canadian
Graduates
0.2%
US Allopathic
Graduates
64%
*Based on AMA estimates (2004)
Edward Salsberg, Director, Center for Workforce Studies, AAMC
Positions Offered / Filled in NRMP
General Surgery: US Graduates
1200
1000
8%
6.5%
6.1%
6.5%
5.8%
5.7%
6.1%
6.3%
6%
800
600
4%
400
2%
200
0
0%
2000
2001
Total Offered
2002
US Filled
2003
2004
2005
2006
% US Seniors applying to General Surgery
AAMC Data Book 2007
The IMG in the US –
Stealing from the Poor to Give to the Rich
Successful IMGs:
Haile T. Debas, MD
Chancellor, UCSF
Dean, UCSF Medical School
President, ASA 2001-2002
The IMG in the US - Strategies for Success
The only sound long-term strategy for the
US is to train more surgeons.
I believe it is unwise and ethically
questionable to try to actively recruit
IMGs from developing countries.
Debas H. Surgery 140:359-361, 2006.
Why a Cancer Center
Retain Staff and Recruit Back Faculty
The IMG in the US - Strategies for Success
From 1958 through 2005,
the ECFMG certified 287,382
international medical graduates (IMGs).
Hallock JA, Kostis JB. Acad Med 81:S7-16, 2006.
Foreign Trained Applicants
Matched to Surgical Residencies
(% of total foreign matched)
2002-2006
% Foreign Applicants
4%
3%
2%
1%
0%
2002
2003
2004
Year
AAMC Data Book 2007
2005
2006
Fellowship Positions Filled by International Medical Graduates
2000-2004
40
35
Percent
30
25
20
15
Pediatric
Surgery
Vascular
Surgery
Colon & Rectal
Surgery
Thoracic
Surgery
Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005.
2003
2004
2001
2002
2003
2004
2001
2002
2003
2004
2001
2002
2003
2004
0
2004
5
2000
2001
2002
10
MIS
Why a Cancer Center
The problem is not only do people leave,
they do not return.
Why a Cancer Center
To Retain Staff and Recruit Back Faculty,
the environment has to be such that they
want to be retained or return
Memorial SloanKettering Cancer
Center
Why a Cancer Center
The environment is not just money,
although money, once attained is
rarely overcome by environment
Focus Resources & People
versus
Decentralization of Resources & People
The Privileged World
versus
The Less Privileged World
Why a Cancer Center
An agenda no matter how “right” will
not succeed if it confronts a greater
political expediency
“Adapt or perish, now as ever,
is nature's inexorable imperative.”
H. G. Wells
Author