principles of surgical oncology · effect of operative volume on morbidity, mortality, and hospital...

Principles of

Surgical

Oncology

Prof. Riccardo A. Audisio, MD, FRCS

Consultant Surgical Oncologist University of Liverpool - UK

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

Surgical Oncologists deal with

the removal of “tumours”

How?

When? Why?

Sub-specialities Organ Based

• Thoracic oncologists

• Urological oncologists

• Gynaecologic oncologists

• Breast oncologists

• Orthopaedic oncologists

• GI oncologists

Patient-Type Based

•Paediatric oncologists

•Geriatric oncologists

New Techniques

• Chemoperfusion: sarcomas

melanomas

liver + Breast? Pancreas?

• Hyperthermia: peritoneal malignancies

• Minimal Access:

laparoscopy/thoracoscopy

NOTES - TEMS

• Nd:YAG Laser: endoscopy

trans-cutaneous

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

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

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.

Surgical Oncology

ESSO “was founded in 1981 to advance the art, science and

practice of surgery in the treatment

of cancer”

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)

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)

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.

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.

What you need to do to become

a surgical oncologist ?

what we were trained for

will soon become obsolete

learn to adapt

learn the method

(not the procedure)

Education

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

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

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

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

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

Pancreatic cancer

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

tissue based treatment

tissue diagnosis

genetically informed oncology

molecular diagnosis

pattern of growth & invasiveness

Impersonal

High toxicity Small benefits

Tissue based treatment

Pathway driven treatment

Personalised

High benefits Low toxicity

Risk assessment councillor

Diagnostician

Locoregional Treatment Director

Multidisciplinary Team Leader

Survivorship Advocate

Salvage Surgeon

Educator

Surgical Oncologist

Risk Assessment Councillor

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 !!!

200 genes associated with

cancer (18 with BC)

Risk assessment councillor

Genes associated with

metastatic spread

CHEK2: low-penetrance tumour

suppressor gene in BC

bilateral BC

few family members

CRC

prostate cancer

Risk assessment councillor

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

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

Diagnostician

New technologies developed

at a high pace:

• imaging techniques

• methylation & microRNA biomarkers

• microfluidic chip based analysis

• LOC (lab-on-a-chip)

• liquid biopsy

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

Locoregional treatment director

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

personalised treatment

=

biologically targeted

multimodal management

Neoadjuvant treatment

Intraoperative RT

Neo-adjuvant CT Targeted surgery

Cyberknife

Terminator

Orchestrator

Patients have a right to say

(with a very powerful voice)

Survivorship advocate

side effects – lymphoedema

side effects of CT & RT

palliation – terminal care

carers – family – children

follow-up (personalised on

genomics?)

depression – ostheoporosis

non responders to CT/RT

M+: brain

liver

lungs

skeletal

local recurrence: breast/axilla

chest cage

axilla

pelvis

bone/soft tissue

Salvage surgery

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

… 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

surgery

cancer

aging

Surgery for older

cancer patients !!!

Surgery is NOT finger

gymnastics

Multidisciplinarity

Pre-operative care

neoadjuvant – PET – stenting –

nutrition - assessment &

preabilitation

No bowel preparation

Per-operative care

anaesthetic care

fluid balance

minimal blood los

function-sparing surgery

Post-operative care

enhanced recovery

nutritional support (fluids)

delirium

prompt mobilisation

early discharge

Targets ???

Prolong survival

Quality of Life

Preserved functionality

Return to normal life

Patient’s aims

Communication free/informed choice

misinformation & misconception may:

•limit treatment options

•impact on survival

Consent

Surgical Procedure...

Possible risks…

Intended benefits…

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

Frailty Assessment

Lengthy procedure

“new tool”

Lack of a unique tool

Unproven advantages

Definition of frailty is crucial in:

Designing Clinical Studies/Trials

Consenting patient

Individualising treatment

Predicting outcome

Comparing series

“”real world” prospective

registry (fase IV trial)

preoperative assessment

surgery

1 – 3 – 12 months

outcomes

correlation with preop assessment

improved assessment

EORTC & ESSO supportive

Cancer

Registries

Plea for original research

Clinical input

EURECCA

Networking

Geographical Variations 1995-2005 Stage I-II

NO surgery

Geographical Variations

NO axillary surgery

Geographical Variations

relative survival

NO surgery

Less surgery in the Netherland over the

last 15 years

NO surgery

More PET in the Netherland over the

last 15 years

NO surgery

No decreased overall- and relative-

survival

Avoid the emergency setting

Pre-abilitation:

Neo-adjuvant CT/RT

Anaemia

Salts & fluid balance

Malnourishment

Depression

Physiotherapy

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

What is right for Y pts might not be appropriate for E pts

Cancer Registry Data: 1,508pt >75yrs

Rutten HJT. Lancet Onc 2008

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

Many thanks for assisting your

surgeons appreciating

the specific needs of

older patients