Transcript Where are we going wrong? The story behind unneccessary

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 intervariabilitypanels
– 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?????