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Slide 1 - Murray F. Brennan, M.D. Why a Cancer Center
Slide 2 - Murray F. Brennan, M.D. Why a Cancer Center
Slide 3 - Murray F. Brennan, M.D. Why a Cancer Center Why a Cancer Center? Is cancer going to be a problem?
Slide 4 - Murray F. Brennan, M.D. Why a Cancer Center 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.
Slide 5 - Murray F. Brennan, M.D. Why a Cancer Center 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.
Slide 6 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020
Slide 7 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006.
Slide 8 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise
Slide 9 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise
Slide 10 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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
Slide 11 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures
Slide 12 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival:
Slide 13 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival:
Slide 14 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Slide 15 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Slide 16 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Slide 17 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Slide 18 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002.
Slide 19 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda
Slide 20 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center
Slide 21 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil
Slide 22 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42
Slide 23 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time
Slide 24 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival:
Slide 25 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis:
Slide 26 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204
Slide 27 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204
Slide 28 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99%
Slide 29 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue
Slide 30 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma
Slide 31 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center
Slide 32 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center
Slide 33 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume
Slide 34 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center
Slide 35 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center
Slide 36 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center
Slide 37 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center
Slide 38 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center
Slide 39 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001
Slide 40 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002.
Slide 41 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center
Slide 42 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000.
Slide 43 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000.
Slide 44 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center
Slide 45 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days)
Slide 46 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center
Slide 47 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center
Slide 48 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center
Slide 49 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year
Slide 50 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year Measures of ‘success’ perioperative mortality length of stay cost long term survival Why a Cancer Center
Slide 51 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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
Slide 52 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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
Slide 53 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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
Slide 54 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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
Slide 55 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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
Slide 56 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center
Slide 57 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003.
Slide 58 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive Year Survival – Specialist vs Non-specialist by Site n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003.
Slide 59 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003.
Slide 60 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival
Slide 61 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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
Slide 62 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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
Slide 63 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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
Slide 64 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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
Slide 65 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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
Slide 66 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center
Slide 67 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center
Slide 68 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002.
Slide 69 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002.
Slide 70 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002.
Slide 71 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center
Slide 72 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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
Slide 73 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center
Slide 74 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region
Slide 75 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region Premise: The future of a Department, Institution , or Country lies in their commitment to the young Why a Cancer Center
Slide 76 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center
Slide 77 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation
Slide 78 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006.
Slide 79 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center
Slide 80 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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.
Slide 81 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004)
Slide 82 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates AAMC Data Book 2007
Slide 83 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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
Slide 84 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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.
Slide 85 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center
Slide 86 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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.
Slide 87 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007
Slide 88 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005.
Slide 89 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. The problem is not only do people leave, they do not return. Why a Cancer Center
Slide 90 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center
Slide 91 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center
Slide 92 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center The environment is not just money, although money, once attained is rarely overcome by environment Why a Cancer Center
Slide 93 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center The environment is not just money, although money, once attained is rarely overcome by environment Why a Cancer Center Focus Resources & PeopleversusDecentralization of Resources & People
Slide 94 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center The environment is not just money, although money, once attained is rarely overcome by environment Why a Cancer Center Focus Resources & PeopleversusDecentralization of Resources & People The Privileged WorldversusThe Less Privileged World
Slide 95 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center The environment is not just money, although money, once attained is rarely overcome by environment Why a Cancer Center Focus Resources & PeopleversusDecentralization of Resources & People The Privileged WorldversusThe Less Privileged World An agenda no matter how “right” will not succeed if it confronts a greater political expediency Why a Cancer Center
Slide 96 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center The environment is not just money, although money, once attained is rarely overcome by environment Why a Cancer Center Focus Resources & PeopleversusDecentralization of Resources & People The Privileged WorldversusThe Less Privileged World An agenda no matter how “right” will not succeed if it confronts a greater political expediency Why a Cancer Center “Adapt or perish, now as ever, is nature's inexorable imperative.” H. G. Wells Author
Slide 97 - Murray F. Brennan, M.D. Why a Cancer Center 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. Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Increase in Cancer Mortality 1990-2020 Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006. Why a Cancer Center Cancer Care is disease based not discipline based Premise Why a Cancer Center When you focus your activities you improve outcome Premise Table of Contents 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 Why a Cancer Center Improve Survival Improve Quality of Life Outcome Measures Why a Cancer Center Prevention Accurate diagnosis Early Diagnosis Improved treatment Improved quality of life Improved Care Improve Survival: Why a Cancer Center Prevention Smoking cessation Improve Survival: Deaths from Tobacco Smoking Of everyone alive today 500,000,000 Will eventually be killed by tobacco Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Smoking Rate for Men & Women Combined Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Demographics of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. A Hard Day’s SmokeNairobi, Kenya Minutes of labour worked to purchase 20 cigarettes Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. The Business of Tobacco Kenya Mackay J, Eriksen M. The Tobacco Atlas. WHO 2002. Uganda Screening & Early Diagnosis Improve Outcome Why a Cancer Center Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004. Cancer Control Programs in Brazil TIS n = 21 T0 n =42 T1 n = 416 T2 n = 550 T3 n = 750 T4 n = 42 1985-1989 n = 347 1990-1994 n = 411 1995-1999 n = 380 2000-2004 n = 567 MSKCC 7/1/85 – 6/30/05 n = 1705 p < 0.001 Gastric AdenocarciomaRO Resections by Time Why a Cancer Center Improved Care Patient Accurate diagnosis Appropriate first treatment Volume & outcome Surgeon Volume vs outcome Institution Efficiency of scale Resource utilization Improve Survival: Centralized referral accuracy efficient use of resources standard for the nation Why a Cancer Center Accurate Diagnosis: Soft Tissue SarcomaHistopathology MSKCC 7/1/82 – 6/30/06 n = 7002 1309 1104 1037 406 2758 184 204 Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 99%? 50%? 10% 99% 99% Sarcomas Presenting in Unusual Primary Sites Confirmed by Translocation Data Sarcoma type Primary Sites Ewing Sarcoma Kidney Ovary Cervix Skin Pancreas Breast Lung Meninges Desmoplastic Small Brain Round Cell Tumor Parotid (DSRCT) Hand Synovial sarcoma Prostate Peritoneum Lung Kidney Heart Tongue “Pediatric” Sarcomas Confirmed in Older Adults (>50) by Translocation Data Typical Oldest Sarcoma type age range confirmed case Ewing Sarcoma 10-30 72 DSRCT 10-30 67 Alveolar 10-20 68 Rhabdomyosarcoma Does centralization make a difference? If it does, how do we measure success? Does volume matter? Why a Cancer Center Does volume matter? surgeon volume? institutional volume? Does surgical specialization / training matter? Questions: Why a Cancer Center Why a Cancer Center Operative survival Long term survival Outcome vs Volume Perioperative Mortality Why a Cancer Center Operative Mortality by Hospital VolumeEsophagectomy Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998. n = 503 p = 0.001 In-Hospital Mortality Hospital and Surgeon VolumeIncrease in Mortalitycompared to high volume surgeon, in high volume hospital Hannan EL, Brennan MF, et al Surgery 131:6-15, 2002. Volume does matter in perioperative mortality / morbidity What other factors influence outcome Sex Race Age Socioeconomic Why a Cancer Center Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 p <0.001 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. Volume matters for operative mortality what about operative morbidity length of stay Why a Cancer Center Adenocarcinoma of the Pancreas - Resected Year MSKCC 1984 - 2006 Median Length of Stay (days) If volume matters, how much is enough? Why a Cancer Center Volume levels have to be procedure / disease specific Why a Cancer Center Hospital VolumeVariation in Volume Loads Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002. Quantiles Procedures/year 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? Why a Cancer Center Outcome and SpecializationColorectal Cancer 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) Specialist vs Non-specialist n = 5173 Smith JAE, et al. Br J Surg 90:583-592, 2003. Colorectal CancerFive 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-SpecialistRelative Failure Rate vs Volume Surgeon Volume / Annum n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. n = 29,666 Skinner KA. Ann Surg Oncol 10:606-615, 2003. Breast Cancer - Specialist vs Non-Specialist Overall Survival 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? Why a Cancer Center Operative Mortality Improvement with Time or Volume 1994-1999 Medicare Goodney PP et al. J Am Coll Surg 195:219-227, 2002. Improved Treatment Why a Cancer Center Table of Contents 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 Why a Cancer Center Distribution of Health Workforce by Cadre WHO AFRO 2006. Kenya African Region 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= Why a Cancer Center Educate the Next Generation Focus Resources & People WHO AFRO 2006. Educate and retain the Next Generation -RETAIN- Why a Cancer Center ECFMG 1958-2005New Applicants vs Number Certified Hollock JA. Acad Med 81:S7-16, 2006. 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. Number & Source of Physicians Entering Training in 2003(23,681* entered in training 2003) Edward Salsberg, Director, Center for Workforce Studies, AAMC *Based on AMA estimates (2004) Positions Offered / Filled in NRMP General Surgery: US Graduates 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. Retain Staff and Recruit Back Faculty Why a Cancer Center 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 ApplicantsMatched to Surgical Residencies (% of total foreign matched)2002-2006 AAMC Data Book 2007 Fellowship Positions Filled by International Medical Graduates 2000-2004 Adapted from Stitzenberg KB, J Am Coll Surg 201:925-932, 2005. 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 Why a Cancer Center Memorial Sloan-Kettering Cancer Center The environment is not just money, although money, once attained is rarely overcome by environment Why a Cancer Center Focus Resources & PeopleversusDecentralization of Resources & People The Privileged WorldversusThe Less Privileged World An agenda no matter how “right” will not succeed if it confronts a greater political expediency Why a Cancer Center “Adapt or perish, now as ever, is nature's inexorable imperative.” H. G. Wells Author