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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
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