Monthly Archives: October 2015

“The purse is closed!” – this is no way to run a hospital

Rosa Giuliani, medical oncologist, S. Camillo-Forlanini Hospital, Rome, Italy

Rosa Giuliani, medical oncologist, S. Camillo-Forlanini Hospital, Rome, Italy

 

As a medical oncologist my primary interest is in helping patients to live longer and better. The best part of my job is the integration of clinical and molecular views: see the problem in the clinic, look for answers in the lab, bring back the solution to patients. I wish it could be as simple as that.

Research & development have a price, which is often difficult to understand. Why new drugs and devices cost that much, and not a penny less, is a complicated conundrum for many of us. The EU regulatory and reimbursement systems, the lack of a universal health policy through Europe and the profound economic crisis are regularly debated.

While I was at ECCO participating in debates on the need to promote equity and defeat disparities in access to precision medicine in Europe, hospital managers where I work notified the oncology department that the budget allocated to cancer drugs expenditure was over:no “expensive” drugs could be purchased until the budget for the new year will be discussed in January. The purse was closed. Meetings followed, some very unpleasant; poor use of resources by medical staff was implied, not even too subtly. Of course, this prompted self-examination: am I a good oncologist? Am I following guidelines? Am I spending money for my pleasure to give drugs?

After this last question, I realized that I was losing my mind and luckily, I returned to my senses. I respect rules, I need rules, I love rules. I appreciate fair rules. Budget negotiations at local hospitals are as obscure as the procedure of setting prices at EU or national level. A rule, which lacks of transparency, is not fair. The fact that the rules are set and dealt by people who are not prepared to manage the process, is terribly wrong. The overwhelming gap between cancer politics at EU Headquarters, where precision medicine is being promoted, and cancer politics at local level, where the only interest is that 2+2 should be equal to 3, because 4 is already too expensive, is frightening.

Money is an important part of the equation: resources are not infinite and their rational employment is of utmost importance. The process of drug development is not cost-effective, and many managers are not, because they have not been adequately prepared to deal with a different type of economy. Cancer medicine cannot be dealt as if providing water or electricity.

The global curriculum for being a good medical oncologist has dramatically changed in the past 10 years. Medical oncologists in 2015 cannot neglect molecular biology, health policies, precision medicine and so on. The same change should happen with managers who allocate resources for health politics, especially at hospital level. Being a good accountant does not suffice anymore, just as being exclusively a good clinician is not enough. Another level of knowledge and preparation is needed. And honestly, sometimes, a little bit of emotional intelligence would not do any harm.

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Smoke gets in your eyes

Simon Crompton

Simon Crompton

The title of Europa Donna’s annual London symposium last week was “New directions in breast cancer”. By the end of the evening, possible new directions were clear, but the route to take was not.

One of the two speakers was Daniel Leff, a cancer surgeon from Imperial College London, who addressed the difficulties of defining the correct margins when surgically removing breast cancer. The object had to be, he said, reducing the chances of reoperation.

He tantalised the audience with the question: “Can surgical smoke be informative?”

Potential of spectrometer analysis

Researchers at Imperial have used mass spectrometers to analyse the smoke arising from tissue incision with electrosurgical knives – a technique known as Rapid Evaporative Ionisation Mass Spectrometry (REIMS). Different types of cell produce different chemical concentrations when burned, so the chemical profile can indicate whether the tissue being cut is cancerous or not.

Identification of cancerous tissue using the technique during surgery, said Leff, was 93% accurate.

It’s a truly impressive technological development, that has potential to radically reduce reoperation rates for breast cancer.

The cost question

But how much did the machinery cost, asked a member of the audience? Half a million pounds, answered Leff. And how much did a pathologist cost? The answer was not given, but the point was made…

Pathologists already have advanced (and cheaper) techniques which can accurately indicate to surgeons which areas are cancerous and which are not. The question, said audience members, was why they were not being used. Leff himself acknowledged that pathology analysis using frozen section and touch imprint cytology were highly effective ways of determining the extent of breast disease and reducing the need for re-excision. But they are not widely used in the UK.

Novelty intoxication

On the systemic therapy side, Stephen Johnston, Professor of Breast Cancer Medicine at the Royal Marsden Hospital, spoke of the real promise of the drug Palbociclib as a first-line treatment for ER-positive breast cancer, and (in combination with Fulvestrant) as a second-line treatment as well. The cost of Palbociclib? Around £90,000 for one year’s treatment. The pressing question of how such expensive drugs are to be made widely available was raised, but not addressed.

New directions in breast cancer are exciting, involving, often inspiring. But we know how easy it is to become intoxicated with novelty and infatuated with technology. Sometimes, it isn’t new directions we need to hear about, but what is already here but under-utilised – and how we can best use what is proven, affordable and practicable to benefit the greatest number of women possible, as soon as possible.

Europa Donna, the European Breast Cancer Coalition, has a Facebook page.

 

 

 

 

 

Progress is made at the boundaries of disciplines

anna portrait  pic

Anna Wagstaff

I’ve been feeling rather smug. Among the 16 sessions taking place on the Sunday evening of the European Cancer Congress (ECC2015), I took a chance on an ASCO–ECCO joint symposium entitled “New Frontiers in Imaging: The solution to individualised treatment”.

Of the 18,000 participants gathered at that congress, I was surprised to find myself as one of only around 25 people at that session, in a hall that could have accommodated 200 times that number. Either I had misjudged the importance of this topic – it wouldn’t be the first time – or I could congratulate myself for having picked up on something of strategic significance that the vast majority of congress goers had completely overlooked.

In this instance, I think I got it right, and this is why.

Treating “the right patient with the right treatment at the right time” has been the mantra of the cancer community for more than a decade now. Yet most of the research highlighted at cancer conferences still speaks to the old agenda.

Typically, the data from the clinical trials show a wide range of responses – some patients barely responding, others deriving a clear benefit. But the presentations are still about the apocryphal “average” patient – if doctors want to give these therapies to “the right patients” they’ll still have to give them to the wrong patients as well.

So this is why, when I spotted a session that focused on “the solution to individualised treatment”, I thought it sounded important.

The presenters offered an alternative approach to personalising therapies that uses the ability of increasingly sophisticated imaging techniques to give a whole-body picture not just of the extent of disease but of many aspects of its biological behaviour.

Some of this is cutting edge science – apparently every one of Hanahan and Weinberg’s “hallmarks of cancer” can now be visualised by different types of imaging.

But what really caught my attention was a creative use of an old nuclear medicine technology to address the problem of overtreatment of patients with colorectal cancer.

Imaging can guide treatment

Around eight out of ten colorectal cancer patients recommended for adjuvant FOLFOX treatment do not benefit from this highly toxic regimen. In some cases this is because they have already been cured by surgery and the additional treatment is redundant ‒ identifying these patients remains a challenge. But in around four patients out of ten the disease comes back because FOLFOX doesn’t work for them.

The solution? Take advantage of the short period between diagnosis and surgery to treat the cancer with FOLFOX, and gauge its level of response by comparing FDG-PET images taken before and after. If FOLFOX has no impact before surgery, it’s unlikely to work as an adjuvant afterwards. That’s the theory, anyway, and it’s currently being tested by Alain Hendlisz and colleagues at the Jules Bordet Institute in Brussels.

If it works in practice, this could be a big deal that would make a significant difference to a sizeable patient group, and open up new approaches to achieving the goal of individualising treatment. It would also be a great example of how important progress so often comes from a creative interplay between different disciplines.

So I’m left wondering why so few people turned up to the session, even though its billing as a joint ASCO–ECCO symposium should have flagged up the importance of the topic.

Was I witnessing the silo mentality in action? Were all the other delegates so focused on their own speciality that they didn’t connect with possibilities coming from elsewhere?

If so, it shows how right the organisers of ECC2015 were to take “Reinforcing multidisciplinarity” as their theme for the conference, but it also shows how much work is need to achieve that goal.

ECC 2015 crowd_arriving small

The European Cancer Congress is a great place for people to connect across the boundaries of discipline and specialism – but you have to want to. Photo: Peter McIntyre