Clinical Leader Article Clinical Leader Article

Dr Geoff Chong
Colorectal Cancer 2018 Summit: where to from here? 31/8/18


Mr Brian Hodgkins
Colorectal Cancer 2018 Summit: where to from here? 31/8/18

A/Prof Brian Le
Evidence for early palliative care mounts 31/8/18

Dr Charles Pilgrim
Pancreatic Cancer Summit outcomes: where to from here? 4/7/18


Publication date Fri 31 Aug 2018
2 minute read

A/Prof Brian Le

Evidence for early palliative care mounts

The existing care structures that make up ‘modern’ palliative care have their roots dating back to the 1950s, originating in the UK and North America. This development arose from recognition that despite advances in medical care, we perhaps had lost the ability for our health services and communities to provide optimal care for dying patients and their carers.

It took further decades to better describe how these services could be involved with care and improve quality of life, beyond solely end-of-life care. A landmark 2010 study conducted at a Harvard University associated hospital in Boston USA demonstrated that for a group of patients with incurable lung cancer, early involvement with palliative care services not only improved quality of life measures but also improved survival, presumably by concurrently addressing oncological treatment aims and palliative care needs. Subsequently, a range of studies have mirrored these findings across North America, Europe and Australasia in a variety of settings, and in cancer and non-cancer conditions. In 2012, the American Society of Clinical Oncology (ASCO) released their first “provisional clinical opinion”. It recommended to its members and oncology services globally that patients with metastatic cancer should be considered for referral to palliative care services early in their disease course and palliative care be provided concurrently with anti-cancer treatments. In 2017, ASCO strengthened this recommendation, on the basis of further evidence, to early palliative care involvement should become part of the standard of care for all advanced-cancer patients.

So what should this look like in 2018 in Victoria, and more specifically in pancreatic cancer? Local data confirms worldwide data that referral to palliative care can and does improve symptoms experienced by patients and improves quality of life. Further data shows that palliative care involvement can assist patients to receive care outside of hospitals, reduce ‘aggressive care’ at end-of-life (ie. ICU admissions and chemotherapy delivery within a short period before death), and in particular can increase rates of death in a patient’s venue of choice. But involvement with palliative care does not appear to be provided uniformly to all across the state, with anecdotal suggestion of considerable variation in care in Victoria. Data suggests higher death rates within acute hospital settings for those with pancreatic cancer when compared to other cancer types.

With the focus of Optimal Care Pathways being on standardisation of care across all settings, it is timely and appropriate that one key area for further work has been identified as the standardised early involvement of palliative care as part of routine care for patients with pancreatic cancer. It is now time for each of us to consider how we progress towards this goal of standardised early integration, and make this work to the benefit of our patients and their carers.

To learn more about the Pancreatic Cancer Summit, click here.

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Publication date Fri 31 Aug 2018
2 minute read

Mr Brian Hodgkins & Dr Geoff Chong, co-chairs Colorectal Cancer 2018 Summit working party

Colorectal Cancer 2018 Summit: where to from here?

On the 16th of March 2018 the second Colorectal Cancer Summit was held at the RACV Club in Melbourne. There was encouraging attendance from across the state including all Integrated Cancer Services. There was also a good spread of disciplines of health practitioners. The goals of the second Summit were:

  1. To revisit the conclusions of the first Summit and assess progress.
  2. To acquaint the participants with new information which has become available due to advancements in data collection and cross-linking of datasets. These data provided demographic, survival and treatment results across the state, enabling comparisons to be made.
  3. Informed by these data, the participants were asked to form views on the importance of variations and the possibilities for eliminating these variations.
  4. Next, there was a panel discussion of examples of improvements made to Colorectal cancer care in various Integrated Cancer Services. The emphasis here was on local action to improve services.
  5. Lastly, participants were grouped according to their local Integrated Cancer Service and were asked to address any variations or issues that were deemed to be relevant to their Service.

The Summit conclusion listed two variations in care which were deemed high impact/low effort to remediate:

  • Increasing the proportion of CRC patients presented at MDM
  • Increasing the utilization of chemotherapy for stage III colon cancer patients

Four variations were deemed high impact/high effort:

  • Increasing the percentage of pre-treatment MDM discussion for rectal cancer patients
  • Addressing the variation in utilization of neo-adjuvant radiotherapy in rectal cancer patients
  • Improving the lymph node harvest in colon cancer resections
  • Improving the timeliness of adjuvant chemotherapy for stage III colon cancer patients

One topic which arose from the panel discussion was the fact that MDM presentation not infrequently resulted in significant changes to radiological and pathological reporting. This was particularly so in rectal cancer patients and more often related to radiology than pathology. There was some discussion regarding standardisation of reporting and specialisation of radiologists and pathologists involved in Colorectal cancer treatment.

A healthy multidisciplinary team provides the ultimate scrutiny of patient’s treatment plans. We believe that many of the variations we have observed would not be evident if all patients had the benefit of their cases being discussed at MDM. For rectal cancer patients this discussion needs to take place pre-treatment. Achieving this goal requires significant time and effort for the MDM participants. Summit attendees noted the extra burden that is carried by the team members.

The success of the Summit will hopefully be measured by improvements in colorectal cancer care and elimination or explanation of variations we noted above. What can be said of the Summit at this point, is that it was an opportunity to identify variations in care and outcomes. It is now time to focus on local actions with the support of our Integrated Cancer Services. In order to continue the momentum created by the Summit we plan to form a committee comprised of members from each Integrated Cancer Service to focus on local actions.

To learn more about the Colorectal Cancer 2018 Summit click here.

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Publication date Wed 4 Jul 2018
2 minute read

Dr Charles Pilgrim, co-chair Pancreatic Cancer Summit working party

Pancreatic Cancer Summit outcomes: where to from here?

The Victorian Pancreas Cancer Summit was held in Melbourne, November 2017 as part of the Integrated Cancer Services Tumour Summits programme. In preparation for the event the working party had analysed state-level data on management of all patients diagnosed and treated for pancreas cancer in Victoria between 2011-2015. Linkage between the Victorian Cancer Registry, the Victorian Admitted Episodes Dataset, the Victorian Radiotherapy Minimum Data Set and the Victorian Death Index provided data on treatment and outcome for all Victorians aged 18 years and older with a primary diagnosis of pancreatic cancer. Statistical analyses were performed to calculate incidence, survival and to demonstrate treatment pathways for metastatic and non-metastatic patient groups.

There were 3,962 Victorians diagnosed with all forms of pancreatic malignancy between 2011-2015 of whom 82% had pancreatic ductal adenocarcinoma (PDAC), and 67% of these patients had metastatic disease at diagnosis. The age standardised incidence rates for all pancreatic malignancies increased from 6.8 cases to 7.4 cases per 100,000 between 2011 and 2015. One-year relative survival for PDAC diagnosed between 2011 and 2015 was 31% overall, 61% for non-metastatic and 16% for metastatic patients. Median survival for patients with metastatic PDAC increased from 2.7 months (95%CI=67-91 days) in 2011 to 3.9 months (95%CI=103-137) in 2015, and from 13.3 months (95%CI=362-460) to 15.9 months (95%CI=425-556) for non-metastatic cases.

More than two thirds of non-metastatic PDAC patients never proceeded to surgical resection, with only 31% undergoing pancreatectomy. There is no state-level data on whether these patients had resectable, borderline-resectable or locally advanced (non-metastatic) disease. Clearly patients with locally advanced/unresectable disease should not proceed to surgery, whereas the only hope for cure of those with resectable disease is complete resection (followed by systemic therapy). Borderline-resectable disease should be treated with neoadjuvant systemic therapy followed by surgery. During this time period, only 1.5% of non-metastatic patients were treated with neoadjuvant chemotherapy or chemo-radiation who proceeded to resection. Future classification of non-metastatic patients as one of these 3 categories is critical to understand how patients are treated, and to enable variations and deficiencies in care to be identified. Discussion of systemic therapy options using this terminology should be undertaken in dedicated multidisciplinary meetings to optimise treatment for patients with all forms of PDAC.

Of those patients undergoing intended curative resection, 77% proceeded to adjuvant chemotherapy or chemo-radiation. This means that nearly one quarter of patients who underwent surgery with curative intent never received intravenous systemic therapy in this time period. As a systemic disease in virtually all patients, treatment with systemic therapy should be at the forefront of management of PDAC and measures to improve this figure should be sought.

Treatment for patients with metastatic disease at diagnosis was more limited. 51% of metastatic PDAC patients did not receive any active anti-tumour therapy, of whom 96% died within one year of diagnosis. End-of-life care remains a priority as one-year survival rates of 31% reflect the sobering reality that most patients with PDAC still die soon after diagnosis and early involvement of palliative care physicians is another important goal at which to aim.

To learn more about the Pancreatic Cancer Summit, click here.

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