Pancreatic Cancer

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Why a Cancer Center
Murray F. Brennan, M.D.
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Why a Cancer Center?

• Is cancer going to be a problem?

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Estimated Global Incidence Rate All Cancers
by Age
Wilson CM, et al. Int J Gynecol Cancer
141-112004.
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Predicted Cancer Incidence Developing vs
Industrialized Countries
Kanavos P, Ann Oncol 17vii15-vii23, 2006.
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Increase in Cancer Mortality 1990-2020
Wilson CM, et al. Int J Gynecol Cancer
141-112004.
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Incidence Mortality for Most Common Cancers in
Less Developed More Developed Countries
Kanavos P, Ann Oncol 17vii15-vii23, 2006.
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Why a Cancer Center
Premise
Cancer Care is disease based not discipline
based
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Why a Cancer Center
Premise
When you focus your activities you improve
outcome
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Table of Contents
Why a Cancer Center

• 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

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Why a Cancer Center
Outcome Measures
Improve Survival Improve Quality of Life
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Why a Cancer Center
Improve Survival

• Prevention
• Accurate diagnosis
• Early Diagnosis
• Improved treatment
• Improved quality of life
• Improved Care

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Why a Cancer Center
Improve Survival

• Prevention
• Smoking cessation

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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.
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Smoking Rate for Men Women Combined
Mackay J, Eriksen M. The Tobacco Atlas. WHO
2002.
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The Demographics of Tobacco Kenya
Mackay J, Eriksen M. The Tobacco Atlas. WHO
2002.
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A Hard Days SmokeNairobi, Kenya
Minutes of labour worked to purchase 20 cigarettes
Mackay J, Eriksen M. The Tobacco Atlas. WHO
2002.
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The Business of Tobacco Kenya
Mackay J, Eriksen M. The Tobacco Atlas. WHO
2002.
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Uganda
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Why a Cancer Center

• Screening Early Diagnosis Improve Outcome

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Cancer Control Programs in Brazil
Wilson CM, et al. Int J Gynecol Cancer
141-112004.
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• TIS n 21
• T0 n 42
• T1 n 416
• T2 n 550
• T3 n 750
• T4 n 42

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Gastric AdenocarciomaRO Resections by Time

• 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 lt 0.001
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Why a Cancer Center
Improve Survival

• Improved Care
• Patient
• Accurate diagnosis
• Appropriate first treatment
• Volume outcome
• Surgeon
• Volume vs outcome
• Institution
• Efficiency of scale
• Resource utilization

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Why a Cancer Center
Accurate Diagnosis

• Centralized referral
• accuracy
• efficient use of resources
• standard for the nation

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Soft Tissue SarcomaHistopathology
1309
1037
1104
406
2758
184
204
MSKCC 7/1/82 6/30/06 n 7002
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Non EWS family gene fusions in sarcomas
65
35
lt1
75
10
99
99
50?
99?
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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

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Pediatric Sarcomas Confirmed in Older Adults
(gt50) 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

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Why a Cancer Center

• Does centralization make a difference?
• If it does, how do we measure success?
• Does volume matter?

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Why a Cancer Center
Questions

• Does volume matter?
• surgeon volume?
• institutional volume?
• Does surgical specialization / training matter?
  

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Why a Cancer Center
Outcome vs Volume

• Operative survival
• Long term survival

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Why a Cancer Center

• Perioperative Mortality

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Operative Mortality by Hospital
VolumeEsophagectomy
n 503 p 0.001
Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA
2801747-1751, 1998.
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In-Hospital Mortality Hospital and Surgeon
VolumeIncrease in Mortalitycompared to high
volume surgeon, in high volume hospital
Hannan EL, Brennan MF, et al Surgery 1316-15,
2002.
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Why a Cancer Center

• Volume does matter in perioperative mortality /
  morbidity
• What other factors influence outcome
• Sex
• Race
• Age
• Socioeconomic

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Hospital Volume vs Colon Cancer
Hospital Volume 1991-1996
p lt0.001
SEER Medicare n 27,986 Schrag D. JAMA
2843028-3035, 2000.
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Why a Cancer Center

• Volume matters for operative mortality
• what about operative morbidity
• length of stay

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Adenocarcinoma of the Pancreas - Resected
Median Length of Stay (days)
Year
MSKCC 1984 - 2006
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Why a Cancer Center

• If volume matters, how much is enough?

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Why a Cancer Center

• Volume levels have to be procedure / disease
  specific

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Hospital VolumeVariation in Volume Loads
Quantiles Procedures/year
Medicare 1994-1999 Birkmeyer JD. N Engl J Med
3461128-1137, 2002.
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Why a Cancer Center

• Measures of success
• perioperative mortality
• length of stay
• cost
• long term survival

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Why a Cancer Center

• Volume matters in perioperative outcome,
• but does it matter in long-term survival?

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Why a Cancer Center

• Does specialization matter?

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Outcome and SpecializationColorectal Cancer
Specialist vs Non-specialist

• 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)

n 5173 Smith JAE, et al. Br J Surg 90583-592,
2003.
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Colorectal CancerFive Year Survival Specialist
vs Non-specialist by Site
n 5173 Smith JAE, et al. Br J Surg
90583-592, 2003.
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Breast Cancer - Specialist vs Non-SpecialistRelat
ive Failure Rate vs Volume
Surgeon Volume / Annum
n 29,666 Skinner KA. Ann Surg Oncol
10606-615, 2003.
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Breast Cancer - Specialist vs Non-Specialist
Overall Survival
n 29,666 Skinner KA. Ann Surg Oncol
10606-615, 2003.
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Why a Cancer Center

• 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

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Why a Cancer Center

• If institutional and surgical volume
• and specialist status matters,
• can society afford high volume, specialist
  centers?

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Why a Cancer Center

• Has anything changed?

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Operative Mortality Improvement with Time or
Volume
1994-1999 Medicare Goodney PP et al. J Am Coll
Surg 195219-227, 2002.
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Why a Cancer Center

• Improved Treatment

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Table of Contents
Why a Cancer Center

• Improve cancer care
• Focus resources and people
• Provide direction for others
• Maximize use of resources
• Maintain and retain staff
• Educate
• Research

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Why a Cancer Center

• Focus Resources and People

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Distribution of Health Workforce by Cadre
WHO AFRO 2006.
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Why a Cancer Center

• Premise
• The future of a Department, Institution , or
  Country lies in their commitment to the young

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Why a Cancer Center

• Educate and retain the Next Generation
• - EDUCATE

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Educate the Next Generation
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Focus Resources People
WHO AFRO 2006.
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Why a Cancer Center

• Educate and retain the Next Generation
• -RETAIN-

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ECFMG 1958-2005New Applicants vs Number Certified
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.
Hollock JA. Acad Med 81S7-16, 2006.
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Number Source of Physicians Entering Training
in 2003(23,681 entered in training 2003)
Based on AMA estimates (2004)
Edward Salsberg, Director, Center for Workforce
Studies, AAMC
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Positions Offered / Filled in NRMP General
Surgery US Graduates
AAMC Data Book 2007
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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
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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 140359-361, 2006.
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Why a Cancer Center

• Retain Staff and Recruit Back Faculty

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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 81S7-16, 2006.
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Foreign Trained ApplicantsMatched to Surgical
Residencies ( of total foreign
matched)2002-2006
AAMC Data Book 2007
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Fellowship Positions Filled by International
Medical Graduates 2000-2004
Adapted from Stitzenberg KB, J Am Coll Surg
201925-932, 2005.
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Why a Cancer Center

• The problem is not only do people leave, they do
  not return.

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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

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Memorial Sloan-Kettering Cancer Center
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Why a Cancer Center

• The environment is not just money, although
  money, once attained is rarely overcome by
  environment

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Focus Resources PeopleversusDecentralization
of Resources People
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The Privileged WorldversusThe Less Privileged
World
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Why a Cancer Center

• An agenda no matter how right will not succeed
  if it confronts a greater political expediency

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Adapt or perish, now as ever, is nature's
inexorable imperative. H. G. Wells Author
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