Why a Cancer Center Murray F. Brennan, M.D.
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.
Increase in Cancer Mortality 1990-2020 Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004.
Incidence & Mortality for Most Common Cancers in Less Developed & More Developed Countries Kanavos P, Ann Oncol 17:vii15-vii23, 2006.
Why a Cancer Center Premise Cancer Care is disease based not discipline based
Why a Cancer Center Premise When you focus your activities you improve outcome
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
Why a Cancer Center Outcome Measures Improve Survival Improve Quality of Life
Why a Cancer Center Improve Survival: • Prevention • Accurate diagnosis • Early Diagnosis • Improved treatment • Improved quality of life • Improved Care
Why a Cancer Center Improve Survival: • Prevention • Smoking cessation
Past & future Annual Deaths due to tobacco estimated worldwide 1950-2030 projected 7 Million projected 3 Million projected 2.1 million 2.1 million 2025 to 2030 1.3 million 2025 to 2030 0.3 million 0.2 million negligible 2000 2000 1975 1950 1950 1975 industrialized countries developing countries 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.
49% 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.
Why a Cancer Center Screening & Early Diagnosis Improve Outcome
Cancer Control Programs in Brazil Wilson CM, et al. Int J Gynecol Cancer 14:1-11:2004.
TIS n = 21 • T0 n =42 • T1 n = 416 • T2 n = 550 • T3 n = 750 • T4 n = 42
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 < 0.001
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
Why a Cancer Center Accurate Diagnosis: • Centralized referral • accuracy • efficient use of resources • standard for the nation
Soft Tissue SarcomaHistopathology 1309 1037 1104 406 2758 184 204 MSKCC 7/1/82 – 6/30/06 n = 7002
Non ”EWS family” gene fusions in sarcomas 65% 35% <1% 75% 10% 99% 99% 50%? 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
Why a Cancer Center Does centralization make a difference? If it does, how do we measure success? Does volume matter?
Why a Cancer Center Questions: • Does volume matter? • surgeon volume? • institutional volume? • Does surgical specialization / training matter?
Why a Cancer Center Outcome vs Volume • Operative survival • Long term survival
Why a Cancer Center Perioperative Mortality
Operative Mortality by Hospital VolumeEsophagectomy n = 503 p = 0.001 Begg CB, Cramer LD, Hoskins WJ, Brennan MF. JAMA 280:1747-1751, 1998.
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.
Why a Cancer Center Volume does matter in perioperative mortality / morbidity • What other factors influence outcome • Sex • Race • Age • Socioeconomic
Hospital Volume vs Colon Cancer Hospital Volume 1991-1996 SEER – Medicare n = 27,986 Schrag D. JAMA 284:3028-3035, 2000. p <0.001
Why a Cancer Center Volume matters for operative mortality • what about operative morbidity • length of stay
Adenocarcinoma of the Pancreas - Resected Median Length of Stay (days) Year MSKCC 1984 - 2006
Why a Cancer Center If volume matters, how much is enough?
Why a Cancer Center Volume levels have to be procedure / disease specific
Hospital VolumeVariation in Volume Loads Quantiles Procedures/year Medicare 1994-1999 Birkmeyer JD. N Engl J Med 346:1128-1137, 2002.
Why a Cancer Center Measures of ‘success’ • perioperative mortality • length of stay • cost • long term survival