15th Congress of the European Society of Surgical Oncology (ESSO), 15–17 September 2010, Bordeaux
Lynda Wyld – ESSO Education Committee
Bert Bonsing – ESSO Education Committee
Pierre Mordant – ESSO Alumni Club
ESSO 2010 highlights
Interviewed by Peter Goodwin
PG: Welcome to ecancer.tv in Bordeaux at the European Society of Surgical Oncology meeting. Three speakers are with me right now, near the end of the meeting: Pierre Mordant from France, from Paris, it’s great to be in your country; on my immediate left Lynda Wyld from Sheffield and also Bert Bonsing from the Netherlands. You are, if I may say so, representing the younger element of surgeons here. We’ve been hearing from some of the older, more established surgeons, President, past President, future President of ESSO. What are your feelings, perhaps I can start with you Lynda, your feelings about the developments you’ve heard here and the possibilities of improving things like quality, for instance, in surgery.
LW: The first thing to say is it has been a very educational meeting with some extremely respected speakers from all over the world. Certainly we’ve heard some very interesting talks presenting some of the most up-to-date advances in a range of different surgical specialties. I have two main specialties, breast surgery and sarcoma surgery, and we had some presentations from one of the most respected sarcoma surgeons in the world, Professor Murray Brennan from the Memorial Sloan-Kettering Cancer Center in America, which was very interesting and informative. Also the current President of the EURCT sarcoma group talking about chemotherapy advances, which again was very state of the art and very informative.
PG: In both breast and sarcoma, we’ve heard about things like over-treatment, haven’t we?
LW: There’s always an element of over-treatment; in breast surgery, certainly, there is concern about over-treatment in particular in relation to breast screening where we think we over-diagnose cancers in ladies where the cancers would never have troubled them during their lifetime. But it’s generally accepted that that is a price that you have to pay to be able to treat people at an earlier stage, and you have to take the view that what you’re doing is to the benefit of the population, not necessarily purely to the benefit of each individual woman. But, for example, in screening we know that we do definitely save lives from breast screening; the price that we as a population pay for that is that some women may be told they have cancer and treated for that cancer when that cancer would never have affected them. So you have to draw the line and set your standards somewhere.
PG: And the treatment may cause other complications?
LW: It may indeed, yes, always.
PG: And Pierre, at the Hôpital Bichat, you’re specialising in thoracic oncology. What have you got out of the meeting so far and what are your fresh feelings?
PM: I would say two different points. The first one is with the general management of surgical oncology, we got a very good presentation regarding quality assurance and management in the operating room which are common to every speciality, so it has been very interesting. Some others regarding lung cancers, there has been a topic on treating lung cancer in the elderly with interesting studies, so altogether it has been very informative.
PG: Chemotherapy has become more prominent, or very prominent, in lung cancer but do you think surgery is still the most significant factor?
PM: I think so. Right now it’s difficult to say that you are going to cure definitively a patient without surgery right now in lung cancer because with either chemotherapy or chemoradiotherapy it’s possible to have control of the disease at a certain stage but it’s not possible to achieve a long term survival. Some of the agents of chemotherapy or targeted therapies have been quite disappointing so definitely surgery remains a cornerstone of lung cancer treatment.
PG: And presumably some of the new ways of imaging and greater accuracy that seems to be emerging may be helping you as a surgeon?
PM: Yes, what we have seen here is new tools to identify, for example, lymph nodes. Right now it’s not applied in lung cancer but maybe during the next step. We have seen some great things about circulating tumour cells in breast cancer but it may also be the next step in lung cancer. So that’s the basis of this kind of congress, is that you can pick up something from other organs and try to bring it into your own speciality.
PG: Bert Bonsing, in the Netherlands, in Leiden, you have the privilege of treating patients with rectal cancer and pancreatic cancer, neither of those are the easiest diseases to deal with. What’s been new in this meeting that you’ve come across?
BB: Well the thing that surprises me the most is that finally we get some centralisation for pancreatic surgery and also for the more complex cases of rectal surgery going in Europe. There are promising results that, in regions and in countries, people are more and more aware that this kind of surgery is specialised surgery and should be treated in centres which can create, in that way, a high volume and get better results. My view on this congress is that it’s the first time that everybody is really aware of that and is trying to incorporate that in daily business. So I’m optimistic about that.
PG: What do you think are the reasons to be optimistic in both rectal cancer and in pancreatic cancer?
BB: I’m optimistic because everybody gets more and more aware that to get better results you need to talk with each other how to describe in the literature, how you treat your patients, so you can compare and get to a higher level. People are getting more and more aware of that, that’s the main thing for both rectal cancer and pancreatic cancer. I must also say that in the papers I’ve seen that we see that treatment during the operative period is getting better and better. More people are getting through this kind of surgery in a better way and that’s a real achievement.
PG: Now we’ve heard quite a lot at this congress about multi-disciplinary approaches; we’ve heard about quality being very important, I want to ask all of you what you think about the way things are going, perhaps ladies first. The way things are going at the moment, as compared with how they were, there’s a lot of huge experience from some of the surgeons of the past but what do you think is happening at the moment?
LW: I think multi-disciplinary team working is becoming the norm across Europe and is translating into some big improvements in the quality of care. There is also greater standardisation, not only within countries, but across the boundaries of Europe where people are sharing best practice. There’s wider availability of knowledge about how to optimise treatment and people aren’t just being seen by one person who makes the decision about their care, perhaps in isolation of the best knowledge of optimised practice. Now there will be a team of people deciding on care – a surgeon, an oncologist, often a specialist nurse with an interest or with a focus on the psychological aspects of the cancer, all working together to try and make sure that each individual patient gets the very best care for their needs. That, I think, is really something that has become a huge theme in cancer management in the last ten years.
PG: If I can ask you about one of your specialisations, breast cancer. There are huge international variations in outcomes in breast cancer, this is clearly due to the way that you arrange it all, what are we doing right in some places and what are we doing wrong?
LW: It’s controversial because if you actually look at the data on which the headline banner about variation in outcomes is based, a lot of the variation is actually accountable for by changes in data recording and data quality. So I suspect if you could sub-analyse the data to get rid of that variation, you’d find that the variation was a lot smaller than it actually is. There are differences across Europe; we know that we have a lot of work to do in certain parts of Europe where they don’t even have access to routine breast screening. So those are issues that, as people involved in ESSO, we’re very keen to address. But generally, meetings like this are helping to raise the standards across Europe, particularly the new accession countries where perhaps the finances haven’t been quite so strong and we’re trying to bring them in to the fold and to help to raise their standards and give them as much support as we can.
PG: And Pierre from France, how do you think France performs extremely well in cancer? Is this in the realm of the surgeons or is this more to do with the way oncology is organised at a national level?
PM: It’s because now things are getting more organised. It used to be very disparate with a lot of centres and we tried to centralise it and to deal with cancer as a multi-disciplinary approach. At the beginning surgeons were afraid of it because they used to think that they were losing the decision and they are going to lose patients but what we have seen and what is reported in the Dutch experiment with pancreatic cancer is that when you centralise the patients you have more patients that go to surgery because the pre-operative care is better and maybe the surgeons are a little bit more active. So altogether surgery does not lose patients, patients are still well treated. So if we act with other specialities we don’t lose the decision and we don’t lose the patient.
PG: It must be quite difficult for surgeons to improve in lung cancer because the fact is making the improvements may be out of their hands?
PM: No, I don’t think so. We have much to improve regarding perioperative care because right now the mortality after lung cancer resection is less than 3% but it’s still usually more than 1% or 2%. So we can improve that and the goal is to send more patients to surgery. So some patients are said to be locally advanced but we can try to make larger resections. The other thing is with metastatic disease we know that it’s possible to operate on a patient with metastatic disease if it’s only one or two metastases, we can operate on the metastasis and the primary tumour. So the goal is to bring more patients to surgery and to have a better outcome for surgery.
PG: And Bert, from your experience in the Netherlands with pancreatic cancer, can you give us any examples of just how organisation, and particularly surgery, needs to be improved to optimise results for those patients?
BB: Yes. In the Netherlands now we’re making more effort to get audits working, so real, correct, data collection and data collection makes a comparison between centres, but also between countries, possible. In former days especially data collection is something which has an enormous influence on the results shown at congresses and what we see, and has been shown here also in the congress, is that when your data collection is more sophisticated you see that there are other trends which you normally don’t see.
PG: So how much would you encourage surgeons to be more systematic and, in fact, very rigorously scientific in their approach? Presumably they are at a very high level already?
BB: We’re at a high level already but scattered not only in my country, we’re working on that, but also in Europe. So we should get the same kind of definitions, the same kind of collecting of data and then it’s comparable.
PG: Can I ask all of you how you react to the suggestion that, for example, hospitals or centres which perform better at surgery than others need to be informed and made more prominent and those who are perhaps not doing so well should be informed that they’ve got to pull their socks up?
BB: I think it’s very important to have control in your case mix. What we don’t want is that people who have a less good position in front of the operation will be rejected because you want to have good numbers from your hospital. So that’s not the way to go. The way to go is to see that you get the correct data with good case mix control and when it’s not OK, the numbers you make them, of course you stop.
LW: This has been a long-term issue about what you might call league tables and it’s been very controversial in the UK. Bert makes the absolutely valid point that sometimes a hospital may have poorer outcomes because it is sent all the really difficult cases that the smaller hospitals don’t want to deal with. It’s very damaging then to say to that hospital, “Well, we’re going to audit your work and if you fall below a certain standard we’re going to stop people coming to you,” because they will then start turning those difficult cases away. Now obviously we need quality control and most specialties now have good means of quality control; in the UK we have something called quality assurance and peer review, I’m sure there are similar systems in France and the Netherlands, and they have to look at the sort of cases referred in in terms of the level of difficulty when they are assessing outcomes. Yes, there will be some units that fall below standard and that has to be addressed but I don’t think necessarily making the crude, unadjusted data public so that patients can choose themselves is terribly meaningful if that data doesn’t mean what it appears to mean at face value, if that makes sense.
PG: Is it any easier in France, Pierre?
PM: No, it’s not easier, it’s the same problem. We are focussing more on quality assurance because just having a look to the outcome is difficult, the case mix is never perfect and we know that there is a centre effect where when you increase the number of patients you treat, at the beginning you increase your results but at the middle of the bridge you will see that things will go down a little bit, your results will be worse because you will have attracted the more difficult cases. So this is a large centre effect, we know this in surgery, so we have to look more at the process and the quality of what we are doing than just looking at a survival rate, otherwise we would only treat people who are not really sick.
PG: I want to ask you all for a wish list. When each one of you is President of ESSO, what would you like to do for improving surgical oncology? Everybody is looking at you, Lynda.
LW: That’s a difficult one to land on someone at short notice; I think there are so many things that would be nice to do. Better quality training for young surgeons which is standardised across Europe would be quite high on that list, as would standardisation of protocols, standardisation and optimisation of protocols so we can reduce some of the differences between EU countries which presently exist.
BB: The same for me. I also joined the ESSO course on liver surgery a few days ahead of this congress and there were some guys who operate a lot on liver metastasis from colorectal cancer. What you see on that kind of course is that the level of the group is growing within 48 hours so that education of the people who should do the surgery is the main topic. All the other things are very worthwhile but training is essential, so that’s high on my wish list.
PM: The same for me because what we are seeing in France is that the training used to only be at the end of residence and what happens now is that we have time limiting policies, we’ve got increasing technologies in the operating room and we have to deal with both. So training should maybe be more organised and it would be a great idea to go across Europe and to see because there are lot of expert people and we can have a look because it’s so close.
PG: So good training is very high on the agenda. What, from this particular meeting of ESSO here in the beautiful town of Bordeaux, are we going to take home as perhaps one or two of the really important things from each of you? Practical things for doctors to remember?
BB: From my point of view it’s that we are now bridging the gap between the very sophisticated CT scans and MRIs with near visible light monocular imaging to the operating room so we can translate what we see on the photos to what we see in the patient. That’s one of the main topics in surgery during this congress in my topics.
LW: The message I’m taking home from this meeting is that the standard of care that we’re giving patients across the board in surgery is improving year on year, which I find incredibly reassuring. It has also highlighted a number of areas where we still have work to do, which gives us ideas for the next ten years’ worth of work.
PM: I have been very surprised by the EUROCARE project on colorectal cancer and the use of databases to improve the quality of care. Just the hour after I’ve seen a study based on a national database in France and so definitely realising that what I will do when I come back home is trying to participate in this database in order to have a better level of quality index to know and to be able to compare with other surgeons and to give data in order to make studies afterwards.
PG: Pierre Mordant, Bert Bonsing and Lynda Wild, thank you all very much for taking part in ecancer.tv here at ESSO in Bordeaux. I look forward to seeing what you all come up with in the future.
