This afternoon I’m giving a talk about the discrepancies, or otherwise known probably more appropriately as the variance, of outcomes in care in gynaecological cancer which is an issue that has been within the NHS, or precedes the NHS, for many years. First noted in 1938 that there were discrepancies in outcomes of surgery depending on where the person was looked after. So that’s always been an element that is not surprising to occur within a large organisation.
Sometimes these variances are, what I would call, the bad ones because they may have a negative outcome for patients so we don’t want that to happen. But other variances are good in the sense that it is progress being made and therefore not everybody is going to progress at the very same level. Sometimes it takes time to disseminate information or acceptance of new techniques or new drugs into the profession that can sometimes take some time – up to ten years actually.
Are there any standout centres in the UK?
When you look at centres, irrespective of the specialty, you will always find one or two of them, Birmingham just happens to be one of them, that seem to be performing much better outside what we call the 95% centile. That means they’re on the top range and you’ll always get a few who, at the point of time that you do your analysis, will be below the 95%, the lower part of it. They will fluctuate as time goes along, as people look and see and try to understand why they’re outside the normal range, be it normally focussing on those who are doing poorer rather than necessarily focussing on those who are doing well, which, in fact, looking at the people who are doing well is probably a well worthwhile venture.
Do you know why this is the case?
At this moment actually we don’t. The work is ongoing and there is a large piece of work which the President of the BGCS, Andy Nordin, has brought together and will start which will be looking at the surgical side, in particular, of ovarian cancer which is the main area that we are focussing on because the outcomes in the UK for ovarian cancer are poorer than comparable countries. So that’s a major focus for the society and for everybody in gynae-oncology. So we look at the surgical side of it and we are just completing work through NCRAS, which I’m involved with, looking at the chemotherapy and how that is administered, because both of these treatments are necessary in advanced ovarian cancer, and trying to decipher out are there elements that we can pinpoint where things could be made better. So we’re beginning all that but it’s actually quite a long process.
Could you tell us about your other research?
In the ovarian cancer front I did a trial called CHORUS and at this moment probably one of the more interesting parts is we’ve combined that with a large trial in Europe and have worked together and have planned this in advance. Essentially when you look at the figures that we have it would seem that the concept of what we call neoadjuvant chemotherapy, or giving it first rather than surgery first, is equivalent compared to surgery first followed by chemotherapy, that taking this different approach gives you the same outcomes. But, interestingly, we’ve found in the people with stage 4 disease it would seem that actually starting with chemotherapy is probably preferable and improves their survival. So that’s something that we’re hoping for a publication in the very near future which will show that element of it. That’s the largest series that’s available so far in the world on this approach to ovarian cancer.
There are other things, of course, that will come out of that and elements of research which will be based on the technique or the approach of neoadjuvant chemotherapy. Other work that we’re doing at the moment is in very, very early stages but is focussing on elements of ovarian cancer and circulating cells and the immune impact, if you like, the host immune, the human immune, impact on ovarian cancer. But they’re very much at a seedling stage at the moment but hopefully we’ll generate some interesting results.
The major thing, because Birmingham is quite a large vulval cancer centre, if you understand me, for research, and Jason Yap, who is the lecturer in gynae-oncology, has been doing a lot of work on this over the last few years, it’s been part of his PhD research. From a clinical viewpoint the major finding there is the understanding that in vulval cancer there is what we call in some patients a field effect, that the tissues that may even look normal or mildly precancerous, or at risk of that, actually have the opportunity to develop a secondary cancer. This has implications on how you’re going to excise. When a woman comes with a skin vulval cancer we normally do a very wide excision but actually when you look at when the disease recurs, the wide excision hopefully making that less likely, but in this proportion of patients in fact it doesn’t have that effect. The effect is they get a cancer in the field outside of the area where the primary tumour was. So that changes your approach for these people in their management and identifies women who are at high risk of the disease coming back within areas of skin which carry abnormalities, some of them which are at a molecular basis and we haven’t deciphered that at the moment.
