European Breast Cancer Conference, Vienna, March 2012
ECCO and cancer care in Europe
Professor Cornelis van de Velde – President of ECCO
Professor van de Velde, congratulations on taking over the role at ECCO and steering the good ship on.
And thanks for giving us a couple of minutes to talk about ECCO under your role, in a visionary sense really. You’ve always been a visionary, we’ve known each other for thirty years, I suppose, 1980 I think we first met, and you’re always looking ahead and you’re looking at how things will go. I don’t think there’s anybody could argue about last year’s meeting in Stockholm, the European multidisciplinary one.
It was a huge success.
It was terrific and before that there was worry about whether it all could be brought together and it could be really a multidisciplinary meeting which reflected what happens on the ground treating patients in multidisciplinary teams. Tell me what’s going to happen now, you’re rolling that forward.
Absolutely. Indeed, the success of Stockholm emphasises the need for multidisciplinary meetings and also that a number of societies who are mono-discipline, see the advantage of being together in panels and seeing the advantage of the comments of the other disciplines. A number of disciplines are not yet included, like radiology, pathology, in the ECCO organisation and we are in contact, with them also because, in our multidisciplinary meetings, a radiologist and a pathologist is the standard there and all decisions are taken around their advice. So my mission is indeed to enlarge the multidisciplinarity in Europe and visualise that in all the different countries and societies more and also put cancer more on the agenda also of the European Union, that cancer is the most prominent disease killing people now in the current century and that should be evident in priorities in health research.
How do you persuade the doubters that multidisciplinarity is the way forward?
Well there are so many data of studies indicating that when you have discussed, for instance in rectal cancer, we have made enormous progress from an age of fifteen years ago with a lot of local recurrences. Now we have good MRIs for staging, we discuss what kind of radiation therapy an advanced cancer should be given, then we operate at the time that is the best for the patient and also considering the risk of this operation for the patient. So there is a lot of input from all the disciplines that we also, I’m by profession a surgeon, as a surgeon should know what are the possibilities but not only in the room in a one-to-one conversation with the patient but in this multidisciplinary team we make treatment decisions which, more or less, are already tailoring treatment because we are tailoring treatment for fifteen years but in fact it’s only still quite limited. And you already have, for the patient, more or less not only a second but a third opinion because it’s a group and team decision rather than a one-to-one decision.
Do you do research in a multidisciplinary team?
You encourage research and what we did in a number of… there’s the EUROCA (?) study, which is an epidemiology study that I, myself, am involved in, and in EURECCA, the European registry of cancer care for colorectal, also for upper GI, we can see that patients who have been discussed in a multidisciplinary setting have a better prognosis than those who are not, have less positive margins. So there’s a lot of advantages for the individual patient to be part of a multidisciplinary team decision. On the other hand, still being in a multidisciplinary team working, you have to be audited, you have to show your data to others and see how you compare to others, and that is auditing that you have mirror information for the hospitals and then you can see that still within a country, and especially within countries, enormous variation where we can learn more, especially in groups that are usually not included in clinical trials. For instance, there is no real evidence based guideline for elderly patients with cancer where hazards of surgery can be enormous, increasing over 75, but also of additional treatments and the burden of additional treatments like chemotherapy, your own profession, or even hormonal therapy. So this is all things we still have to learn from each other, including now also research identifying patients who are more benefiting for certain treatments than others.
I have a passion about this low number of patients in clinical trials and it seems to me that ECCO is an ideal showcase for the best that’s around because most of our clinical trials nowadays, apart from new targeted agents which hit one receptor, never mind the cancer, I think that ECCO is the ideal showcase for these multidisciplinary clinical trials. What’s your approach to the non-believers? Is it shame and blame, or how do you…? Do you say, “Here’s the data”?
I’m heavily involved in the audits we set up in the Netherlands and more or less use the Scandinavian countries as an example. There was a diminishing in the Scandinavian countries of the number of hospitals treating certain cancers because there certainly is a relationship with volume and outcome, you can also only maintain a team when you have enough volume to sit together every week. Secondly, every year you could see an improvement, despite that guidelines or machineries were no different. So the interaction really proves to be better. ECCO is not a trial organisation, EORTC is a trial organisation, so trials are important to answer certain research questions but good databases and good control can enhance that even further. In the Netherlands by doing a quality control we improved rectal cancer outcome survival by 10% in ten years, just by having this multidisciplinary interaction and changing practice.
What’s important about a trial which is frequently overlooked is the dissemination of the results. I believe that EORTC is a member of ECCO and does superb trials and we saw last week the 50th anniversary of how spectacularly important that had been. But ECCO is now the showcase, in my view, and I think over the next five years or so we’ll see more of the top class clinical research results being presented at ECCO than, say, at ASCO or AACR because people are now getting a feeling of self-belief that we actually do good stuff in Europe.
Honestly, I must say, there was more news in Stockholm than at ASCO, more new clinical trials and more innovative research presented there than at ASCO and I think in quality we are already better than ASCO. Obviously we are really a multidisciplinary organisation, ASCO in essence is a mono-disciplinary organisation, now with specialities like ASCO GI involving also other disciplines. But already we have established that we should improve that further and, of course, we have nurses, we have all the organisations and the research organisations on board to together get a higher level with every conference.
The consumer is the patient or the pre-patient, in planning your next meeting how are you going to have the patient’s voice heard, how are you going to make it clear that actually you’re not just having a nice freebie in a nice city but actually you’re going to be delivering something of great value for the patients at grass roots level?
The next ECCO meeting will be in Amsterdam and obviously patients are involved, also here are the breast patient organisations at EBCC present, but that’s not the way I want to demonstrate that. Before the opening ceremony there will be a patient-oriented symposium where two patients, leaders in the world, that are all convinced of multidisciplinary care, explain what advantages have been made so that it is with very good editing of this whole thing. It will be a public symposium for the patients but also for the new generation of students, high school students, that can come there for free and it will be broadcast. So that’s towards the patient and then, of course, we have science and education at the conference itself with patients and nurses and other disciplines’ involvement, but for the patient is this public symposium.
I like the innovation at Stockholm of patients sitting in the education sessions and being able to ask questions of the learned expert who was on the panel and the learned expert having to explain in language that the patient understood what, indeed, it was all about. And I thought that was innovative and I thought it worked and I personally would like to see more of that.
Yes, obviously we involve patients in the oncopolicy, in convincing the politicians of the importance of oncological research. The second thing that needs improvement in Europe is that for certain cancers there are 20-25 guidelines, national guidelines, consensus guidelines with a group of experts sitting together in an afternoon and publishing this. There should be good rules of how to make guidelines based, not only on evidence, but especially, for instance on the elderly, on the evidence that’s there from cancer registries how are patients treated. Certain differences between the countries do not lead to different outcomes and others do so we have to learn more from the registries and in these aspects patients’ input is very important. So in guidelines we are setting a meeting and will organise certain meetings that all the organisations are involved, including patient organisations, with the hope that this will really be accepted as European guidelines.
ECCO, of course, was a partner in the FP7 project, Eurocancercoms, and out of that came a very stark message that 90% of guidelines have been set up without the patients being involved.
We need to carry that message through into the next ECCO. You’ve mentioned the heterogeneity of outcomes and this, I know, has been a passionate concern of yours at ESSO and beyond. One of the issues that you also just mentioned in passing was the care of the elderly patient. Now we are going to have more and more elderly patients in Europe, thanks to a lot of other good things that have happened in healthcare, and we’re not doing the clinical trials in this group of patients, we are looking at the date of birth and deciding this is how we don’t treat the patient, we’re withholding the patients actively and we know this from an ecancer symposium we ran in Rome on haemato-oncology. This is a fixable area of heterogeneity.
Yes, well this is a priority. The reason that this morning I organised and chaired a session on elderly breast cancer patients, which had a thousand participants which was more than I expected, considering all aspects of surgery, of radiation therapy, of systemic treatment, of quality of life, of over-treatment, of number needed to treat and all these aspects should be further developed in perhaps onco-geriatric assessment of these patients before treatment decisions are taken because they are taken on evidence-based guidelines from clinical trials with elderly patients not included at all. So they are not to be extrapolated, we are not treating these patients on an evidence-based basis so we have to give that a priority.
So the geriatricians are in there with the groups of people who have yet to join ECCO?
Along with the psychologists and two or three groups, I think this is very exciting. So you’re actually increasing the number of disciplines coming to the party?
That’s right, yes. And there should be a good interaction and also a good motivation for all these people that ECCO is really the one voice for cancer in Europe. And when they want to address something, do that jointly together and not as a fraction of one of the societies.
President van de Velde, thank you very much indeed. Inspirational leadership and I know that ECCO in Amsterdam will be fantastic.