World Congress on Gastrointestinal Cancer, Barcelona, Spain
The EUREKA Initiative
Professor Cornelius van de Velde – Leiden University Medical Center, Netherlands
I talked today about the EUREKA Initiative; EUREKA today of upper GI, that means gastric and oesophageal cancer, and we already started as an ESSO organisation the EUREKA colorectal which is already well established with ten countries cooperating. The aims of EUREKA is an audit system where you look at outcomes of cancer, not only surgery but cancer treatment, so including medical oncology, radiation oncology, patterns of care but specifically also looking at adequacy of operation and, in upper GI, very important is operative mortality.
I introduced my talk today with some very old pictures of the nineteenth century, gastric cancer was then the most common cancer in the world and the first resections were performed in a number of countries and we only know Billroth from Vienna and still the gastrectomy called a B1 or B2 resection, so he’s well known for it. He had very good results, that was 50% operative mortality whereas all the others had way higher mortality. So my introduction was why was he performing so well and why did he get so many followers throughout Europe? Is it about individual performance; is it about volume; is it about infrastructure; is it about a good multidisciplinary team, diagnostic pathology, radiology etc? Obviously it’s all of that but volume plays a very important role. We did outcome registries in the Netherlands and we centralised oesophageal cancer approximately twelve years ago. We saw a frighteningly high operative mortality of 14% going down to 4%, so a dramatic improvement, and not only in operative mortality but also in curative resections, resectability, in-hospital stay and even in survival. We did not centralise gastric cancer like many countries did. There is a decreasing incidence of gastric cancer currently and so it was still an all surgeons operation. There was some tendency of specialisation into surgical oncology or gastrointestinal surgeons but not in the sense that certain hospitals would not do the operation any more. That was shown in the Netherlands, but also in other countries, that this centralisation effect in oesophageal cancer had a dramatic effect and it did not happen in gastric cancer. So we did something wrong, and not only in the Netherlands, obviously, but also in other countries. So now, as of this year, we are centralising gastric cancer as well; we are starting now with upper GI cancers, both for gastric and oesophageal cancer and also looking at the infrastructure. And this auditing system we started before in colorectal cancer has the effect that all the disciplines involved, but especially surgery, it’s a surgery initiative, improve every year. I told about the EUREKA upper GI initiative which is made by the European Society of Surgical Oncology, but now also ESMO and ESTRO under the ECCO umbrella is doing this. I showed differences in a number of countries. We looked at Sweden, Denmark, the Netherlands and the UK and we saw that there is indeed a volume outcome relationship and that is for oesophageal cancer more than forty cases and for gastric cancer more than twenty cases.
Could you define high volume?
That was the question, of course; I also asked myself what is high volume? So you have to look at these kinds of datasets and see are differences still significantly better when you increase the volume further. At this conference tomorrow, my good friend Takeshi Sano will talk about gastric cancer surgery in Japan. There are still very high volume hospitals - he comes from a hospital where there are more than 700 cases per year in his department. Obviously you have a very experienced team there, we do not have that in the Western world but we should have dedicated teams, not only in surgery but very important in post-operative mortality and selection of patients, but also in the other disciplines – radiology, pathology, medical oncology, radiation oncology. So it is not only volume, I demonstrate that, that in Sweden you do not have that high volume centres but centres with very good infrastructure that can produce good results.
The specific aspect I didn’t mention specifically of Sweden is that they put their results publically on the internet so, as a patient, you can see I’m going to that hospital, you can see how many cases they did last year, what is their operative mortality. So there is a more natural change that patients will go to the centres which have the best results. You have to be careful with that, I often give the example of President Clinton being operated in a hospital in New York for his cardiac surgery with the highest mortality but also the most experienced in high risk patients. So you have to make a case mix and see what kinds of patients are treated there. So my plea is also that eventually all these results will become public so available for patients in the first place, because that’s what it’s all about; for treating the medical community, but surgeons, the medical community, is in charge in organising this, and not insurance companies and not the government or other structures.
Are patients the best group to use in this setting?
Yes and no. We, in the Netherlands, had patient organisations coming with lists of best hospitals; we have newspapers coming with best hospitals. There is no correlation whatsoever what are the criteria to be a best hospital – nice doctors, good coffee, parking space or really the operative results. So I think as professionals we should be in charge and obviously should incorporate patients as well to have their experiences in the outcome. So it can be that technically you’re very well treated but that the patient communication is not very good. And that is all things – look at your results, have them compared with others and see where you can perform better and give initiatives to perform better.
What is the take home message from your presentation?
Contrary to it is important that new drugs are developed, that radiation therapy is involved, but such fast improvements can be made by restructuring your care. It’s very important in doing so that the medical profession itself takes charge and is leading that restructuring. That’s for the benefit of every cancer patient. Very little improvements in certain drug combinations are important for science but this is really an improvement on a nationwide and perhaps European scale. So we have to convince politicians also in Europe to invest, not only for upper GI, for colorectal but also for all kinds of other cancers, the audits will come in Europe and will be managed through the professionals and also have consequences. This is not for free, when you perform not very well, you have to stop or retrain or reorganise.
Could you briefly discuss staging laparoscopy?
Staging laparoscopy, I gave an example of some 15,000 patients from the US where in staging laparoscopy the operative mortality was 4% where it was well over 10% in a futile laparotomy. So to open a patient and to close it again without doing any resection alone carries a 10% operative mortality. That would be a plea of performing a laparoscopy rather than a laparotomy where you have to recover from that. So I agree with that notion. What I pled for was that also laparoscopic resections in early gastric cancer should be part of the equipment of a team, of the capabilities of a team, so that you do not perform a laparoscopy, refer a patient to elsewhere. No, the patient should be staged at a high volume centre where surgeons are also capable of performing laparoscopic resections, which carry less in-hospital stay, can be performed very adequately so are more pleasant for the patient to perform. So I see more or less, not an increasing role for laparoscopic evaluation, I see it as part of the treatment and then perhaps continue, even in laparoscopic resection.