Towards Multidisciplinary Cancer Care at KKH- Najran

Ahmed Badheeb , MD. Professor Of Oncology & internal medicine

King Khalid Hospital- Najran

Objectives

• Cancer : the size of the problem in Najran• Cancer unit : the goals.• The Tumor Board at KKH: functions & guidelines• The importance of multidisciplinary approach.

Cancer in Saudi Arabia : Cancer in Saudi Arabia : 20042004

Cancer in Saudi Arabia : Cancer in Saudi Arabia : by sexby sex

Cancer in Saudi Arabia : Cancer in Saudi Arabia : by ageby age

Cancer in Saudi Arabia : Cancer in Saudi Arabia : by ASRby ASR

In Najran: In Najran: GeneralGeneral

MalesMales::::In NajranIn Najran

In Najran: In Najran: femalesfemales

There is an urgent need for Cancer registry

• Saudi Cancer Registry (population based).

• Hospital based registry

Objectives

• Cancer : the size of the problem in Najran

• Cancer unit : the goals.• The Tumor Board at KKH: functions & guidelines• The importance of multidisciplinary approach.

Goals of the oncology Service:

• A comprehensive evidence based cancer (including the psycho-social care).

• To be a nucleus for the upcoming cancer center.• Training Centre for the doctors, medical students,

nurses ,pharmacists, social workers, etc.• Cancer registry service (both hospital based & population

based).• Cancer research .

Phases of the development• Phase (I): Medical & surgical oncology (?).• Phase(II): Nuclear medicine• Phase (III): addition of radiation oncology service.

Phase : 1

Chemotherapy Preparation room

Chemotherapy infusion room

Chemotherapy infusion room

VAD team

Safe handling of chemotherapy

Social support

Your diagnosis is cancer !!

Psychological support

Nutritional support

Palliative care & pain management

Pain

Step 1Nonopioid Adjuvant

Pain persisting or increasing

Step 2Opioid for mild to moderate pain

Nonopioid Adjuvant

Pain persisting or increasing

Pain persisting or increasing

Step 3Opioid for moderate to severe pain

Nonopioid Adjuvant

Invasive treatments

Opioid Delivery

Quality of Life

Modified WHO Analgesic Ladder

Proposed 4th Step

The WHOLadder

Deer, et al., 1999

Cancer research unit

• Epidemiologists • Bio- statistician

Early detection clinic

Early detection clinic

Procedure Room

KHH lab upgrade

immunohistochemistry

Flowcytometry

Cytogenetics

Phase II

Bone Scan Bone Scan

Phase IIPhase II

Multiple Multiple bone bone

metastasesmetastases

Patient APatient A

Phase: III

Phase: III

Objectives

• Cancer : the size of the problem in Najran• Cancer unit : the goals.

• The Tumor Board at KKH: functions & guidelines

• The importance of multidisciplinary approach.

FunctionTo approve the best evidence based multidisciplinary diagnostic & therapeutic approach for tumor cases.

Multidisciplinary Tumor Board

Surgical, medical & radiation oncologists, radiologists, pathologists, nuclear medicine, and coordinator nurses , social worker & psychologist specialists

Saudi cancer Guidelines• Modified from NCCN• Written by the most expert oncologists in the country in each branch.

What is the NCCN?An Alliance of 21 Academic Cancer Centers in USA

NCCN Levels of Evidence

• Category 1: Based upon high-level evidence and uniform NCCN consensus that intervention is appropriate

• Category 2A: Based on lower-level evidence and uniform NCCN consensus that it constitutes appropriate care

• Category 2B: Based upon lower-level evidence and NCCN consensus that it constitutes appropriate care

• Category 3: Any level of evidence but major NCCN disagreement that the recommendation is appropriate.

Examples from Breast Cancer Guideline

Objectives

• Cancer : the size of the problem in Najran• Cancer unit : the goals.• The Tumor Board at KKH: functions & guidelines• The importance of multidisciplinary approach.

Fundamental questions

When is surgery enough?

Should we use chemotherapy?difficult to reverse practice

Which treatment should we use?toxicity-many 'equal' therapiesefficacydosage

What is the best for the patient?

Neoadjuvant ?Neoadjuvant ?

Adjuvant ?Adjuvant ?•Mastectomy vs. Mastectomy vs. lumpectomylumpectomy

•Lymph node Lymph node dissection vs. sentinel dissection vs. sentinel lymph node biopsylymph node biopsy

Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy

2. Track the 2. Track the lymphatic drainage lymphatic drainage of the tumorof the tumor

Personalized OncologyPersonalized Oncology

P13K

FKHR

Akt

mTOR

PTEN

MEK 1/2

MAPK

BADGSK-3

SOS

Grb-2

Shc

Grb-2

SOS Ras

Raf

JunFOS Myc

p27

Cyclin D-1

LigandLigand

Signal

Adapters

and Enzymes

Signal

Cascade

EGFr dimer

MAPK = mitogen-activatedprotein kinase

P13k = phosphatidylinositol

3-kinase

TranscriptionFactors

Thank you