CARATTERISTICHE CLINICO-STRUTTURALI DEI CENTRI DI RIFERIMENTO

Prof. PAOLO ZOLA SSCVD Ginecologia Oncologica

Ospedale Sant’Anna Università di Torino

04 maggio 2016

INTRODUCTION

Integrated multidisciplinary decision making Complex multimodality treatment Rare/uncommon cancers Working to protocols Train a subspecialities in gynaecological malignancies

ORGANIZATION OF GYNAECOLOGICAL CANCER CARE

Primary care

Gynaecological Cancer Unit (GCU)

Gynaecological Cancer Center (GCC)

1. CANCER UNITS: would serve populations (men and women, all ages) of at least 200,000 (anticipated range, 100,000 to 400,000); this would usually represent about 50 new cases for gynaecological cancer/ year 2. CANCER CENTERS: would serve population of at least one million, with arround 200 new cases/year

ORGANIZATION OF GYNAECOLOGICAL CANCER CARE

CANCER UNITS

A - Local rapid assessment service for all types of gynaecological cancers

B - Treat superficially invasive cervical disease and early cancers of the endometrium

C - Refer to Cancer Center of women with all other tumours

Members of the Cancer Unit Team

Mandatory linked services

A lead gynaecologist, A lead pathologist A radiologist A nurse

Pathology Chemotherapy Psychosocial and psychosexual counselling Stoma care Lymphoedema treatment Palliative care

CANCER UNITS

CANCER CENTER

General requirements for Gynaecologic Cancer Care

Anaesthesiology Intensive / Subintensive care Radiodiagnostics (CT and RMN) Hematologic laboratory Endoscopy Pathology - Frozen section Cytology

Within the same hospital

In the same metropolitan area

Radiotherapy Medical Oncology Psycho-Oncology Nuclear Medicine Plastic surgery Vascular Surgery Palliative Care Stoma Care Lymphoedema treatment

CANCER CENTRE

The Equipe Gynaecological Oncologist: with a subspeciality in

gynaecological oncology or with experience > 5 y (surgery and scientific publications)

Oncological Radiotherapist: with experience > 5 y

Medical Oncologist: with experience > 5 y

Pathologist: dedicated on gynaecological malignancies

Radiologist Anaesthesiologist Plastic surgery General surgery Psycho-Oncologist Palliative Care

QUALITY INDICATORS OF

SURGICAL CARE CENTER

to improve the average standard of surgical care by providing a set of quality criteria which can be used for self-assessment

for institutional quality assurance programs for governmental quality assessment to build a network of certified centres for cancer

surgery

Why?

What?

QUALITY INDICATORS: - structural indicators, - process indicators, - outcome indicators

What?

QUALITY INDICATORS: - STRUCTURAL INDICATORS, - process indicators, - outcome indicators

STRUCTURAL INDICATORS Refer to health system characteristics that affect the system’s ability to meet the health care needs of individual patients or a community. Describe the type and amount of resources used by a health system or organization to deliver programs and services, and they relate to the presence or number of staff, clients, money, beds, supplies, and buildings.

For example: OVARIAN CANCER 1. Number of cytoreductive surgeries performed per center per year 2. Center participating in clinical trials in gynecologic oncology

3. Pre-, intra-, and post-operative management

1. Number of cytoreductive surgeries performed per center per year

DESCRIPTION Only surgeries with an initial objective of complete cytoreduction are recorded. TARGET(S) per year: • Optimal target: N ≥ 100. • Intermediate target: N ≥ 50. • Minimum required target: N ≥ 20

2. Center participating in clinical trials in gynecologic oncology

DESCRIPTION The center actively accrues patients in clinical trials in gynecologic oncology. TARGET(S) Not applicable.

3. Pre-, intra-, and post-operative management

DESCRIPTION The minimal requirements are: (1) intermediate care facility, and access to an intensive care unit (ICU) in the center are available, (2)An active perioperative management program is established. TARGET(S) Not applicable.

What?

QUALITY INDICATORS: - structural indicators, - PROCESS INDICATORS, - outcome indicators

Assess what the provider did for the patient and how well it was done. Measure the activities and tasks in patient episodes of care.

For example: OVARIAN CANCER

PROCESS INDICATORS

2. Surgery performed by a gynecologic oncologist or a trained surgeon specifically dedicated to gynaecological cancers management 3. Treatment planned and reviewed at a multidisciplinary team meeting 4. Required preoperative workup 5. Minimum required elements in operative reports 6. Minimum required elements in pathology reports

1. Number of cytoreductive surgeries performed per surgeon per year

1. Number of cytoreductive surgeries performed per surgeon per year

DESCRIPTION Only surgeries with an initial objective of complete cytoreduction are recorded. TARGET(S) ≥ 95% of surgeries are performed or supervised by surgeons operating at least 10 patients a year.

2. Surgery performed by a gynecologic oncologist or a trained surgeon specifically dedicated to gynaecological

cancers management

DESCRIPTION Surgery is performed by a certified gynecologic oncologist or, in countries where certification is not organized, by a trained surgeon dedicated to the management of gynecologic cancer (accounting for over 50% of his practice) or having completed an ESGO accredited fellowship. TARGET(S) ≥ 90%.

3. Treatment planned and reviewed at a multidisciplinary team meeting

DESCRIPTION The decision for any major therapeutic intervention has been taken by a multidisciplinary team (MDT) including at least a surgical specialist, a radiologist, a pathologist and a physician certified to deliver chemotherapy (a gynecologic oncologist in countries where the subspecialty is structured and/or a medical oncologist with special interest in gynecologic oncology). TARGET(S) ≥ 95%

4. Required preoperative workup

DESCRIPTION Unresectable parenchymal metastases have been ruled out by imaging. Ovarian and peritoneal malignancy secondary to gastrointestinal cancer has been ruled out by suitable methods and/or by biopsy under radiologic or laparoscopic guidance. TARGET(S) ≥ 95%

5. Minimum required elements in operative reports

DESCRIPTION Operative report is structured. Size and location of disease, all the areas of the abdominal cavity must be described and the size and location of residual disease at the end of the operation. The reasons for not achieving complete cytoreduction must be reported. TARGET(S) 90%.

6. Minimum required elements in pathology reports

DESCRIPTION Pathology report contains all the required elements listed in the International Collaboration on Cancer Reporting (ICCR) istopathology reporting guide. TARGET(S) ≥90%.

What?

QUALITY INDICATORS: - structural indicators, - process indicators, - OUTCOME INDICATORS

OUTCOME INDICATORS Outcomes are states of health or events that follow care, and that may be affected by health care.

For example: OVARIAN CANCER

1. Rate of complete surgical resection

2. Existence of a structured prospective reporting of postoperative complications

1a. Rate of complete surgical resection

DESCRIPTION Complete abdominal surgical resection is defined by the absence of remaining macroscopic lesions after careful exploration of the abdomen. TARGET(S) • Optimal target: > 65%. • Minimum required target: > 50%.

Complete abdominal surgical resection

1b. Rate of complete surgical resection

Patients who are operated upfront

DESCRIPTION Surgery can be decided upfront, or planned after neoadjuvant chemotherapy. However, the quality assurance program must take into account that patients who can be operated upfront with a reasonable complication rate benefit most from primary debulking surgery. TARGET(S) >80%

2. Existence of a structured prospective reporting of postoperative complications

DESCRIPTION Data to be recorded are reoperations, interventional radiology, readmissions, secondary transfers to intermediate or intensive care units, and deaths. TARGET(S) Optimal target: 100% of complications are prospectively recorded. Minimum required target: selected cases are discussed at morbidity and mortality conferences.

SUBSPECIALISTS TRAINING PROGRAMME IN

GYNAECOLOGICAL ONCOLOGY

SUBSPECIALTY IN OBSTETRICS AND GYNECOLOGY Definition

Subspecialty is a highly qualified branch of obstetrics and gynaecology which requires: - Expertise, practice and knowledge about the discipline. - A multidisciplinary team leaded by a subspecialist gynaecologist. - Specific personnels

- Specific equipment and technology.

- Specific and well established training curriculum

- Free access to International Journals and collaboration with International Societies.

The Gynaecological Oncologist is a specialist in Obstetrics and Gynecology who is prepared to provide: comprehensive management of gynaecological and breast cancer: - screening, - diagnostic and therapeutic procedures - follow-up medical or surgical treatment of malignant disease of the female genital tract and breast. … and practice in an institutional setting where all effective forms of cancer therapy are available.

SUBSPECIALTY IN OBSTETRICS AND GYNECOLOGY Definition

BASIC SCIENCES Anatomy Oncology Genetics Pathology Statistics and

epidemilogy Microbiology Biochemistry Biophysics Immunology Pharmacology

MINIMUM OF 2 YEARS

CLINICAL SCIENCES Gynaecological Oncology (epidemiology, pathogenesis, screening, diagnosis, prognpstic factors and staging) Breast cancer Imaging (CT, RMN, US) Surgical management Non surgical management (CT, RT and HRT) Psycology Palliative and terminal care

GYNECOLOGIST ONCOLOGIST SHOULD BE TRAINED IN:

EVALUATION OF CLINICAL AND TECHNICAL SKILLS

SCORING SYSTEM :

1 : Passive attendance , assistance

2 : Needs close supervision

3 : Able to carry out procedure under some supervision

4 : Able to carry out procedure without supervision

5 : Able to supervise and teach the procedure

The general aim is to get at least mark 4

SURGICAL MENAGEMENT

Minimal surgical procedures to be performed by the fellow: Surgery of endometrial, ovarian and tubal cancer: 30 cases Radical hysterectomy: 15 cases Other pelvic malignancies: 5 cases Vulvectomy and groin dissection: 5 cases

Country Duration (years) ESGO training system

Belgio 5 Yes

Rep. Ceca 2 Yes

Danimarca 3 No

Finlandia 2 No

Francia 2 Yes

Germania 3 Yes

Georgia 4 No

Grecia 3 No

Lettonia 2 No

Olanda 2 Yes

Polonia 3 Yes

Portogallo 3 No

Romania 2 No

Russia 2 No

Serbia 1 No

Slovacchia 1 Yes

Svizzera 3 No

Turchia 3 No

UK 2-3 Yes

Despite that, the gyanaecological oncology subspecialist exists only in a few European countries and with different modality Only a few european countries have adopted the ESGO training programme

Gynecologic Oncology Training System in Europe: a report from the European Network of Young Gynaecological Oncologists Gultekin et al, Int J Gynecol Cancer 2011; 21:1500-1506 Surgical education and training in gynecologic oncology: European perspective Cibula, Kesic, Gynecol Oncol 2009, 114:S52-S55

CAS: struttura di riferimento del paziente in termini di assistenza, orientamento e supporto GIC: stabilisce i percorsi di cura più appropriati fondandosi su un approccio clinico interdisciplinare

La Rete si articola sul territorio interregionale grazie all'attivazione di Centri di Riferimento e a modalità operative specifiche

La Rete Oncologica del Piemonte e della Valle d'Aosta è un sistema di cura e assistenza dedicato alle persone affette da patologie tumorali.

RETE ONCOLOGICA PIEMONTE – VALLE D’ AOSTA

PRESA IN CARICO DA PARTE DEL CAS ACCETTAZIONE E ACCOGLIENZA

VALUTAZIONE DEL RISCHIO ANESTESIOLOGICO STADIAZIONE CAS (in caso di invio della paziente da altro centro è necessaria la revisione dei vetrini da parte di anatomopatologi del centro di riferimento prima della valutazione GIC) GIC Definisce il piano di trattamento verificandone l’aderenza ai PDTA Assicura l’adeguata comunicazione con i pazienti e i suoi familiari.

La situazione in Piemonte 2009

Ospedali piemontesi suddivisi in base al numero totale di tumori ginecologici trattati all’anno per singola struttura ospedaliera

N. casi/anno

La situazione in Piemonte 2009

Ospedali piemontesi suddivisi in base al numero totale di tumori ginecologici trattati all’anno per singola UNITA’

ospedaliera

N. casi/anno

La situazione in Piemonte 2015

Sede N° nuove diagnosi N° decessi

T. Cervice uterina 194 56

T. Corpo dell’utero 579 151

T. Ovaio 453 304

Ricoveri chirurgici per tumore dell'ovaio nella Rete Oncologica Piemonte 2015

Piemonte NORD-EST

N=61

Piemonte SUD-EST

N=30

Piemonte SUD-OVEST

N=61

Ricoveri chirurgici per tumore dell'ovaio nella Rete Oncologica Torino 2015

Torino NORD N=52

Torino SUD-EST

N=95

Torino OVEST N=83

Grazie per l’attenzione