Dr Chris Jackson - GP CMEgpcme.co.nz/pdf/2017 South/Sat_Room1_0915_CJackson CHC Practice...
Transcript of Dr Chris Jackson - GP CMEgpcme.co.nz/pdf/2017 South/Sat_Room1_0915_CJackson CHC Practice...
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Dr Chris JacksonConsultant Medical Oncologist
Southern Blood and Cancer Service (SDHB)
University of Otago
9:15 - 9:45 The Changing Landscape of Cancer Care in NZ
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The Changing Landscape of Cancer Care in NZ
Dr. Chris Jackson
Medical Oncologist, Southern DHB
Medical Director, CSNZ
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Cancer29%
Cerebrovascular disease9%
Ischaemic heart disease
18%
Motor vehicle accidents1%
Diabetes 3%
Pneumonia / flu 2%
Other heart disease 4%
Respiratory disease 6%
Suicide2%
Assault0%
Other26%
Cancer is NZ’s leading cause of death
Smoking – 22%
Alcohol
UV radiation
Obesity
Inactivity
Infectious diseases – 22%eg HPV; Hep B, C; H Pylori
Environmental and industrial
carcinogens – 4%
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Lower mortality, more cases, more survivors.
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Male registrations
Female registrations
Male deaths
Female deaths
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Cancer has increased in importance.
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5 types account for the majority of cases
Prostate
14%
Breast
14%
Colorectal
14%
Melanoma
11%
Lung
9%
Non-Hodgkins
4%
Leukaemia
3%
Uterus
2%
Kidney
2%
Pancreas
2%
Other
25%
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Cancer Care – 50 years ago
• Breast Cancer Surgery
• Lymphoedema
• Extensive Radiotherapy
• Chemo including high dose
• Tamoxifen for all
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Improvements in Cancer Staging
• Improved local staging means more precise extent of surgery
• Futile surgery is avoided for those with distant disease
• Some patients with stage 4 disease can undergo extensive resections
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Radio-isotope scanning
• Bone scanning
• Iodine scanning
• FDG-PET
• PSMA
• Gallium-DOTATATE
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PET scan - melanoma
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PET scan - lymphoma
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Improvements in Surgery
• All visible disease and a margin must be treated– R0 / R1 / R2
• Extent of margin is cancer specific• Often draining lymph nodes excised• Vital organ preservation• Infection control• Haemostasis• Patient co-morbidity• Post-operative supportive care
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Surgery: luminal excision
http://colorectalsurgeonssydney.com.au/?page_id=1152
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Surgery: metastasectomy and ablation
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Surgery: palliative
• A complete resection not always needed to alleviate symptoms
• Indications include pain, fungation (ulceration), obstruction (eg bowel obstruction) that cannot be relieved by non-surgical means
• Often has a recovery period that is important to consider in a palliative situation
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Radiotherapy: 3D Conformal
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Brachytherapy: Interstitial implantation of radioisotopes
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Systemic therapies
• Chemotherapy
• Hormonal Therapy
• Monoclonal Antibodies
• Targeted therapies
• Immunotherapy
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EGFR family
– activated in many cancers
Ciardiello F and Tortora G. N Engl J Med 2008
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Ras
RAF
MEK
EGFR
Cell growth, proliferation,
invasion and metastases
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Ras
RAF
MEK
EGFR
Cell growth, proliferation,
invasion and metastases
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Ras
RAF
MEK
EGFR
Cell growth, proliferation,
invasion and metastases
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Vemurafenib in V600E mutated melanoma
• “Objective response”: 57%
• Rapid: days
• Well tolerated
• Photosensitivity, diarrhoea, HFS, KA and SCC
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Immunotherapy: T-cell priming and evading inhibition
• APC’s present antigens to T cells
• T-cells become activated
• T-cells replicate
• Have to be “switched off”
• Cancers can inactivate T-cells via PD1/L1
Ribas NEJM June 28 2012
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PD-1 like a “fend”
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Anti PD-1/PDL-1
PDL-1 PD-1
TCRMHC
No inhibition of killing response tumour killingInhibition of killing response no tumour killingNo inhibition of killing response tumour killing
PDL-1PD-1
Anti PDL-1
Anti PD-1
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Responses with Pembrolizumab
Robert C et al. N Engl J Med 2015;372:2521-2532.
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Immune-related adverse events
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People with cancer in 2017
• Triple pop > 65 by 2050
• Double the deaths in next 15 years
• One quarter of patients are already > 80
• Frailty
• Multi-morbidity
• Social dependency
• Increasing expectations
• Uptake of lower toxicity treatment • e.g. immune therapies
• Changing role of Dr, Nurse, Allied Health
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Priorities
1. Prevention– Smoking– Alcohol– Obesity– Exercise– UV
2. Screening– Cervical– Breast– Colorectal– Lung
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Cost-effective implementation
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Preparing for the future
Cancer is changing.
Patients are changing.
Treatments are changing.
Staying the same is going backwards.
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Conclusions
• Increasing burden of cancer
• Risk factors modifiable with social policy, primary prevention
• Future patients are elderly, have multi-system diseases
• Sustainable health services will need to re-organise diagnosis, chronic management, survivorship, surveillance
• Governments will need to critically assess and carefully implement all new health technologies
• Major role for central planning, big data
• Providers roles are evolving at a rapid rate.