THIRD PILLAR: MANAGEMENT OF INVASIVE CERVICAL CANCER
Transcript of THIRD PILLAR: MANAGEMENT OF INVASIVE CERVICAL CANCER
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THIRD PILLAR:MANAGEMENT OF INVASIVE CERVICAL CANCER
Dr Elena Fidarova
Towards Elimination of Cervical Cancer in the Americas, 1-2 August 2019, Washington DC, USA
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Valentine Gode-Darel
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1914
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1915
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17 Jan1915
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21 Jan 1915
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Time
Access
CURE
Quality
Why cervical cancer management?
Why cervical cancer management?
CERVICAL CANCER IS CURABLE
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Why cervical cancer management?
Why cervical cancer management?
CERVICAL CANCER IS CURABLE
Liu et al, Am J ObstetGynecol 2016;
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Why cervical cancer management?
Why cervical cancer management?
• Treatment of early stage cervical cancer is cost-effective
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Why cervical cancer management?
Why cervical cancer management?
Whose responsibility is to provide care? 100 000 women screened
10 000 screen (+)3-5% with cancer
300-500 women with cancer
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Why cervical cancer management?
Comprehensive approach to cervical
cancer control ?
No screening
Screening with treatment
Screening without treatment
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Why cervical cancer management?
Comprehensive approach to cervical
cancer control ?
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BR
Putting into perspective
Health System
NCDs
Cancer Control
PreventionEarly
detectionDiagnosis and
TreatmentPalliative Care Survivorship
Care
CERVICAL CANCER
Broad Social Context
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Care pathway for screening and early diagnosis
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Presentation in late stages • No or misdiagnosis• Progression of disease
due to delays
• Inappropriate treatment • High toxicity• Treatment refusal/abandonment• High relapse rate• No supportive and palliative careCurative treatment is not possible
Poor survival
Understanding barriers to care
• Health System approach• Linking different levels
of care
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Treatment outcome
Stage at diagnosis
Accuracy of diagnosis
Access to
diagnosis and
treatment
Quality
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Pathology
• Pathology services are essential for diagnosis, differential diagnosis and treatment choice
• Differential diagnosis: cancer or not?
• Diagnosis: what type of cancer?
• Treatment choice:• Suitable for surgery?• Need for adjuvant treatment (high risk for
recurrence?)• What radiotherapy?• What chemotherapy?
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Why Staging?
• Prognostic factor• Selection of treatment
(stage-appropriate)
Stage Description Primary Treatment
Stage IA
Tumour confined to cervixB
Stage IIA Tumour invades adjacent
tissues B
Stage III
A Dissemination to lymph nodes, spread to the pelvic wall and/or lower 1/3 of vagina
B
C
Stage IV
A Tumour invades adjacent organs (bladder, rectum) and/or spread to distant organs
B
Surgery
Radiotherapy+concurrent chemo
Palliative treatment
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Cancer Surgery
• Complex surgery• Requires special training• Quality of surgery
influences outcomes
ALL STAGE LACC
82.8%
74.5%
69.9%
57 %
Wu et al. OncoTargets and Therapy, 2016
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Radiotherapy
• Population 5-year overall survival benefit 18%
• Additional 3% OS benefit for chemoradiation
• Quality of radiotherapy has impact on outcomes
Hanna et al, Radiother Oncol 2018
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Chemotherapy
• Off patent cancer medicines
• WHO EML recently updated to extend indications
Cytotoxic and adjuvant medicinescisplatin
carboplatin
paclitaxel
fluorouracil
gemcitabine
docetaxel
ifosfamide
filgrastim
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• Pain
• Ureteric obstruction +/- renal failure
• Bleeding
• Malodorous vaginal discharge
• Lymphoedema
• Fistulae
Palliative care
• Symptom management is complex
• Pain is not the only symptom
• Palliative care is not only end-of life care
• Early integration of palliative care is essential
Common Symptoms:
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Multidisciplinary care
• Improves patients’ assessment and management practice
• Impact on quality of care• MDTs also within
individual disciplines
MDT:
• Pathologist
• Radiologist
• Gyn Oncologist
• Radiation Oncologist
• Medical Oncologist
• Palliative Care Specialist
• Oncology Nurse
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Health System Lens• Analyzing and removing barriers to care
• Integrated service delivery models
• Guidelines adapted to local context
• Quality of care and patient safety
Service Delivery
• Optimizing performance and quality of cancer health workforce
• Aligning investments in human resources with current and future needs and investments in infrastructure
• Policies to improve retention and regulate the private sector
Health Workforce
• Strengthening of population-based cancer registries: survival and stage distribution
• Monitoring and evaluation of clinically relevant facility level data (e.g. quality of care indicators)
Registries and Information Systems
• Selection, procurement, supply, storage and distribution chain management
• National lists of priority medical devices and essential medicines
Access to Technology and Medicines
• Efficient use of domestic funding
• Financial protection: inclusion in UHC benefit package
• Innovative solutions for sustainable financing of cancer programmeFinancing
• Integrated national cervical cancer control programme
• Strengthening of regulatory framework Governance
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THANK YOU!
Dr Elena Fidarova
“It is time to consign cervical cancer to the history books”