philippine perspective - s3-ap-southeast-1.amazonaws.com · - woc = without compensation solution:...
TRANSCRIPT
Sarcoma Surgery
Philippine Perspective
Edward HM Wang, MD MSc
Professor, Dept of Orthopedics
Univ of the Phil-Phil General Hospital
2015 Singapore Sarcoma Symposium
Session 4: Resource Stratified Care
1990s - organized approach to extremity sarcomas - 2 Musculoskeletal Tumor Units established
Univ of the Phil-Phil Gen Hosp Philippine Orthopedic Center
paradigm shift among doctors
more awareness among laymen
gradual improvement in patient survival
with adequate treatment
OSA 5yr OS 1993 2008
<10% 55%
Univ Phil-Phil Gen Hosp
Philippine Orthopedic Center
12 Musculoskeletal Tumor Referral Centers
Jose R Reyes Mem MC
Baguio Gen Hosp
JLingad Mem Reg Hosp
Davao Med Center
DLSU Health Science Institute
Perpetual Succour Hosp
East Ave Med Center
Univ of Sto Tomas Med Ctr
St Luke’s Med Center
The Medical City
Univ Phil-Phil Gen Hosp
Philippine Orthopedic Center
12 Musculoskeletal Tumor Referral Centers
Jose R Reyes Mem MC
Baguio Gen Hosp
Davao Med Center
DLSU Health Science Institute
Perpetual Succour Hosp
East Ave Med Center
Univ of Sto Tomas Med Ctr
St Luke’s Med Center
The Medical City
JLingad Mem Reg Hosp
7 / 12 in MetroManila
Univ Phil-Phil Gen Hosp
Philippine Orthopedic Center
12 Musculoskeletal Tumor Referral Centers
Jose R Reyes Mem MC
Baguio Gen Hosp
Davao Med Center
DLSU Health Science Institute
Perpetual Succour Hosp
East Ave Med Center
Univ of Sto Tomas Med Ctr
St Luke’s Med Center
The Medical City
JLingad Mem Reg Hosp
only 6 / 12 government hospitals
patient
MD team/unit environment
Brand, Galindo & Gross. Situational Analysis of
the Filipino Pediatric Oncology System 2014
Solution:
PGH musculoskeletal tumor files (1993 - )
- “Bone Tumors in Filipinos” 2007 1st ed
- 876 cases from the PGH
- Local and international publications
No national registry
Patient - Inadequate reporting
Osteosarcoma
- 5 per M in 0-19 y.o.
- Philippine population 0 -19 y.o. (56.5M)
= 280 new OSA patients (0-19) p.a.
- 75% of all OSA patients (Wang & Vergel de Dios, BTIF 2007)
= 375 new OSA patients p.a.
30-35
Univ Phil-Phil Gen Hosp
30-35
Philippine Orthopedic Center
Osteosarcoma
10-15
Jose R Reyes Mem Hosp
10
Baguio Gen Hosp
15-20
Jose Lingad Mem
Reg Hosp
15-20
Davao Med Center
10-15
DLSU Health Science Institute
15-20
Perpetual Succour Hosp
10-15
East Ave Med Center
15
Univ of Sto Tomas Med Ctr
170 / 375 cases
Soft tissue sarcoma (STS)
- 6/100T or 60/M in general population
= 6000 new patients p.a.
- 30% extremity
- 20% H&N
- 20% trunk
= 1800 extremity STS
- 3 GS : 1 Ortho
= 450 new extremity STS patients p.a.
30
Univ Phil-Phil Gen Hosp
30
Philippine Orthopedic Center
Soft Tissue Sarcoma
15
Jose R Reyes Mem Hosp
10
Baguio Gen Hosp
15
Jose Lingad Mem
Reg Hosp
20
Davao Med Center
15
DLSU Health Science Institute
15
Perpetual Succour Hosp
5
East Ave Med Center
10
Univ of Sto Tomas Med Ctr
165 / 450 cases
Patient – Poor access to care
- Archipelago: good for tourism
bad for patient navigation
7100 islands
odin.tic romyocon.net
flickrhivemind.net www.youtube.com
Those who access care
- late presentation
- OSA patients 2006-2008 :
57 service patients: 61% M1
20 pay patients: 30% M1
- limb salvage 60% vs amputation 40%
466 cm3 vs 5616 cm3
Why the delay in accessing care?
1 Finances
- Transport
- Diagnostics
commons.wikimedia.org christianfilipina.com
min daily wage = $S15
MRI = $S400
transport fare = $S2
Why the delay in accessing care?
2 Low index of suspicion by MD
3 Traditional healers / present day quacks
Patient - Treatment abandonment
= failure to complete therapy for disease that
could be cured or definitively controlled
= missing treatment for a prolonged, consecutive
period (4 weeks) that impacts ability for
cure or disease control Weaver etal Defining & Distinguishing Treatment Abandonment
in Patients with Cancer JPHO 2015
- Common in LMIC
- Of 675 OSA patients 1993-2013
< 200 patients completed treatment (<30%)
with our Unit
Causes of treatment abandonment
- finances
- level of education & understanding
- socially based causes predominate
“ God will provide. “
“ … bahala na si Lord… “
vs
providing a bus/train ticket
min daily wage = $S15 for family of 5
patient
MD team/unit environment
Brand, Galindo & Gross. Situational Analysis of
the Filipino Pediatric Oncology System 2014
Sarcoma Team
- no government sponsored continuing education
courses for 1o MDs or health workers
- no sustained “sarcoma awareness campaign”
- misdiagnosis common
Orthopedic oncology training programs - 2
Surgical oncology training programs – 2 major
H&N, trunk cancers, <0.5% extremity SA
Gen Surg exposure program often inadequate
and even when well-trained and dedicated…
- poorly compensated
- full time: $S 1300 per month
- WOC = without compensation
Solution:
government & private practice = 1 hospital
Univ of the Phil - Phil Gen Hosp
- 3 consultant ortho oncologists
- 3 trainees (1 fellow, 2 residents)
- theater, OP clinics, ward rounds
- 200 Bone & ST tumor patients p.a.
monthly Sarcoma rounds but not matured to
level of MultiDisciplinary
Conference as primary means of
communication among Sarcoma
Team members
- No national guidelines
- Adherence to protocols from developed
countries difficult because lack resources
capacity & trained staff
Solution: Resource appropriate protocols
Example:
- CT rather than MRI preBiopsy
- DOX-CDDP protocol
- no chemo change despite low tumor necrosis
- staged surgeries
(1) wide excision + IM nail w/ PMMC spacer
(2) convert to EPR
- modified implants
Sarcoma Unit
Staging studies:
- high quality available but unaffordable
- long queues at the PGH
Solution:
arrangements with other hospitals
myriadrainbowhues.wordpress.com
Diagnostic
- Pathologic assessment
basic (H & E)
limited (immunohistochem)
translocation studies
genomic research
uncommon uncommon
Therapeutic
- Surgery:
675 OSA patients
< 200 completed treatment
60% limb salvage rate = 120 patients
- wide excision
- reconstruction
Therapeutic
- examples of improvisations:
“ stacked nail “ – knee arthrodesis
“ PHA + IM nail ” – proximal femur
“ PMMC “ – upper extremity
Therapeutic
- Teams:
microvascular (VFG, flaps)
Ilizarov
Total Joint reconstruction
- Tissue & Bone bank:
only 1 in entire country
patient
MD team/unit environment
Brand, Galindo & Gross. Situational Analysis of
the Filipino Pediatric Oncology System 2014
- current govt more supportive of
cancer prevention and cure
- 2012 : sin tax
- 2014 : graphic warning law
- Dept of Health budget increased:
42.1B >> 83.7B
$S 1.28 B >> $S 2.53 B
Environment
How does the individual pay?
- Phil health insurance
15-20% of total expenses
- Private insurance
- Out-of-pocket
approx 30% of all Filipinos enrolled with Phil health
10-15% Filipino patients have private insurance
Majority
cliparthut.com
How does government help?
- aim: Universal Health Coverage
- Z-benefit packages :
all expenses covered
sarcomas not included
- Philippine Charity Sweepstakes Office:
additional help
for surgical &
medical care
ffemagazine.com
girlytechstuff.wordpress.com
patient
MD team/unit environment
Brand, Galindo & Gross. Situational Analysis of
the Filipino Pediatric Oncology System 2014
Urgent Concern !!
5 OSA per million
375 OSA yearly
45% seen at musculoskeletal tumor centers
PGH: 30% receive complete treatment
50% survival
375
60
170
30
90% !!
Problems & recommendations
problem Recommend (Local) Recommend (Regional)
Lack of SA expertise Choice of fellow-trainees based on need of Regions
Training Exchange program Twinning
No national registry Standard registry per Hosp Through PMTS Dedicated registry personnel
Poor access Poor follow-up
Budget for transport (patient or Sarcoma Unit personnel)
Abandonment Sarcoma nurse, personnel Sarcoma support group
Poor communication among MDs
Regular, standardized MDC
SA support group
Problems and recommendations
problem Recommend (Local) Recommend (Regional)
Inability to adhere to international protocols
Standardized resource appropriate protocols
Sharing of best practices
Inadequate pathologic assessment
Consultations Telemedicine
Consultations
Lack of resources for treatment
Coordinate civil society and government resources Legislation eg Tissue Bank
ASEAN specific concerns
Data collection Multiinstitutional & multi national collaborations