Kickoff for Changing Cancer Care University of Lbeck, September 11 - - PowerPoint PPT Presentation

Kickoff

for Changing Cancer Care

University of Lübeck, September 11th 2019

Welcome

by

• Prof. Dr. Alexander Katalinic, Research director at the

Institute for Cancer Epidemiology, University of Lübeck

Interreg’s support of Changing Cancer Care

by Freddy Blak, member of the regional Council of Region Zealand, Denmark

Blood test in the patient’s home

by Program manager, Søren Stig Tvilsted, Research Projects and Clinical Optimization, Zealand University Hospital, Denmark

• Patients: less transportation time, less waiting time, more

knowledge, less insecurity

• Relatives: less unnecessary involvement (e.g. help with

transport), less insecurity

• Financial gain for the hospitals
• Device could be used by other patient groups
• Device could be developed to measure other elements /

parameters, reaching yet other patient groups

Why Point of Care (POC)?

Devices

Possible devices

Büsum

Changing Cancer Care; new perspective on diagnosis and treatment

by Prof., Chief Phys. Julie Gehl, Center for Experimental Drug and Gene Electrotransfer (C*EDGE), Department of Clinical Oncology and Palliative Care, Zealand University Hospital

• Wp5.1 – Liquid Biopsy - Diagnosis

(Dr. Malene Støchkel Frank)

• Wp5.2 Calcium Electroporation - Treatment

(Prof. Julie Gehl)

• Wp5.3 Spinal cord compression radiotherapy -

Treatment

(Prof. Dirk Rades)

WP5 - Innovative diagnosis and treatment of cancer

• If liquid biopsy works, treatment that will not work may be
• avoided. Benefit for the patient, benefit for society.
• If calcium electroporation, single, low-cost, once-only

treatment for cancer may become reality.

• Benefit for the patient, benefit for society.
• If radiotherapy for spinal cord compression can be refined,

patients may remain ambulatory longer.

• Benefit for the patients, benefit for society.

The overall goal: Benefit for the patient, benefit for society

• Wp5.1 – Liquid Biopsy - Diagnosis
• (Dr. Malene Støchkel Frank)
• Wp5.2 Calcium Electroporation -

Treatment

• (Prof. Julie Gehl)
• Wp5.3 Spinal cord compression

radiotherapy - Treatment

• (Prof. Dirk Rades)

WP5 - Innovative diagnosis and treatment of cancer

Liquid biopsy

Collaboration

• Universitätsklinikum Schleswig-Holstein, Campus Kiel, Institut für

Klinische Molekularbiologie (IKMB) – Molecular Biologist, Michael Forster

• Performing analyses of a variety of mutations in a subgroup of 10

patients to explore potential resistance-mechanisms during treatment

• Collaboration meeting at IKMB, May 2019

Perspectives

• A dynamic measurement of treatment-response through ctDNA
• An early registration of treatment failure

– To avoid long-lasting ineffective costly treatments – To avoid unneccesary side-effects

• Wp5.1 – Liquid Biopsy - Diagnosis
• (Dr. Malene Støchkel Frank)
• Wp5.2 Calcium Electroporation -

Treatment

• (Prof. Julie Gehl)
• Wp5.3 Spinal cord compression

radiotherapy - Treatment

• (Prof. Dirk Rades)

WP5 - Innovative diagnosis and treatment of cancer

Protocol and patients

• 3 centers will treat each 10 patients = 30

patients.

• Patients will have cutaneous metastases

from any cancer

• Primary endpoint will be clinical response

at two month follow-up

• We will discuss secondary endpoints

between the partners

Calcium electroporation study

5.2 Calcium electroporation collaborators

• SUH, Zealand (Julie Gehl)



Write and submit multi-center protocol



Training Treat 10 patients with follow-up of a minimum of 2 months.



Secondary endpoints TBA

• Vejle Sygehus (Lars Henrik Jensen)
• Facilitate protocol start
• Treat 10 patients with follow-up of at least 2 months.
• Secondary endpoints TBA
• Lübeck University Clinic (Mascha Pervan and Achim Rody)
• Facilitate protocol start
• Treat 10 patients with follow-up of at least 2 months.
• Secondary endpoints TBA

• Wp5.1 – Liquid Biopsy - Diagnosis
• (Dr. Malene Støchkel Frank)
• Wp5.2 Calcium Electroporation -

Treatment

• (Prof. Julie Gehl)
• Wp5.3 Spinal cord compression

radiotherapy - Treatment

• (Prof. Dirk Rades)

WP5 - Innovative diagnosis and treatment of cancer

• Aim is to show if high-precision radiotherapy with 18x2.33 Gy should be

recommended for patients with favorable survival prognoses

• Study leader: Prof. Dr. Dirk Rades, Department of Radiation Oncology,

University of Lübeck

• Participating study centers:

– Odense Universitetshospital, Onkologisk Afdeling, Denmark – Clinic for Radiation Oncology, Hannover, Germany – Other interested centers in Spain, Slovenia, Canada and Georgia

RAdiotherapy for Metastatic Spinal cord compression with increased radiation dosES (RAMSES-01)

• 65 Patients with motor deficits of the lower extremities resulting from

MSCC and a favorable survival prognosis

• Treatment with 2.33 Gy per fraction on 5 days per week

= EQD2 of 43.1 Gy = dose escalation by 33%

• Comparison to a historical control group treated with 10x3 Gy of

conventional radiotherapy (ca. 235 patients, previous study data documented in the EU)

RAMSES-01: Patient selection and treatment

22

Interventions led or delivered by general or specialized cancer nurses

by

• Prof. Dr. Sascha Köpke, Head of the Nursing Research Unit

at the Institute for Social Medicine and Epidemiology, University of Lübeck

Interventions led or delivered by general

• r specialized cancer nurses

Kick-off Meeting, Lübeck, September 11, 2019 Sascha Köpke Nursing Research Unit Insitute of Social Medicine and Epidemiology

Agenda

2 4

• ANP, APN, CNS…
• International view (substitution of roles, task shifting)
• National view (delegation of roles)
• Possibly future roles
• Relevance for CCC

ANP, APN, CNS…

2 5

Definition by the International Council of Nurses (ICN) (2008) „A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision- making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master's degree is recommended for entry level.“

https://international.aanp.org/Practice/APNRoles

Professional motivation

2 6

Nurses in countries with major skill-mix reforms are

• more frequently motivated to new roles (67 vs. 39%)
• more frequently able to do so (52 vs. 25%)

Physicians’ and nurses’ motivation are influenced

• more by intrinsic factors (personal satisfaction, use of qualifications)

and

• less by extrinsic factors (salary, career opportunities)

Barrier

• workforce shortages

Facilitator

• professional and management support

Professional motivation

2 7

Managers’ recruitment decisions on choice of staff were mainly influenced by

• skills,
• competences and
• experience of staff

2 8

Task Shifting

2 9

Intervention in cancer nursing

3

Intervention categories (OMAHA nursing intervention classification)

• Case management (n=38 studies)
• Surveillance (n=27)
• Teaching, counselling and guidance (n=131)
• Treatment and procedures (n=18)

Intervention in cancer nursing

3 1

Intervention categories (OMAHA nursing intervention classification)

• Case management (n=38 studies)
• Surveillance (n=27)
• Teaching, counselling and guidance (n=131)
• Treatment and procedures (n=18)

Workpackage 3

3 2

Aims

• To systematically review published research and generate new

knowledge on re-organizing and changing tasks from doctors to nurses, related to cancer care

• To distribute healthcare resources more equally concerning

patients' needs in cancer care by involving health care technologies

• To develop two prototype curricula for nurses aiming to develop

nurses’ clinical competencies in cancer care, to handle processes of new tasks and methods in cancer care, and to acquire new knowledge about health care technology in the work with cancer patients in primary care

Thank you very much!

3 3

34

The cancer patient’s perspective

by

• Prof. Dr. med. Frank Gieseler, Chairman of the Cancer

Society Schleswig-Holstein, Head of Department for Experimental Oncology, Palliative Medicine and Ethics in Oncology, University Hospital Schleswig-Holstein, Lübeck

"The Cancer Patient's Perspective"

Frank Gieseler, MD

Professor for Internal Medicine Cancer Society Schleswig-Holstein

UNIVERSITÄTSKLINIKUM Schleswig-Holstein

UK SH

what is "quality" in cancer care?

"quality parameters"

• adequate equipment
• enough workforce, personnel
• localized guidelines
• interdisciplinary tumor boards
• reports to tumor registry
• certifications

"quality indicators"

• patients treated according guide lines
• complications
• hospital stay durations
• survival times

"public reputation"

• referring medical colleagues and hospitals
• confidants, care keeper
• treated patients
• public relations, PR work

what is "quality" in cancer care?

"public reputation"

• referring medical colleagues and hospitals
• confidants, care keeper
• public relations, PR work
• treated patients

cancer center patient referring collegue cancer registry

The "transparent patient" or my contribution to progress?

• Will my personal data be reported?
• Can I inform myself about what is stored about me?
• Who has access to my personal data?
• Do I have the opportunity to withdraw my data?

During the past week: Not at All A Little Quite a Bit Very Much . .

• 8. Were you short of breath?

1 2 3 4 . . .

The QLQs are not personalized! Retiree: "It's worth it" Concert flutist: "Stop it right away!" PROM – patient reported outcome measurement

PROpatient – a feasibility study "bring the patient's perspective into cancer registry"

QLQ C-30: "Were you short of breath?" Personalizing questions: 1. How did this symptom develop during therapy? 2. How does it influence your life quality? 3. Why?

Aim: To use the cancer registry for individual therapy monitoring and decisions First results: Huge difference between both ways of interpretation!

what is "quality" in cancer care?

"public reputation"

• referring medical colleagues and hospitals
• confidants, care keeper
• public relations, PR work
• treated patients

cancer center patient referring collegue cancer registry PR and information

Take home message

• listen to patients´ fears
• listen to the referring colleagues´ concerns
• integrate referring colleagues in the quality process (during the process)
• accompany quality improvements with public information
• oncologists
• care givers, patients
• family doctors

"The Cancer Patient's Perspective"

Frank Gieseler, MD

Professor for Internal Medicine Cancer Society Schleswig-Holstein

UNIVERSITÄTSKLINIKUM Schleswig-Holstein

UK SH

44

Do all patients benefit equally from cancer treatment?

by

• Prof. Dr. Susanne Dalton, Danish Research center for

Equality in Cancer (COMPAS), Department of Clinical Oncology, Zealand University Hospital

Social inequality in cancer – implications for research and practice….

Susanne Dalton Survivorship, Danish Cancer Society Research Center, Copenhagen & Dept of Clinical Oncology & Palliative Care Zealand University Hospital, Næstved

Increasing inequality in health in Denmark

A welfare system guaranteeing very efficient and free-for-all health care and low social inequality in income still did not prevent (increasing) social inequality in health through the last 3 decades

47

Low social position is associated with cancer incidence

Head&Neck Esophagus Stomach Lung Cervix Kidney Bladder Pancreas Colon Rectum Endometrium Ovary Testicle Brain Lymphoma Leukemia Breast Prostate Melanoma

Dalton et al, 2008

Social inequality in health behaviour is increasing In the future more cancer diseases will be social disease…

48

Low social position is associated with cancer survival

Head&Neck Esophagus Stomach Lung Cervix Kidney Bladder Pancreas Colon Rectum Endometrium Ovary Testicle Brain Lymphoma Leukemia Breast Prostate Melanoma

Dalton et al 2008

Across cancer types persons with low social positon have lower survival than persons with high social position

Pattern over time is clear

• Either stable or increasing differences in short- and long-term survival

by SEP:

• Patients with high SEP are increasingly experiencing better survival
• Patients with low SEP are either experiencing less increase or no

increase in survival Some groups of cancer patients are systematically not benefiting from advances in diagnostics and treatment!

Dalton et al 2019

Proportion (%) of cancer patients (who died) who would still be alive at five years if their relative survival had been as patients with top quintile income

1,5 1,7 2 2,8 7,1 8,9 13,2 13,5 16,5 20,5 20,9 21,6 28,2 35,1 5 10 15 20 25 30 35 40

Pancreas Lung CNS Stomach NHL Kidney Colon Melanoma Rectum Bladder Breast All sites Head and Neck Prostate

Total 11,737 persons %

Dalton et al 2019

51

Mundhule Strube Spiserør Mavesæk Lunge Cervix Nyre Blære Bugspytkirtel Tyktarm Endetarm Livmoder Æggestok Testikel Hjerne Lymfom Leukæmi Bryst Prostata Modermærke

Baggrund & metode Ulighed i kræftforløbet Ulighed i livet efter kræft Ulighed i risiko for kræft

Social inequality in relative survival after cancer

– concerns (a lot of) lives

IF WE COULD LIFT SURVIVAL TO LEVEL OF HIGH SEP:

11.000 (22%) more 5-years survivors in Denmark

Videnshuller & perspektiver Dalton 2019

Disparities are seen in all cancer-related health outcomes (www.cancer.dk/hvidbog)

We know that patients with few ressources

• Screen less (i.e. Rees 2018, Lyle 2017, Wools 2016)
• Present later with cancer (i.e. Dalton 2011, Forester 2016, McCutchan 2015, Mounce 2017)
• Have more comorbid diseases (i.e. Hovaldt 2015, Kjær 2019)
• Receive less/drop more out of treatment (i.e. Forest 2013, Dalton 2015, Østgaard 2017)
• Are offered less rehabilitation (and palliation) (Holm et al 2013, Dalton 2019,

Lycken 2018)

Even in a country with free and equal access to health care - - transitions introduce disparities…..

Diagnosis Treatment Early monitoring End of life care Progressive illness Later monitoring Time since diagnosis

Health problems and risk behaviour cluster in vulnerable groups of citizen

With serious consequences for health and for prognosis when diagnosed with cancer

… Social inequality in cancer is not to a large degree DUE to

the health care system BUT…… This does not mean that the health care system can not be a part of the solution!!

WHO exactly is the vulnerable patient?

How to adress social inequality in cancer treatment

Recruitment in cancer trials or new treatment is skewed towards more resourceful patients When we develop or implement new treatments - we need to make sure that they DO NOT INCREASE cancer disparities The excuses: We can not focus on SEP factors because they are beyond the scope for health care professionals to treat But….SEP are associated with differential cancer risk and care – and this may be modified!

• 5. oktober 2018

Ulighed i Sundhedsvæsenet, temadag 57

COMPAS - National Research Center on Equality in Cancer

We will challenge the paradigm that if we treat all the same they have equal chances …Perhaps if we give some patients more they will get the same We will:

• Target interventions towards vulnerable patient groups
• Put a critical eye on daily clinical practice and collaborations in the health care

system

• Acknowledge that patient resources play a vital role for their cancer treatment

and prognosis

Patient

Personality Communication Health litteracy Behaviour Family/Network Income Education Cancer Prognosis Treatment Comorbidity Primary health system Community Secondary health system

Patient ressources Transitions – Bermuda triangle Organisation & Clinical practice Health promotion as treatment

Steering committee and WP leaders

• Susanne Oksbjerg Dalton (Chairman), Danish Cancer Society Research Center

& Zealand University Hospital, Næstved/Roskilde

• Mads Nordahl Svendsen, Zealand University Hospital, Næstved/Roskilde
• Tine Tjørnhøj Thomsen (WP1 leader), University of Southern Denmark

(Copenhagen)

• Christoffer Johansen, Department of Oncology, Rigshospitalet
• Jan Maxwell Nørgaard (WP2 leader), Hematology, Aarhus University Hospital
• Pernille Bidstrup (WP3 leader), Danish Cancer Society Research Center
• Hanne Tønnesen (WP 4 leader), WHO-CC & Bispebjerg Hospital
• Karen la Cour (WP5 leader), National Knowledge Center for Rehabilitation

and Palliative Care (REHPA)

Thank you sanne@cancer.dk & sdalt@regionsjaelland.dk

62

Reception

Changing Cancer Care wird gefördert mit Mitteln des Europäischen Fonds für regionale Entwicklung. Changing Cancer Care finansieres af midler fra Den Europæiske Fond for Regionaludvikling.