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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

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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%

Philippine Musculoskeletal Tumor Society 2004 8 founding members

2015 20 active members

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




Jose R Reyes Mem MC

Baguio Gen Hosp

Davao Med Center



East Ave Med Center



The Medical City


7 / 12 in MetroManila




Jose R Reyes Mem MC

Baguio Gen Hosp

Davao Med Center



East Ave Med Center



The Medical City


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


30-35


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


15-20


10-15

East Ave Med Center

15


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


30


Soft Tissue Sarcoma

15

Jose R Reyes Mem Hosp

10

Baguio Gen Hosp

15

Jose Lingad Mem

Reg Hosp

20

Davao Med Center

15


15


5

East Ave Med Center

10


165 / 450 cases

Patient – Poor access to care

- Archipelago: good for tourism

bad for patient navigation

7100 islands

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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

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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




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

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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

- implants: out-of-pocket

Good function

6 – 12 month interval

Therapeutic

- staged surgeries

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




- 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

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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

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patient




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

20 years

THANK YOU !!

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