GP Education Series Women s cancers. GP Education Day 11 July 2016

Transcription

1 GP Education Series Women s cancers GP Education Day July 26

2 The Royal Marsden Endometrial cancer- A side effect of bigger health problems Mr Thomas Ind Consultant Gynaecology oncology surgeon The Royal Marsden

3 3 Endometrial Cancer

4 4 Endometrial Cancer

5 5 Endometrial Cancer

6 6 Endometrial Cancer

7 7 Endometrial Cancer 2 6.5

8 8 Endometrial Cancer

9 9 Endometrial Cancer 2 2.5

10 Endometrial Cancer Now 27.7/,

11 Endometrial Cancer

12 2 Obesity 99-2

13 3 Endometrial Cancer Hypertension Systemic Disorder Obesity Diabetes Side Effect EC

14 How 4 Liver SHBG Adipose Bound (inactive) Oestrogens Androstenedione Oestrone (& other Oestrone oestrogens) Endometrial Cancer Endometrial Hyperplasia

15 5 Laparoscopic Surgery For Endometrial Cancer In 996

16 6 Laparoscopic Surgery For Endometrial Cancer In 996 Too many complications Poor quality of life Too expensive Poor oncologically Increased vault recurrences

17 7 Laparoscopic vs Open Hysterectomy for Endometrial Cancer COMPLICATIONS Just RCTs

18 8 Laparoscopic Vs Open Surgery Endometrial Cancer LACE study QoL survey Janda et al 2 9 TLH arm 34 TAH arm Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. In the early phase of recovery, patients who had TLH reported significantly greater improvement in QoL from baseline compared with those who had TAH, in all subscales apart from emotional and social wellbeing. Improvements in QoL up to 6 months after surgery continued to favour TLH, except in the emotional and social wellbeing measures of FACT and the visual analogue scale of the EuroQoL five dimensions (EuroQoL-VAS)

19 9 Laparoscopic Vs Open Surgery Endometrial Cancer Obese Elderly Comorbidity

20 2 Laparoscopic Vs Open Surgery Endometrial Cancer

21 2 Laparoscopic Vs Open Surgery Endometrial Cancer Kalogiannidis et al Recurrence % Overall Survival % Disease-free survival % LH AH Zullo et al LH NR AH NR Nezhat et al LH NR AH NR Malzioni et al LH AH

22 22 Laparoscopic Vs Open Surgery Endometrial Cancer Vault recurrence LH (%) AH (%) Obermair et al 24 Kalogiannidis et al Nezhat et al.5 3.

23 23 Laparoscopic Vs Open Surgery Endometrial Cancer Level evidence Longer operating time Shorter hospital stay Less blood loss Less post-operative complications

24 24 Laparoscopic Vs Open Surgery Endometrial Cancer Einarsson et al 2, J Min Inc Gynecol 7: Nationwide US survey of 5 randomly selected gynaecologist. 25.8% response. 83.9% said most commonly used routed was TAH. 8.% said that they would use TAH as there preferred route for themselves or spouse.

25 25 National statistics for endometrial cancer Approaches to hysterectomy for endometrial ca Open Vaginal Laparoscopic Unclassified Acknowledgment to Osama Abughazza

26 26 Laparoscopic Vs Open Surgery Endometrial Cancer Click on image to magnify.

27 27 Case 2 Overweight (BMI 66)

28 28 Case 2 Overweight (BMI 66) Midline incision Mesh chronically discharging pus

29 29 Case 2 Panniculectomy

30 3 Case 2 Panniculectomy 4738g panniculous

31 3 Case 2 Panniculectomy 24g uterus!

32 32 Case 2

33 33 Case 2 Six months later

34 34 Laparoscopic Surgery Endometrial Cancer

35 Our UK Experience July 27 Training at Beth Israel (Newark)

36 36 Laparoscopic Surgery Endometrial Cancer November 27 First Robotic hysterectoy in UK

37 37 Laparoscopic Surgery Endometrial Cancer

38 38 Robotic Surgery Endometrial Cancer

39 39 Robotic Surgery Endometrial Cancer

40 4 Robotic Surgery Endometrial Cancer

41 4 Robotics Endometrial Cancer Too expensive? Too many complications? No proven oncological benefit?

42 42 Robotics Endometrial Cancer I don t need a robot because I m so good

43 43 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Wright et al 22 JCO: ; Laparoscopic 437 Robotic No difference in complication rates $292. more expensive More likely to have robotic surgery if; White Teaching Hospital Health Insurance Conversion rate? AH rate in institutions where LH the norm compared to RH?

44 44 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Bell et al 28 RH - $822. LH - $ AH - $

45 45 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer LAP Item code Cost (including VAT) 2 x 2mm trocar B2LT 6.48 for 2 x 5 mm trocar B5LT 9.7 each Harmonic scalpel ACE36E each +/- disposable Scisssors 5DLS (5DCS?) 69.9 each LIGACLIP ER each Camera cover DCC each Suction (standard) CB385ULT 27.2 each Total:,9.98 Robot Robot DRAPE CAMERA each ROBOT DRAPE MONITOR each ROBOT DRAPE INSTRUMENT X for 2 Canula seal x for 2 Scissor tip cover each Robotic monopolar scissors use % OF = % Robotic bipolar use % OF = % BIPOLAR LEAD each Long suction STRYKER IRRIGATION each Total: 9.36 Both procedures Specimen bag HUBERT each INSUFFLATION TUBE WEINSF each Hasson trocar autosuture 7975p 68.9 eachlap

46 46 The Royal Marsden NHS Foundation Trust Robotic Surgery For Endometrial Cancer

47 47 Methods 4 year review Independent assessment of cost by financial auditors Ward/Clinic Staff Theatres Drugs Blood Products Imaging Pathology Rehab ITU Cost of Robot & OR Included

48 Cases Patients over 4 Years 3 Before the Robot 66 After the Robot 95 Open 77 Straight Stick 24 Robotic

49 49 Co-morbidity Average BMI = % Surgical Comorbidity 27.% previous laparotomy 26.5% uterus over 4/4 5.% had abdominal hernia 76.5% medical co-morbidity 3.2% with stage 3 or 4 disease (8.2% stage 4) 44.4% high risk pathology

50 5 Open cases

51 Drugs / Pharmacy Costs ( ) 5 (6 5,78) 39 (7 579) The Royal Marsden NHS Foundation Trust 5 Blood Products Costs ( ) ( 49) Footer ( dd.mm.yyyy 588) Costs Before & After Imaging Costs ( ) 54 ( 893) 33 ( 62) Pathology Costs ( ) 64 (35,84) 585 (35,34) Rehab Therapy Costs ( ) 98 ( 3,582) ( 8,74) High Dependency Care Costs ( ) 2,83 ( 9,639) 2,56 ( 5,222) Total Cost ( ),463 (3,62 34,276),48 (4,92 7,36), Cost Including Depreciation ( ),476 (3,88 34,276),274 (4,42 7,36),

52 52 Outcomes Before & After Table 3: Outcomes Following Primary Surgery for Endometrial Cancer Before and After the Introduction of Robotics Pre-Robot Post-Robot All Cases Mann-Whitney P (Med. Dif.: 95%CI) or Fischer s Exact Test (FET) Operative Time (min) - Median (Range) 85 (75 43) 228 (2 585) 94 (73 585) P =.2 (37: 7 to 55) High Dependency Post Operative Care - n/n (%) 2/3 (86.%) 57/66 (86.4%) 69/96 (86.2%) FET NS Estimated Blood Loss (ml) - Median (Range) 25 (5 3,7) 2 (,2) 25 ( 3,7) P =.8 (55: to 5) Drop in Hb (g/l) - Median (Range) 2 (-8 58) 9 (-5 38) 2 (-8 58) NS (3: - to 6) Days Stay - Median (Range) 5 ( 26) 3 ( 8) 4 ( 26) P <. (2: to 3) Any Complication - n/n (%) 64/3 (49.2%) 9/66 (28.8%) 83/96 (42.4%) FET P =.45 - Urinary Tract Infect - n/n (%) 3/3 (23.8%) 3/66 (9.7%) 44/96 (22.4%) FET NS - Wound Infection - n/n (%) 7/3 (3.%) 2/66 (3.%) 9/96 (9.7%) FET P =.77 - Blood Transfusion - n/n (%) 29/3 (22.3%) 8/66 (2.%) 37/96 (8.9%) FET NS - Other Complications - n/n (%) 24/3 (8.5%) 5/66 (7.6%) 29/96 (4.8%) FET P =.38 Ileus Pyrexia Unknown Origin Clostridium Difficile Chest Infection Arrythmia Severe Constipation MRSA Vascular Injury Septicaemia Urine Retention Bladder Injury Vault Bleeding Acute Tubular Necrosis Bowel Serosa Tear

53 53 Outcomes Before & After Table 3: Outcomes Following Primary Surgery for Endometrial Cancer Before and After the Introduction of Robotics Pre-Robot Post-Robot All Cases Mann-Whitney P (Med. Dif.: 95%CI) or Fischer s Exact Test (FET) Operative Time (min) - Median (Range) 85 (75 43) 228 (2 585) 94 (73 585) P =.2 (37: 7 to 55) High Dependency Post Operative Care - n/n (%) 2/3 (86.%) 57/66 (86.4%) 69/96 (86.2%) FET NS Estimated Blood Loss (ml) - Median (Range) 25 (5 3,7) 2 (,2) 25 ( 3,7) P =.8 (55: to 5) Drop in Hb (g/l) - Median (Range) 2 (-8 58) 9 (-5 38) 2 (-8 58) NS (3: - to 6) Table 3: Outcomes Following Primary Surgery for Endometrial Cancer Before and After the Introduc Days Stay - Median (Range) 5 ( 26) 3 ( 8) 4 ( 26) P <. (2: to 3) Any Complication - n/n (%) 64/3 (49.2%) 9/66 (28.8%) 83/96 (42.4%) FET P =.45 Pre-Robot Post-Robot A - Urinary Tract Infect - n/n (%) 3/3 (23.8%) 3/66 (9.7%) 44/96 (22.4%) FET NS - Wound Infection - n/n (%) 7/3 (3.%) 2/66 (3.%) 9/96 (9.7%) FET P =.77 Operative Time (min) - Median (Range) 85 (75 43) 228 (2 585) 94 - Blood Transfusion - n/n (%) 29/3 (22.3%) 8/66 (2.%) 37/96 (8.9%) FET NS - Other Complications - n/n (%) 24/3 (8.5%) 5/66 (7.6%) 29/96 (4.8%) FET P =.38 Ileus Pyrexia Unknown Origin Clostridium Difficile Chest Infection Arrythmia Severe Constipation MRSA Vascular Injury Septicaemia Urine Retention Bladder Injury Vault Bleeding Acute Tubular Necrosis Bowel Serosa Tear High Dependency Post Operative Care - n/n (%) 2/3 (86.%) 57/66 (86.4%) 69/ Estimated Blood Loss (ml) - Median (Range) 25 (5 3,7) 2 (,2) 25 Drop in Hb (g/l) - Median (Range) 2 (-8 58) 9 (-5 38) 2 Days Stay - Median (Range) 5 ( 26) 3 ( 8) 4 Any Complication - n/n (%) 64/3 (49.2%) 9/66 (28.8%) 83/ - Urinary Tract Infect - n/n (%) 3/3 (23.8%) 3/66 (9.7%) 44/

54 54 Outcomes Before & After Table 3: Outcomes Following Primary Surgery for Endometrial Cancer Before and After the Introduction of Robotics Pre-Robot Post-Robot All Cases Mann-Whitney P (Med. Dif.: 95%CI) or Fischer s Exact Test (FET) Operative Time (min) - Median (Range) 85 (75 43) 228 (2 585) 94 (73 585) P =.2 (37: 7 to 55) High Dependency Post Operative Care - n/n (%) 2/3 (86.%) 57/66 (86.4%) 69/96 (86.2%) FET NS Estimated Blood Loss (ml) - Median (Range) 25 (5 3,7) 2 (,2) 25 ( 3,7) P =.8 (55: to 5) Drop in Hb (g/l) - Median (Range) 2 (-8 58) 9 (-5 38) 2 (-8 58) NS (3: - to 6) Days Stay - Median (Range) 5 ( 26) 3 ( 8) 4 ( 26) P <. (2: to 3) Any Complication - n/n (%) 64/3 (49.2%) 9/66 (28.8%) 83/96 (42.4%) FET P =.45 - Urinary Tract Infect - n/n (%) 3/3 (23.8%) 3/66 (9.7%) 44/96 (22.4%) FET NS - Wound Infection - n/n (%) 7/3 (3.%) 2/66 (3.%) 9/96 (9.7%) FET P =.77 - Blood Transfusion - n/n (%) 29/3 (22.3%) 8/66 (2.%) 37/96 (8.9%) FET NS - Other Complications - n/n (%) 24/3 (8.5%) 5/66 (7.6%) 29/96 (4.8%) FET P =.38 Ileus Pyrexia Unknown Origin Clostridium Difficile Chest Infection Arrythmia Ileus Severe Constipation MRSA Vascular Injury Septicaemia Urine Retention Bladder Arrythmia Injury Vault Bleeding Acute Tubular Necrosis Bowel Serosa Tear Pre-Robot Post-Robot A Operative Time (min) - Median (Range) 85 (75 43) 228 (2 585) 94 High Dependency Post Operative Care - n/n (%) 2/3 (86.%) 57/66 (86.4%) 69/ Estimated Blood Loss (ml) - Median (Range) 25 (5 3,7) 2 (,2) 25 Drop in Hb (g/l) - Median (Range) 2 (-8 58) 9 (-5 38) 2 Days Stay - Median (Range) 5 ( 26) 3 ( 8) 4 Any Complication - n/n (%) 64/3 (49.2%) 9/66 (28.8%) 83/ - Urinary Tract Infect - n/n (%) 3/3 (23.8%) 3/66 (9.7%) 44/ - Wound Infection - n/n (%) 7/3 (3.%) 2/66 (3.%) 9/ - Blood Transfusion - n/n (%) 29/3 (22.3%) 8/66 (2.%) 37/ - Other Complications - n/n (%) 24/3 (8.5%) 5/66 (7.6%) 29/ Pyrexia Unknown Origin 3 Clostridium Difficile Chest Infection Severe Constipation MRSA Vascular Injury 2

55 S The Royal Marsden NHS Foundation Trust High Dependency Post Operative Care - n/n (%) 9/95 (94.7%) 62/77 (8.5%) 7/24 (7.8) R 55 R S Outcomes by Route R S R S R S R S R S R S R S Estimated Blood Loss (ml) - Median (Range) 4 (5 3,7) 2 (5 85) ( 25) R Drop in Hb (g/l) - Median (Range) 23 (-8 58) 9 (-8 4) 7 ( 33) R Days Stay - Median (Range) 6 (3 26) 3 ( ) 2 ( 4) R Conversion to Laparotomy - n/n (%) NA 4/77 (8.2%) /24 (.%) R Any Complication - n/n (%) 59/95 (62.%) 23/77 (29.9%) /24 (4.2%) R - Urinary Tract Infect - n/n (%) 3/95 (3.6%) 4/77 (8.2%) /24 (.%) R - Wound Infection - n/n (%) 5/95 (5.8%) 4/77 (5.2%) /24 (.%) R - Blood Transfusion - n/n (%) 36/95 (37.9%) /77 (.%) /24 (4.2%) R - Other Complications - n/n (%) 8/95 (8.9%) /77 (4.3%) /24 (.%) R Ileus Pyrexia Unknown Origin Clostridium Difficile Chest Infection Arrythmia Severe Constipation R S

56 56 Summary Less complications Shorter hospital stay Longer time in theatre Cheaper

57 57 Robotic Surgery Endometrial Cancer Outcomes comparable and possibly better

58 58 Robotic vs Laparoscopic Surgery Endometrial Cancer Operative Time

59 59 Robotic vs Laparoscopic Surgery Endometrial Cancer Days Stay

60 6 Robotic vs Laparoscopic Surgery Endometrial Cancer EBL

61 6 Robotic vs Laparoscopic Surgery Endometrial Cancer Complications

62 62 Robotic vs Laparoscopic Surgery Endometrial Cancer Conversions

63 63 Robotic Surgery Endometrial Cancer Other advantages

64 64 Robotic Surgery Endometrial Cancer

65 65 On-going Studies FRIENDS

66 66 FRIENDS

67 67 On-going Studies MARRIED

68 68 Series to date

69 69 Series to date

70 7 The Royal Marsden NHS Foundation Trust Clinical independence is the last refuge of the clinically incompetent