philstar.com philstar.com globalnation.inquirer.net tikichris.com sg.news.yahoo.com

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1 philstar.com philstar.com globalnation.inquirer.net sg.news.yahoo.com tikichris.com

2 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

3 mjlsha/wiki/makati

4 cookiesound.com Lamkaicee.worldpress.com stevemiddlehurst.worldpress.com

5 1990s - organized approach to extremity sarcomas - 2 Musculoskeletal Tumor Units established Univ of the Phil-Phil Gen Hosp Philippine Orthopedic Center

6 paradigm shift among doctors more awareness among laymen gradual improvement in patient survival with adequate treatment OSA 5yr OS <10% 55%

7 founding members Philippine Musculoskeletal Tumor Society active members

8 12 Musculoskeletal Tumor Referral Centers Baguio Gen Hosp Univ of Sto Tomas Med Ctr JLingad Mem Reg Hosp Univ Phil-Phil Gen Hosp Jose R Reyes Mem MC East Ave Med Center St Luke s Med Center Philippine Orthopedic Center DLSU Health Science Institute Perpetual Succour Hosp The Medical City Davao Med Center

9 Baguio Gen Hosp JLingad Mem Reg Hosp Univ Phil-Phil Gen Hosp Jose R Reyes Mem MC East Ave Med Center 12 Musculoskeletal Tumor Referral Centers 7 / 12 in MetroManila Univ of Sto Tomas Med Ctr Philippine Orthopedic Center DLSU Health Science Institute St Luke s Med Center Perpetual Succour Hosp The Medical City Davao Med Center

10 Baguio Gen Hosp JLingad Mem Reg Hosp Univ Phil-Phil Gen Hosp Jose R Reyes Mem MC East Ave Med Center 12 Musculoskeletal Tumor Referral Centers only 6 / 12 government hospitals Univ of Sto Tomas Med Ctr Philippine Orthopedic Center DLSU Health Science Institute St Luke s Med Center Perpetual Succour Hosp The Medical City Davao Med Center

11 patient MD team/unit environment Brand, Galindo & Gross. Situational Analysis of the Filipino Pediatric Oncology System 2014

12 Patient - Inadequate reporting No national registry Solution: PGH musculoskeletal tumor files ( ) - Bone Tumors in Filipinos st ed cases from the PGH - Local and international publications

13 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.

14 10 Baguio Gen Hosp Jose Lingad Mem Reg Hosp Univ Phil-Phil Gen Hosp Jose R Reyes Mem Hosp East Ave Med Center Osteosarcoma 170 / 375 cases 15 Univ of Sto Tomas Med Ctr Philippine Orthopedic Center DLSU Health Science Institute Perpetual Succour Hosp Davao Med Center

15 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.

16 10 Baguio Gen Hosp 15 Jose Lingad Mem Reg Hosp Soft Tissue Sarcoma 165 / 450 cases 10 Univ of Sto Tomas Med Ctr 30 Philippine Orthopedic Center 30 Univ Phil-Phil Gen Hosp 15 Jose R Reyes Mem Hosp 5 East Ave Med Center 15 DLSU Health Science Institute 15 Perpetual Succour Hosp 20 Davao Med Center

17 Patient Poor access to care 7100 islands - Archipelago: good for tourism bad for patient navigation flickrhivemind.net romyocon.net odin.tic

18 Those who access care - late presentation - limb salvage 60% vs amputation 40% 466 cm 3 vs 5616 cm 3 - OSA patients : 57 service patients: 61% M1 20 pay patients: 30% M1

19 Why the delay in accessing care? 1 Finances - Transport min daily wage = $S15 transport fare = $S2 - Diagnostics christianfilipina.com commons.wikimedia.org MRI = $S400

20 Why the delay in accessing care? 2 Low index of suspicion by MD 3 Traditional healers / present day quacks

21 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 Common in LMIC - Of 675 OSA patients < 200 patients completed treatment (<30%) with our Unit

22 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

23 patient MD team/unit environment Brand, Galindo & Gross. Situational Analysis of the Filipino Pediatric Oncology System 2014

24 Sarcoma Team - no government sponsored continuing education courses for 1 o MDs or health workers - no sustained sarcoma awareness campaign - misdiagnosis common

25 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

26 and even when well-trained and dedicated - poorly compensated - full time: $S 1300 per month - WOC = without compensation Solution: government & private practice = 1 hospital

27 Univ of the Phil - Phil Gen Hosp - 3 consultant ortho oncologists - 3 trainees (1 fellow, 2 residents) - theater, OP clinics, ward rounds 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

28 - 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

29 Sarcoma Unit Staging studies: - high quality available but unaffordable - long queues at the PGH myriadrainbowhues.wordpress.com Solution: arrangements with other hospitals

30 Diagnostic - Pathologic assessment basic (H & E) limited (immunohistochem) translocation studies uncommon genomic research uncommon

31 Therapeutic - Surgery: 675 OSA patients < 200 completed treatment 60% limb salvage rate = 120 patients - wide excision - reconstruction

32 Therapeutic - implants: out-of-pocket

33 Therapeutic - staged surgeries Good function 6 12 month interval

34 Therapeutic - examples of improvisations: stacked nail knee arthrodesis PHA + IM nail proximal femur PMMC upper extremity

35 Therapeutic - Teams: microvascular (VFG, flaps) Ilizarov Total Joint reconstruction - Tissue & Bone bank: only 1 in entire country

36 patient MD team/unit environment Brand, Galindo & Gross. Situational Analysis of the Filipino Pediatric Oncology System 2014

37 Environment - current govt more supportive of cancer prevention and cure : sin tax : graphic warning law - Dept of Health budget increased: 42.1B >> 83.7B $S 1.28 B >> $S 2.53 B

38 How does the individual pay? - Phil health insurance 15-20% of total expenses approx 30% of all Filipinos enrolled with Phil health - Private insurance 10-15% Filipino patients have private insurance - Out-of-pocket Majority cliparthut.com

39 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

40 patient MD team/unit environment Brand, Galindo & Gross. Situational Analysis of the Filipino Pediatric Oncology System 2014

41 Urgent Concern!! 5 OSA per million 375 OSA yearly %!! 45% seen at musculoskeletal tumor centers 170 PGH: 30% receive complete treatment 60 50% survival 30

42 Problems & recommendations problem Recommend (Local) Recommend (Regional) Lack of SA expertise No national registry Poor access Poor follow-up Abandonment Poor communication among MDs Choice of fellow-trainees based on need of Regions Standard registry per Hosp Through PMTS Dedicated registry personnel Budget for transport (patient or Sarcoma Unit personnel) Sarcoma nurse, personnel Sarcoma support group Regular, standardized MDC Training Exchange program Twinning SA support group

43 Problems and recommendations problem Recommend (Local) Recommend (Regional) Inability to adhere to international protocols Inadequate pathologic assessment Lack of resources for treatment ASEAN specific concerns Standardized resource appropriate protocols Consultations Telemedicine Coordinate civil society and government resources Legislation eg Tissue Bank Data collection Sharing of best practices Consultations Multiinstitutional & multi national collaborations

44 20 years THANK YOU!!