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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%
2004 8 founding members Philippine Musculoskeletal Tumor Society 2015 20 active members
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
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
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
patient MD team/unit environment Brand, Galindo & Gross. Situational Analysis of the Filipino Pediatric Oncology System 2014
Patient - Inadequate reporting No national registry Solution: PGH musculoskeletal tumor files (1993 - ) - Bone Tumors in Filipinos 2007 1 st ed - 876 cases from the PGH - Local and international publications
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.
10 Baguio Gen Hosp 15-20 Jose Lingad Mem Reg Hosp 30-35 Univ Phil-Phil Gen Hosp 10-15 Jose R Reyes Mem Hosp 10-15 East Ave Med Center Osteosarcoma 170 / 375 cases 15 Univ of Sto Tomas Med Ctr 30-35 Philippine Orthopedic Center 10-15 DLSU Health Science Institute 15-20 Perpetual Succour Hosp 15-20 Davao Med Center
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.
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
Patient Poor access to care 7100 islands - Archipelago: good for tourism bad for patient navigation flickrhivemind.net www.youtube.com romyocon.net odin.tic
Those who access care - late presentation - limb salvage 60% vs amputation 40% 466 cm 3 vs 5616 cm 3 - OSA patients 2006-2008 : 57 service patients: 61% M1 20 pay patients: 30% M1
Why the delay in accessing care? 1 Finances - Transport min daily wage = $S15 transport fare = $S2 - Diagnostics christianfilipina.com commons.wikimedia.org MRI = $S400
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 1 o 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 myriadrainbowhues.wordpress.com Solution: arrangements with other hospitals
Diagnostic - Pathologic assessment basic (H & E) limited (immunohistochem) translocation studies uncommon genomic research uncommon
Therapeutic - Surgery: 675 OSA patients < 200 completed treatment 60% limb salvage rate = 120 patients - wide excision - reconstruction
Therapeutic - implants: out-of-pocket
Therapeutic - staged surgeries Good function 6 12 month interval
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
Environment - 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
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
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 375 90%!! 45% seen at musculoskeletal tumor centers 170 PGH: 30% receive complete treatment 60 50% survival 30
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
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
20 years THANK YOU!!