“Estado Atual, da Arte e dos Ânimos”

Grupo Paulistano de Apoio ao Tratamento do Câncer de Pulmão

Instituto Brasileiro de Cancerologia Torácica (IBCT)Instituto Paulista de Cancerologia (IPC)

Instituto TóraxCentro de Cirurgia Torácica Minimamente Invasiva (CTMI)

Dr. Ricardo Sales dos SantosCoordenador, Centro de Cirurgia Torácica Minimamente Invasiva

Hospital Israelita Albert Einstein

Maio, 2010

Albert Einstein Jewish Hospital

Research & Education Institute

Social Responsability Institute

Diagnostic & Preventive Medicine

ONCOLOGY

INTERVENÇÃO CARDIOTORÁCICA MINIMAMENTE INVASIVA

Intervenção Cardiovascular

Percutânea

Cirurgia Cardíaca Minimamente

InvasivaDr. Marco Perin Dr. Robinson Poffo

Cirurgia Torácica Minimamente

InvasivaDr. Ricardo Santos

•CARDIOLOGIA INTERVENCIONISTA Intervenção Coronária percutânea Implante de Valva Aórtica Correções de Cardiopatias congênitas Implante de Dispositivos de Assistência Circulatória (Impella)

CENTRO DE ARRITMIA CARDÍACA Tratamento de Arritmias (Centro de Arritmia)

• Cirurgia Cardíaca Robótica Cirurgia vídeo-assistida - Troca valvar - Revascularização miocárdica - Correção de Cardiopatia congênitas - Tratamento de FA

•Cirurgia Torácica Video-Assistida (VATS) & Robótica (RATS) nas doenças do mediastino, pulmao e esofago

Terapia oncologica ablativa por via endoscopica ou percutanea guiada por imagem

Endoscopia respiratoria e digestiva intervencionista (Stent, laser, crioterapia)

Cirurgia estereotactica (Cyberknife)

Procedimentos multidisciplinares

•TERAPIAS COMBINADAS Revascularização do miocárdio Tratamento combinado de FA

1 - To present the big picture 2 - Deficiency of equipment 3 - Lack of multidisciplinary approach

– Conflict of interest among specialties?4 - Delay on the diagnosis of cancer

– Mistreatment is also related to the high incidence of tuberculosis

Challenges for the Brazilian Thoracic Oncologists

1 -To present the big picture

Challenges for the Brazilian Thoracic Oncologists

Population Economy 1 China 1,338,612,968

2 India 1,166,079,217

3 European Union 491,582,852 4 United States 307,212,123.

5 Indonesia 240,271,522

6 Brazil 198,739,269

7 Pakistan 176,242,949

8 Bangladesh 156,050,883

9 Nigeria 149,229,090

10 Russia 140,041,247

11 Japan 127,078,679

12 Mexico 111,211,789

https://www.cia.gov/library/publications/the-world-factbook/geos/br.html

1 European Union $ 14,910,000,000,000

2 United States $ 14,260,000,000,000

3 China $ 7,973,000,000,000

4 Japan $ 4,329,000,000,000. 5 India $ 3,297,000,000,000

6 Germany $ 2,918,000,000,000

7 Russia $ 2,266,000,000,000 8 United Kingdom $ 2,226,000,000,000

9 France $ 2,128,000,000,000

10 Brazil $ 1,993,000,000,000

12 Mexico $ 1, 563,000,000,000

24 Argentina $ 573,900,000,000

World Economy

Thoracic Oncology

• Early detection– Expensive– Less effective than prevention

- Tobacco control - Comprehensive programs and policies to reduce

tobacco consumption.

Tobacco use

Global Warming

• 1.3 billion of smokers• 80 % living in under developing countries• Every day , there are 100,000 new smokers

worldwide

Tobacco use – USA • In the United States, an estimated 25.6 million men (25.2 percent) and 22.6 million women

(20.7 percent) are smokers. These people are at higher risk of heart attack and stroke. The latest estimates for persons age 18 and older show...

• Among whites, 25.1 percent of men and 21.7 percent of women smoke

• Among black or African Americans, 27.6 percent of men and 18.0 percent of women smoke

• Among Hispanics/Latinos, 23.2 percent of men and 12.5 percent of women smoke

• Among Asians (only), 21.3 percent of men and 6.9 percent of women smoke

• Among American Indians/Alaska Natives (only), 32.0 percent of men and 36.9 percent of women smoke

• Studies show that smoking prevalence is higher among those with 9-11 years of education (35.4 percent) compared with those with more than 16 years of education (11.6 percent).

• It's highest among persons living below the poverty level (33.3 percent).

Tobacco use – Brazil

Tobacco prevalence in 15 Brazilian Capitals

MenWomen

Lung Cancer - Massachusetts

Lung Cancer in Brazil by region(Rates per 100,000)

Incidence of cancer – Brazil 2008

Challenge – understand the differences

• Smoking • USA – 20 to 30 % Brazil

– same

• Cancer • USA – 215,000 new

cases• Brazil – less than 25,000

new cases/year

Population in Brazil is about 2/3 US population

Official lung CA in Brazil is near 10% of US cases

Lung Cancer in Brazil

SEXO

68%

32%

Masculino Feminino

Lung Cancer in Brazil

31 23

38 196

133 498

259

670

262

531

214

12154

51

<30 30-39 40-49 50-59 60-69 70-79 80-89 > 89

FAIXA ETÁRIA - MASCULINO E FEMININO

F

M

3009 patients from January 2000 to December 2007 – One major cancer center

Lung Cancer in Brazil

772 227502 306

37 46217 139

15 1048 18

414 1938828 12

8 1

CEC

ADENO CBA

IPC /CARCINÓIDES

INDETERMINADO

OUTROS

TIPO HISTOLÓGICO

M

F

•3009 patients from January 2000 to December 2007 – One major cancer center•Squamous cell is still more frequent than adenocarcinoma; •High incidence of undetermined NSCLC

Courtey Dr José Pereira

Courtesy from Dr Jose Pereira.

Lung Cancer in Brazil

> 20 % were classified as undetermined NSCLC, further evaluation after this study was completed

Lung Cancer in BrazilHow about Staging ?

Courtesy from Dr Jose Rodrigues Pereira

I/IIIII

IV

Showing respect to the cop

Treatment and survival

564 patients with Stage IV NSCLC

Survival Stage IV

• Median survival = 8.3 months

• 1 year survival = 37 %

• 47 types of chemotherapy combination in 4 institutes

• Media # cycles = 4• Almost 30% received 3

drugs • 83.5% cisplatinum /

Carbotaxol564 patients with Stage IV NSCLC

2 - Deficiency of equipment

– What is going on in Minimally Invasive Thoracic Surgery ?– Is it important ? – At least we hope so...

Challenges for the Brazilian Thoracic Oncologists

Deficiency of equipment

• Assessment of technology • Cost effectiveness analysis• When and how to implement

3 - Lack of multidisciplinary (MD) approach- Small number of hospitals with tumor board- Resistance “to share” patient care ?– Why is MD important ?

Challenges for the Brazilian Thoracic Oncologists

Lack of multidisciplinary approach

4 - Delay on the diagnosis of cancer

Challenges for the Brazilian Thoracic Oncologists

Lung Cancer in Brazil

Delay on the diagnosis of cancer– Is mistreatment also related to the high incidence of

tuberculosis ? • It is not uncommon for Cancer patients to receive Tb

drugs. Is it true ?

–Is the delay related to Medical education or related to the health system?

Instituto Israelita de Responsabilidade Social

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

• Prolonged delay of the diagnosis of Lung Cancer in Brazil.

• Is it the Patient, Physician or Health system fault ?

• Method : Prospective questionnaire applied to 372 patients treated for lung cancer at the ICAVC – Sao Paulo

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

0.0

10.0

20.0

30.0

40.0

% de pacientes

1 - 7 8 - 30 31 - 90 > 90

dias

Graphic 1: Delay before looking for Medical assistance

• 29 % < 1 week• 61.5% < 30 days • 81.4% < 90 days • 18.5% > 90 days

Patient’s delay

Slide Courtesy Dr Pereira – Pulmonary Oncologist

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

Gráfico 2: Main symptoms (n=372)

31%

13%16%8%

32% tosse

dispnéia

dor torácica

hemoptise

outros

0%

50%

100%% de

pacientes

Tosse Dispnéia Dortorácica

Hemoptise

Gráfico 7: Tempo para procura de assistência, segundo sintomas

>90 dias31 - 90 dias8 - 30 diasaté 7 dias

Cough

SOBChest Pain

Hemoptysis

Other symptoms

Cough SOB Chest Pain

Hemoptysis

Hemoptysis

Time for looking for medical assistance X symptoms

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

3061

47

234

050

100150200250300

nº de pacientes

particular público

tipo de serviço

Graphic 5: First consult diagnosis based on type of service: Private or Public

outros

câncer

• 79.3% received a non cancer diagnosis at the first consult

Other diagnosis

Cancer suspicious

Private Public

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

• 11.8% - visited one physician before the diagnosis

• 24.5 % - visited 2 physicians • 45.4% - 3 or more physicians were necessary

to obtain a diagnosis

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

Gráfico 3: Primeiro diagnóstico obtido pelo paciente

7%28%

5%

10%5%

21%

12%12%

resfriado

pneumonia

bronquite

tuberculose

ortopédico

câncer

outros

sem diagnóstico

• only 20.7% suspicious for cancer at first

• 28% were treated for pneumonia

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

18.6

10.6

15.317.9

0

5

10

15

20

% de acertos

tosse dispnéia dor torácica hemoptise

Gráfico 6: Percentage of correct diagnosis of cancer based on symptoms at the first consult

Cough

SOB Chest pain Hemoptysis

EXCESSIVA DEMORA NO DIAGNÓSTICO CLÍNICO DO CÂNCER DE PULMÃO. DEPENDE DO MÉDICO, DO PACIENTE OU DO SISTEMA?

Mariana Lista, Fernanda C. Bes, José Rodrigues Pereira, Flora Kazumi Ikari, Sueli M.Nikaedo.Instituto do Câncer Arnaldo Vieira de Carvalho (ICAVC) – Santa Casa de Misericórdia de São Paulo.

São Paulo. Brasil.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

% de pacientes

≤ 30 31-90 91-180 181-365 >365

dias

Gráfico 4: Time delay to obtain diagnosis following the symptoms beginning

CONCLUSIONS

• 80% of patients had a non neoplastic diagnosis at the fisrt consult

• 18.5% never sought medical assistance before 3 months from the onset of symptoms

• In almost 40% , diagnosis was obtained after 6 months following the onset of symptoms, which is evidence that medical practioners and/or health system play an important role contributing to this major delay.

ESTADO DA ARTE

Robótica em esôfago

MWA em pulmão

RFA em Esôfago

Robótica em pulmão

Crioterapia sp

ray

100

2736

42

126

79

128

RFA em esôfago

200

1000

Hiperidrose

10000

2295

VATS

3592

5000

Drenagem Pleural

4370

Empiema

8425

Toracotomia

16845

9087

Ablação por radiofrequência (RFA)

Cirurgia Robótica2850

723

Ablação por micro-ondas (MWA)

485

Lobectomia por VATS

423

Radiofrequência em pulmão (RFA)●

●

●

●

●

●●

●●●●

●

●

●

●

●

Procedimentos

Usuários de vanguargaÁrea de inovação

“Late adopters” Usuários comuns (alvo)

Publicações até setembro de 2009

Lobectomia video assistida

ROBÓTICA

Cirurgia Video Assistida - Robótica

Standard instrumentation Open /close and rotation only

Lobectomia video assistidaInstrumentação

Estadiamento Mediastinal

Broncoscópio com US (EBUS)

• Broncoscópio com ultrassom na extremidade

• Permite ao usuário avaliar além da parede do brônquio; vasos em tempo real.

Estadiamento Mediastinal

EBUS

Estadiamento Mediastinal

EBUS

No presente momento EBUS não substitui e sim complementa a mediastinoscopia no estadiamento mediastinal

Estadiamento Biológico

• Terapia alvo – Marcadores • ERCC1 , RRM1, BRCA 1, P53, KRAS, P27, EGFR

• Platina, Gencitabina, Erlotinibe, Cetuximab

• LACE – Lung Adjuvant Cisplatinum Trial

• ITACA – International Tailored Chemotherapy Adjuvant Trial

• TASTE – Tailored Post Surgical Therapy in Early Stage NSCLC

• SCAT – Spanish Customised Adjuvant Treatment

– Necessidade de biópsias - antes, durante ou após o tratamento

Lancet Oncol Oct, 2009; 10:1001-10

DPOC, ICC, IAM, IRA, DM , baixa reserva cardiopulmonar, etc, etc........

Diminuir a recidiva local

125 Iodine radio-active seeds into the sutures

Braquiterapia intra-operatória

Implante da Braquiterapia

Ablação pulmonar (RFA)

RF & MW Circuit Diagrams

RFAVia circuitoEletrodo passa corrente

MWASem fluxo de corrente

pelo pacienteRadiação pela antena

Ablação pulmonar - Microondas

Ablação pulmonar - Microondas

Santos et al , STS 2010, Fort Lauderdale USA

Navegação eletromagnética

Electromagnetic navigation to aid radiofrequency ablation and biopsy of lung tumors.Santos RS, Gupta A, Fernando HC et al. Ann Thorac Surg. 2010 Jan;89(1):265-8.

Ablação guiada por imagem

Electromagnetic navigation to aid radiofrequency ablation and biopsy of lung tumors.Santos RS, Gupta A, Fernando HC et al. Ann Thorac Surg. 2010 Jan;89(1):265-8.

Navegação eletromagnética

Superdimension bronchoscopy

Endoscopia Torácica Intervencionista

Centro Cirúrgico BWH - Harvard

Endoscopia Torácica Intervencionista

Pre-Treatment 6 Weeks Post-Treatment

Glottic Stricture (Web)

74 yr old female with laryngeal cancer treated with external beam radiation therapy (EBRT) Laryngoscopy demonstrated a severe, circumferential glottic web

Treatment

Currently 8-months out with no recurrent symptoms

CRIOTERAPIA ENDOBRÔNQUICA

ESTADO DOS ÂNIMOS

Building the Future

IX Curso Internacional da Sociedade Brasileira de Cancerologia Boston Medical Center

6-11 de setembro de 2010

Coordenadores– Benedict Daly, MD.

– Chrish Fernando, MD– Dr. Ricardo Antunes– Dr. Ricardo Santos– Dr. Roberto Gomes