More than 800 delegates gathered in the convivial atmosphere of the Gold Coast. Sun was abundant, surf beckoned, but there were serious oncological matters to consider.
The ANZBCTG teamed with COSA for a theme of breast cancer in a new age approach to cancer care. There was an emphasis throughout the three days on high level discussions about genomics and immunotherapy; but along with a focus on novel, innovative targeted therapies came considerations of new ideas for the better management and empowerment of patients.
Invited International Speaker Professor Melinda Irwin, with a background in epidemiology and public health, heads up the Cancer Prevention and Control Research Program within Yale University. Her breakfast session on exercise and physical activity was the first event of the ASM, and it set the tone for taking a new and different look at well-being for cancer survivors. The theme of exercise and physical activity continued throughout several sessions, including in the Exhibition Hall where those who were brave enough tried out the exercise equipment under the watchful eyes of exercise physiologists.
An eminent group of clinicians lined up for the first plenary session on “Global Advances in Breast Cancer”. Drawn from the disciplines of medicine, surgery, radiation oncology and nursing, all speakers gave a consistent message that to truly personalise cancer treatment one needs to look at the individual patient’s presentation and circumstances to offer optimal treatment and care. Expatriate Australian Shom Goel, now at Dana-Farber Cancer Institute made a plea for de-escalation of treatment; of doing less but doing it safely. “Doing less” also begins to address some of the inequities and disparities in cancer care.
Breast surgeon Laura Esserman from the University of California, San Francisco, followed by Boon Chua a radiation oncologist from Prince of Wales Hospital in Sydney (and latterly from Peter MacCallum Cancer Centre in Melbourne) both echoed Shom’s sentiments by stating that there is no “one size fits all” approach to cancer care because cancer is a collection of heterogeneous diseases. We need to find opportunities to safely do less, and personalised medicine may make this possible. We should turn our attention to strive for better outcomes at less cost to optimise the utilisation of the health care budget.
Deborah Fenlon, from the University of Southampton and with a background in nursing, finished the opening session by addressing the survivorship needs of people with breast cancer, who make up one quarter of all cancer survivors in the UK. Commonly identified survivorship issues are pervasive and include poor general health, decreased physical activity, lower workforce participation, poorer cognitive function and poorer emotional well-being. Self-management has been shown in research studies to enhance quality of life and to address some of the morbidity of survivors. With that in mind, MacMillan Cancer Support has developed a “Recovery Package” to assist cancer survivors. The message is clearly communicated that health professionals and patients are partners in their recovery.
Another thoughtful session harnessed a trio of multidisciplinary clinicians from psychiatry, medicine and nursing to confront the management of depression, fear of cancer recurrence, menopausal symptoms and cognitive decline in women recovering from breast cancer treatment.
Male breast cancer accounts for just under 1% of all breast cancer diagnoses, but it is the very rarity of the diagnosis, coupled with a community emphasis on female breast cancer that makes it such a difficult challenge for men with this diagnosis. A well-attended symposium addressed the issues, again with a multidisciplinary lens. John Boyages, Professor of Breast Oncology at Macquarie University Hospital in Sydney, opened the session with an overview of the challenges involved in diagnosing and treating man with breast cancer; and then closed the session with a thoughtful “interview” of two male breast cancer advocates. The session was a well-rounded one with Professors Nicholas Wilcken and Judy Kirk, both from Westmead Hospital in Sydney, discussing the issues around the evidence for hormonal treatments for men, and the genetic implications for these men and their families. Clinical Psychologist, Dr Jemma Gilchrist gave a clear and concise summary of the potential for psychological morbidity for male breast cancer patients. The overwhelming message is that breast cancer in men is similar but different from that in women. We need to be mindful of those differences.
The advocates, Herb Wagner from the USA and founder of “A Man’s Pink” and Robert Fincher who works with BCNA in Australia, both gave insightful perspectives about the difficulty of finding appropriate information resources for men, exacerbated by the lack of psychosocial services to support men. The audience came away with a resonating message that breast cancer has no gender and that men can’t manage the diagnosis alone.
As we progress through the 21st century, and those of us who continue to struggle with under-resourced and inadequate services to provide psychosocial care to all people with cancer and their carers, a session on the development of e-technologies in psycho-oncology was timely and well received. We were reminded that e-therapy programs are more than websites. They are derived from a sound theoretical base, and are educational and interactive. Further, they are patient-driven and not reliant on direct clinician referral. Even when patients are identified as being in need of psychosocial support services, referrals frequently don’t happen, or if they do, there are insufficient personnel to meet the need. Self-directed interventions, particularly as for Rekindle (sexuality), iCanADAPT (anxiety and depression) and Finding My Way (cancer-related distress) can help to overcome problems of stigma, isolation, remoteness and lack of face to face services. PROMPT-Care is used by clinicians in the Sydney South West Local health District. Patient reported outcomes promote and support patient-centred care and self-management. Australia is in the forefront of the development of e-technologies, at least in part because of our geographical challenges. All four programs presented are in the early stages of evaluation. Watch this space!
Financial toxicity is a hot topic in cancer care and is gaining momentum. Even in Australia, with an excellent public health care system, many people still incur significant out of pocket expenses: from prescription co-payments, to travel costs, to Medicare gaps and parking costs. Adding to the financial toxicity is the difficulty of resuming work after treatment.
Returning to gainful employment is a challenge for many people with cancer; and this is a big issue when one considers that 50% of people are of working age when diagnosed with cancer. Ian Olver from the Sansom Institute for Health Research in South Australia, reminded us that after cancer treatment, patients are 1.4 times more likely to be unemployed and that many people don’t work for up to five years after completing cancer treatment. Still more suffer significant reductions in income if they can’t work full-time. The problem may be compounded if carers also have to reduce or stop their employment to assist with the cancer treatment and the duties of caring for other family members. Employment can be a source of distraction for many, and contributes to self-esteem and a sense of social connectedness.
Louisa Gordon from QIMR Berghofer Medical Research Institute in Brisbane gave a powerful presentation on financial toxicity, one definition of which is when greater than 30% of household spending is consumed by health care costs. This can result in “catastrophic spending” in which families borrow money, over-extend their credit cards, forego other spending and sometimes reduce their medications and miss appointments to save money. Those most at risk are women, low income workers, younger age, people with advanced disease requiring more extensive adjuvant treatments and rural, regional and remote patients. Not only do they experience lower quality of life, but they may be at increased risk of treatment non-compliance and non-completion of recommended treatment.
Bogda Koczwara from Adelaide’s Flinders Centre for Innovation in Cancer finished the session on a positive note with an introduction to an online resource developed by her team in South Australia to support cancer survivors. Developed with a Cancer Australia grant, www.workaftercancer.com.au is a website that helps people with cancer, their carers, employers and health care providers to devise a return to work plan incorporating a return to work (and driving) assessment. There are question prompts, links to existing resources and testimonials by survivors.
The final day started with Dr Ranjana Srivastava, a medical oncologist and regular columnist for The Guardian imploring all clinicians to write and publish our thoughts about the work we do. She reminded us that the stuff of our everyday lives is novel and insightful to others. Ranjana amusingly related her dogged attempts to have her work published.
Ranjana also held captive the audience for the penultimate session of the ASM; the Presidential Lecture which she entitled “The Good Doctor” and then this was followed by an interview with Adam Spencer. She outlined her voluntary work with asylum seekers to describe the complex interplay of good care, ethics, disparities and inequities, even in a so-called first world, affluent and just society such as Australia.
She posed questions upon which the audience could reflect: What is the role of an oncologist in a top class, first world facility? Who is the best advocate for patients who don’t have a voice? She argued that the hardest part of cancer care is to understand the nuances of an individual patient’s situation and then communicate this to others who can advocate on their behalf.
Oncologists differentiate according to tumour specialty, but as global citizens we must look after all patients. Advocacy is not the role of a chosen few argued Ranjana; but the responsibility of all. Ranjana described medicine as a moral enterprise in which we must all make a difference. In response to Adam’s invitation to describe in three words the qualities of an oncologist, Ranjana said: compassionate, informed, with perspective.
As is customary, the ASM finished with a debate, moderated once more by the inimitable Adam Spencer. The topic was “To screen or not to screen: Is it time to stop population screening for breast cancer?” After six stirring contributions, it was hard to know which side actually won the debate. It wasn’t a traditional debate with each side sequentially presenting their arguments and then hearing the rebuttals of the opposition. Adam awarded gold, silver and bronze medals to the speakers, and with that the Gold Coast ASM had come to an end.
So, on to Sydney!
For more COSA ASM coverage including exclusive commentaries click here.
The 2017 COSA ASM will be held in Sydney, 13-15 November.