Now that the Covid-19 buriana seems to be losing intensity, public health priorities need to be recalibrated. Among these, there is assistance to cancer patients: starting with those patients for whom even a few weeks’ delay in formulating the diagnosis and starting the therapeutic path can make a difference. Among them, there are those I deal with every day: people with a pancreatic cancer. In this case, we have one of the most aggressive forms of cancer. Its global load, as recalled by an article just published in Nature, has doubled in the past 25 years. In the Western world, where it is most widespread, it represents the fourth cause of death in the oncology field. And in Italy, without going far, every year it claims more victims of breast and stomach cancer.
For this reason, faced with a disease that, in ten years’ time, could become the second cause of death among those oncology, it is necessary to put in place resources that have never been invested before. A sort of “Marshall Plan” in the oncology field. The gradual exit from the health emergency offers the opportunity to pick up those dossiers in the meantime dusty on the desks of those called to deal with health policy: from the Ministry of Health to the Regions, without forgetting the role that a important agency like Agenas. At the top of the list is the need to set up the pancreas unit, multidisciplinary structures within which all the professionals called to take care of the (not only) oncological diseases of one of the most complex organs to be treated must live together. And therefore: from gastroenterologists to radiotherapists. Passing through oncologists, surgeons, specialized pathologists, radiologists, psycho-oncologists and nutritionists.
Cancer: over 1.4 million deaths in 2021 in the EU and the UK
by Tiziana Moriconi
As happened in the case of breast cancer, with the establishment of breast units, making available to citizens specialized centers in the research and treatment of pancreatic cancer is the first step to take to give more hope to those who, discovered to be affected by this form of cancer, in almost all cases he suddenly sees the horizon shortening that separates him from the end of that path called life. The presence of all professionals involved in the management of this disease within a pancreas unit is essential. Making a diagnosis of pancreatic adenocarcinoma in a center with little experience can lead, for example, colleagues – radiologists, endoscopists, pathologists and oncologists – to overestimate or underestimate the risks of malignant transformation of a cyst, to delay a cancer diagnosis or to operate on a patient who he could have avoided getting under the knife.
Pancreatic cancer, can be caught in time but causes Covid interventions down 34%
by Irma D’Aria
The evaluation of the outcomes of surgery – currently the only possibility to resolve the disease, but only indicated in 1 out of 5 cases in pancreatic cancer – offers the only measurable result. Mortality, in the centers that carry out few interventions and do not foresee the co-presence of all the indicated specialists, is higher than 10 per cent. The same scenario, observed from another point of view, leads to say that the risk of dying following an operation for the removal of a pancreatic adenocarcinoma in a hospital with little experience increases by 400 percent. Diseases of the pancreas, on the other hand, require special expertise. They are difficult to spot and – consequently – to cure. Unfortunately, pancreatic cancer is among the most aggressive: less than one in ten patients is alive five years after diagnosis. And surgery on the pancreas is one of the most complex procedures in abdominal surgery. These are the main reasons why assistance to these patients can only be entrusted – as already happens in the United Kingdom, the Netherlands, Finland and partly in Germany: to cite the example of some countries not too far from ours. – to a limited number of centers.
This is the first step to take to ensure access to adequate care for all patients, guaranteeing a multidisciplinary approach, the humanization of care and attention to the quality of life beyond overcoming the disease. Where to start, then? From the consolidation of those centers that already meet the required requirements and from the identification and development of new ones, paying attention to distribution on the national territory. The first, in Italy, are few. As already reported in these columns, they are almost all located in Northern Italy. And, among the new patients who enter it every year, almost 1 in 2 comes from Central and Southern Italy. A figure without terms of comparison, which makes pancreatic cancer one of the main causes of health migration.
Pancreatic cancer, 130 avoidable deaths every year in Italy
by Fabio Di Todaro
In this case, the injustice is twofold: health and economic. On the one hand, there are those who can afford to go for treatment hundreds of kilometers from home in exchange for better chances of treatment. On the other hand, there is a majority share of southern citizens (6 out of 10) who get sick and end up being assisted in structures burdened by an operative mortality of 10 percent or more. Yes, because this is an average figure, conditioned by values even six times higher recorded in some hospitals in Puglia and Sicily. This is equivalent to saying that 6 out of 10 patients, among those who end up in the operating theaters of centers with little experience in the treatment of pancreatic cancers, die within 30 days of surgery. Something unacceptable, in 2021 and in Italy. Without neglecting the downside: the load on the reference structures, called to jump through hoops every day in order to face what has now become a health emergency.
Precision oncology, the revolution starts from Italy
by SIMONE VALESINI
Moving beyond such distortions, now that Covid-19 seems to be biting the brakes, is a public health emergency. What requirements should a hospital ready to assist patients with pancreatic cancer have? Italy, at the moment, has never regulated the matter. With five colleagues – Gianpaolo Balzano, Giovanni Guarneri, Nicolò Pecorelli, Michele Reni and Gabriele Capurso – we tried to provide input to centralize surgical interventions. One step, the one described in the scientific journal HPB, which could serve as a prelude to the establishment of pancreas units in the same centers. The model predicts that facilities authorized to treat this disease should perform at least ten resections per year, with a mortality of less than 2 percent. But since surgery is indicated for a minority of patients, its outcome cannot be the only indicator for evaluating the care of people with pancreatic cancer. It is also fundamental to guarantee waiting lists compatible with the disease, quality of care independent of surgery and short distances (less than an hour) for almost all patients.
While also speaking as the manager of a structure that reflects the requirements to be defined as a reference, at the moment patients with pancreatic cancer are exposed to unacceptable risks and disparities. The effort that is made in the most experienced centers is equivalent to that of a sailor trying to plug a leak in the keel of his ship. This is not how hope can be offered to those who are called to deal with this terrible disease. The request that – as president ofItalian Association for the Study of the Pancreas (AISP) – I address the Ministry of Health is to take over the dossier relating to the establishment of the pancreas unit in the next few days. At least one for every 4-5 million inhabitants would be needed.
Tumors of the pancreas, in Italy almost 1 out of 10 patients has a Brca mutation
by Tina Simoniello
In the meantime, the Regions have a duty to do something immediately to meet the needs of their citizens. So far, especially the southern ones, they have mostly limited themselves to reimburse the services provided in other areas of the country. Now all of them – including Lombardy and Veneto, which host the centers with the highest volume in the treatment of pancreatic neoplasms – are instead called upon to carry out a finer, more complex and in some ways unpopular work which first of all provides for the selection of hospitals which, if not yet able to provide optimal performance, they can start a path in this direction. It must be clear to everyone – colleagues, local politicians and citizens – that pancreatic cancer requires centralization of care in a limited number of centers. The population needs to be honestly explained why, but above all to offer the opportunity to treat this disease in a hospital that can be reached within an hour. This is what can and must be expected: not the solution in the nearest hospital, without knowing with what prospects.
Once the centers of reference have been identified, the Regions are also called upon to create a specific training course for specialists, to implement essential services to formulate a correct diagnosis and to manage possible surgical complications and to monitor the results. It is good that the policy is aware that the most experienced specialists in the treatment of pancreatic cancer have long been available to activate collaborations throughout the national territory to move towards greater homogenization of the possibilities of treatment. Only in this way will we be able to try to improve the survival and quality of life of all patients suffering from pancreatic cancer: whether they have the possibility of being operated on or who can only undergo an oncological treatment path.
*Massimo Falconi is Director of the Pancreas Surgery Center of the Irccs San Raffaele Hospital in Milan and President of the Italian Association for the Study of the Pancreas (AISP).