Centralising care for patients with pancreatic cancer: a hybrid model approach

Reducing regional variations in treatment rates for pancreatic cancer requires an inclusive, standardised approach and cooperation

The successful treatment of pancreatic adenocarcinoma with curative intent depends on a number of factors: the patient must present to a medical service for investigation, the appropriate investigations for diagnosing and staging the disease must be undertaken, and curative surgery and adjuvant therapy must then be considered in an appropriate setting.

The vast majority of patients with pancreatic cancer who present to medical services have locally advanced or disseminated disease.1 This is largely because of the absence of symptoms during early stage disease. Apart from the classic symptoms of jaundice, weight loss and epigastric pain, important red flags include unexplained pancreatitis and recent onset of type 1 diabetes, especially in older patients. There is currently no strategy for detecting early stage disease; although a number of promising biomarkers that could be useful in screening tests have been identified, trials are still in the early stages.2,3

In the consensus findings published earlier this year in the MJA,4 the Pancreatic Cancer Workshop of the Australasian Gastro-Intestinal Trials Group recommends standardised protocols for the staging and work-up of patients with suspected pancreatic adenocarcinoma. A multidisciplinary team (MDT) approach is strongly recommended, together with compulsory registration with a hepato-pancreato-biliary MDT to facilitate standardised, appropriate care and prospective data collection, and to improve access to clinical trials.4

In the study published in this issue of the MJA,5 Creighton and colleagues analysed data collated from several retrospective sources and compiled by the Centre for Health Care Linkage. In New South Wales, considerable variation between local health districts in the rates of curative intent treatment for pancreatic cancer was identified. It is impossible to ascertain whether this variation was at the primary or tertiary care levels, but the general suggestion is that patients from regional NSW are not receiving the same care as those in metropolitan areas. The argument that in some centres too many patients undergo pancreatectomy is refuted by the finding that areas with higher rates of resection were associated with improvements in long term survival. Advances in pancreatectomy techniques have increased the numbers of patients who can undergo curative surgery; despite this rise in numbers, morbidity and mortality rates have fallen. The volume–outcome relationship was also investigated by Creighton and her co-authors, with medium and higher volume centres (six or more resections per year) having higher survival rates, a finding that makes the case for centralising pancreatectomy procedures.5

However, centralised care raises a number of questions for patients, health practitioners and local health authorities,6 and may contribute to the lack of uptake of pancreatectomy in some areas.7 Improving access may help rectify this situation, but accessibility is not the only problem. Regional patients generally accept the need to travel for complex medical care, but they prefer treatment in a familiar environment, and may indeed accept lesser outcomes as the price for local treatment.8 Another criticism of centralisation is the drain on subspecialty surgical care in regional areas that it causes, with difficulties in recruiting and retaining clinicians in regional hospitals.

A more recent hybrid model of centralisation has been implemented by some centres. Reciprocal care arrangements are granted to clinicians at low volume regional and higher volume metropolitan centres, as has been organised by the Prince of Wales Hospital in Sydney and the Orange Base Hospital, for instance.9 Reciprocal care arrangements include reciprocal admitting and operating rights, networked access to specialist MDTs, rapid access to metropolitan facilities, and an “equal partner” relationship with metropolitan surgical teams. Regional and metropolitan specialists can operate together, taking advantage of the facilities at the metropolitan centres or supporting surgery in a regional, low volume environment. Regional patients have been shown to incur greater costs and to stay in hospital much longer for pancreatectomy treatment than local patients in metropolitan hospitals.6,10 Reciprocal care enables earlier repatriation to regional centres under the care of their own surgeon, making the metropolitan stay shorter and more predictable9 and avoiding the problems of poor handover to regional services.

While a global approach would be beneficial, “improving awareness of and access to specialist centres”5 is unlikely to significantly improve outcomes for people with pancreatectomy. Widespread education of the population will increase the numbers of patients who present with localised disease, but widespread screening is still many years away. Ensuring equality and standards of care across Australia with compulsory networked MDTs, prospective data collection, and guideline adherence is possible with existing technology, and at a relatively low cost.4 Many would agree that improved outcomes are more likely to result from discussions around a meeting room table rather than from actions at the operating table. Centralisation of pancreatic cancer services is probably inevitable, but will nevertheless be somewhat unpalatable for regional patients and clinicians. A hybrid approach that employs reciprocal care agreements may help overcome their reservations, and also improve the flow of patients to curative treatment.