Gastric cancer:Where is the place for the surgeon,the oncologist and the endoscopist today?

Gastric cancer remains a major health issue and a leading cause of death worldwide.While the incidence is decreasing in western countries,there has been a shift to more proximal cancers of the diffuse type,which are usually more aggressive and associated with a worse prognosis.Radical surgery still offers the only chance of long term survival,but surgery has reached a plateau of effectiveness and more aggressive approaches like"ultraradical" lymphadenectomy have not improved prognosis.There are three options to improve the situation:Earlier detection,neoadjuvant chemotherapy and adjuvant therapy.Whilst systematic gastroscopic screening makes sense in countries with a high incidence of gastric cancer,in other regions targeted investigation of risk groups including first-degree relatives of cancer patients,patients with a chronic corpusdominant gastritis or with defined genetic abnormalities may help to detect cancer at an earlier stage.Neoadjuvant chemotherapy has meanwhile proved to significantly improve the prognosis not only in patients with a locally advanced cancer who cannot be resected for cure but but also in those who are potentially amenable to curative resection.In the largest randomised study so far reported,perioperative chemotherapy raised overall survival after 5 years from 23%to 36%.The role of adjuvant chemotherapy has been discussed for over 30 years.Meta-analyses demonstrate a small but significant effect which,however,seems to be restricted to Asian patients.In a large USstudy,adjuvant radiochemotherapy appeared to significantly improve outcomes.However,less than 50%of the study patients underwent a systematic lymphadenectomy and so the results of the therapy group were not better to those of"only resected"patients in two large European studies.Thus,the indication of adjuvant(radio-)chemotherapy in gastric cancer currently remains uncertain.Endoscopists have found a therapeutic role through endoscopic resection of early cancers,introduced mainly by Japanese authors.With the development of high resolution endoscopy,endosonography and adequate equipment,the endoscopic curative resection of T1a-tumors(restricted to the mucosal layer) has been established.

Update Knowledge Assessment and Influencing Predictor of Female Fertility Preservation in Oncologists

Objective:This study aims to offer an update assessment of the knowledge of Chinese oncologists on female fertility preservation,and identify the determinants that influence the implementation of fertility preservation.Methods:A total of 713 Chinese oncologists with different specialties completed the online self-report questionnaire to assess their understanding of fertility risks in cancer treatment,knowledge on female fertility preservation,and perceptions on the barriers in referring patients for fertility preservation.Results:Although most oncologists were familiar with fertility risk in cancer treatment,half of them lacked the knowledge for reproduction and preservation methods.In the multivariable model,oncologists in a hospital with a specialized reproductive institution,positive precaution for fertility risk,and fertility preservation discussion with patients were significantly correlated with the possibility of fertility preservation referral.Conclusions:The intervention targets based on the update evaluation and identified influencing determinants will be helpful for all the oncofertility researchers,oncologists and institutions in future efforts for well-established female fertility preservation services.

Observed communication between oncologists and patients:A causal model of communication competence

AIM: To investigate and test a causal model derived from previous meta-analytic data of health provider behaviors and patient satisfaction.METHODS: A literature search was conducted for relevant manuscripts that met the following criteria: Reported an analysis of provider-patient interaction in the context of an oncology interview; the study had to measure at least two of the variables of interest to the model(provider activity,provider patient-centered communication,provider facilitative communication,patient activity,patient involvement,and patient satisfaction or reduced anxiety); and the information had to be reported in a manner that permitted the calculation of a zero-order correlation between at least two of the variables under consideration.Data were transformed into correlation coefficients and compiled to produce the correlation matrix used for data analysis.The test of the causal model is a comparison of the expected correlation matrix generated using an Ordinary Least Squares method of estimation.The expected matrix iscompared to the actual matrix of zero order correlation coefficients.A model is considered a possible fit if the level of deviation is less than expected due to random sampling error as measured by a chi-square statistic.The significance of the path coefficients was tested using a z test.Lastly,the Sobel test provides a test of the level of mediation provided by a variable and provides an estimate of the level of mediation for each connection.Such a test is warranted in models with multiple paths.RESULTS: A test of the original model indicated a lack of fit with the summary data.The largest discrepancy in the model was between the patient satisfaction and the provider patient-centered utterances.The observed correlation was far larger than expected given a mediated relationship.The test of a modified model was undertaken to determine possible fit.The corrected model provides a fit to within tolerance as evaluated by the test statistic,χ2(8,average n = 342) = 10.22.Each of the path coefficients for the model reveals that each one can be considered significant,P < 0.05.The Sobel test examining the impact of the mediating variables demonstrated that patient involvement is a significant mediator in the model,Sobel statistic = 3.56,P < 0.05.Patient active was also demonstrated to be a significant mediator in the model,Sobel statistic = 4.21,P < 0.05.The statistics indicate that patient behavior mediates the relationship between provider behavior and patient satisfaction with the interaction.CONCLUSION: The results demonstrate empirical support for the importance of patient-centered care and satisfy the need for empirical casual support of provider-patient behaviors on health outcomes.

Modified Triple P Approach by Gynecologic Oncologist-Led Team for Placenta Accreta Spectrum Improves the Outcome: Non-Randomized Controlled Trial

Introduction: Placenta Accreta Spectrum (PAS) is associated with significant maternal and fetal morbidity and mortality. The ideal conservative management still does not exist. We aimed to compare the outcome of cesarean section for PAS by a gynecologic oncologist-led team using the modified triple P approach and by a non-gynecologic oncologist-led team. Material and Methods: This is non-randomized controlled trial. Group A had Cesarean Section by gynecologic oncologist. Gynecologic oncologist-led team did all Cesarean Section following a modified triple P approach. The first P is for “Plan” the uterine incision. The second P for “Pelvic” devascularization by internal iliac artery ligation. The third P is for Placenta non-separation with resection of the myometrium. Group B had Cesarean Section by non-gynecologic oncologist-led team. The main outcome measures were the need for hysterectomy, amount of blood loss, and the management-related complications. Results: Group A had significantly less estimated blood loss, and received less number of backed RBCs units, and less operative time than group B. The uterus is preserved in all cases of group A and in 50% of cases of group B. The overall maternal morbidity rate was 17.5% in group A and 72.2% in group B. Conclusion: This study provides evidence that the modified triple P approach for PAS by gynecologic oncologist-led team presents lower maternal morbidity in comparison to surgery by non-gynecologic oncologist-led team.

What factors are important to new patients when selecting an orthopedic oncologist?

BACKGROUND Understanding how patients choose a provider may improve the overall experience by identifying ways to tailor a clinical practice.AIM To identify factors that patients consider important when choosing an orthopedic oncologist.METHODS New patients presenting to an orthopedic oncology clinic within a tertiary academic medical center from January 2019 to August 2020 were invited to complete an anonymous survey.The questionnaire consisted of 27 items including a Likert-type assessment of the importance of selection factors.RESULTS A total of 101 new patients with a median age of 66 years(range,14 years to 91 years)responded.Most were referred by another doctor(n=63,62.4%),and of the referring providers,the most frequent specialty was orthopedic surgery(n=32,51%).Using a Likert-type scale with 1 representing‘least important’and 5 representing‘most important’,the most important factor was the hospital reputation(mean,4.65;SD,0.85).Additional factors of importance were the number of years in practice(3.87±1.3)and a primary care provider referral(3.71±1.6).Patients younger than 40 years old found social media(P=0.016)and internet presence(P=0.035)of their surgeon to be more important than older patients.In contrast,older patients considered care within an academic center to be of greater importance than younger patients(P=0.014).CONCLUSION This investigation suggests a primary care referral,as well as hospital and physician reputation,are among the most important factors when selecting an orthopedic oncologist.Furthermore,social media utilization appears to be more important for younger patients.

Being an oncologist in China: my notes about cancer treatment in China

Today I read a popular article about the management of cancers in China （1）. Although written by foreign doctors, it does utter some ＇unspeakable helplessness＇, as commented by a netizen. Many unique dilemmas do exist, and must be honestly faced by government, industry, doctors, patients, and the society. I was born in a remote village, had spent a few years as a medical student in a big city, and now am a tumor surgeon and hospital manager in a tertiary hospital in Beijing. Many of my patients have become my friends. I think I have a deep knowledge and understanding of people involved in the oncology.

SUN Yan (孙燕)——A Prominent Oncologist of Internal Medicine

Professor SUN Yan, a famous medical oncologist, was graduated from Yenching University with a B. S. degree in 1951, and from Peking Union Medical College with a M.D. degree in 1956. He studied traditional Chinese medicine from 1960 to 1961, and worked, between 1979 and 1980, as a visiting professor in M. D. Anderson Cancer Center, USA. Since 1959, he has been working in the Department of Medical Oncology in Cancer Hospital of Chinese Academy of Medical Sciences （CAMS）, holding the post of professor ＆ director of Department of Medical Oncology during 1986-1994. He was honored as the ＂Outstanding Physician＂ by CAMS and Peking Union Medical College （PUMC） in 1993, designated as an ＂Advanced Worker＂ in national health care system by the Ministry of Human Affairs in 1994, and elected an academician of Chinese Academy of Engineering in 1999. Since 1991, he has been enjoying the governmental special stipend.

Digestive oncologist in the gastroenterology training curriculum

Until the late 1980s, gastroenterology (GE) was considered a subspecialty of Internal Medicine. Today, GE also incorporates Hepatology. However, Digestive Oncology training is poorly defined in the Hepatogastroenterology (HGE)-curriculum. Therefore, a Digestive Oncology curriculum should be developed and this document might be a starting point for such a curriculum. HGE-specialists are increasingly resisting the paradigm in which they play only a diagnostic and technical role in the management of digestive tumors. We suggest minimum endpoints in the standard HGE-curriculum for oncology, and recommend a focus year in the Netherlands for Digestive Oncology in the HGE-curriculum. To produce welltrained digestive oncologists, an advanced Digestive Oncology training program with specific qualifications in Digestive Oncology (2 years) has been developed. The schedule in Belgium includes a period of at least 6 mo to be spent in a medical oncology department. The goal ofthese programs remains the production of well-trained digestive oncologists. HGE specialists are part of the multidisciplinary oncological teams, and some have been administering chemotherapy in their countries for years. In this article, we provide a road map for the organization of a proper training in Digestive Oncology. We hope that the World Gastroenterology Organisation and other (inter)national societies will support the necessary certifications for this specific training in the HGE-curriculum.

Gynecologic oncologists involvement on ovarian cancer standard of care receipt and survival

AIM:To examine the influence of gynecologic oncolo-gists(GO) in the United States on surgical/chemotherapeutic standard of care(SOC), and how this translates into improved survival among women with ovarian cancer(OC).METHODS: Surveillance, Epidemiology, and End Result(SEER)-Medicare data were used to identify 11688 OC patients(1992-2006). Only Medicare recipients with an initial surgical procedure code(n = 6714) were included. Physician specialty was identified by linking SEER-Medicare to the American Medical Association Masterfile. SOC was defined by a panel of GOs. Multivariate logistic regression was used to determine predictors of receiving surgical/chemotherapeutic SOCand proportional hazards modeling to estimate the effect of SOC treatment and physician specialty on survival. RESULTS: About 34% received surgery from a GO and 25% received the overall SOC. One-third of women had a GO involved sometime during their care. Women receiving surgery from a GO vs non-GO had 2.35 times the odds of receiving the surgical SOC and 1.25 times the odds of receiving chemotherapeutic SOC(P < 0.01). Risk of mortality was greater among women not receiving surgical SOC compared to those who did [hazard ratio = 1.22(95%CI: 1.12-1.33), P < 0.01], and also was higher among women seen by non-GOs vs GOs(for surgical treatment) after adjusting for covariates. Median survival time was 14 mo longer for women receiving combined SOC. CONCLUSION: A survival advantage associated with receiving surgical SOC and overall treatment by a GO is supported. Persistent survival differences, particularly among those not receiving the SOC, require further investigation.

Effect of gynecologic oncologist availability on ovarian cancer mortality

AIM: To determine the association between the distribution of gynecologic oncologist(GO) and populationbased ovarian cancer death rates. METHODS: Data on ovarian cancer incidence and mortality in the United States was supplemented with United States census data, and analyzed in relation to practicing GOs. GO locations were geocoded to link association between county variables and GO availability. Logistic regression was used to measure areas of high and low ovarian cancer mortality, adjusting for contextual variables. RESULTS: Practicing GOs were unevenly distributed in the United States, with the greatest numbers in metropolitan areas. Ovarian cancer incidence and death rates increased as distance to a practicing GO increased. A relatively small number(153) of counties within 24 miles of a GO had high ovarian cancer death rates compared to 577 counties located 50 or more miles away with high ovarian cancer death rates. Counties located 50 or more miles away from a GO practice had an almost 60% greater odds of high ovarian cancer mortality compared to those with closer practicing GOs(OR = 1.59, 95%CI: 1.18-2.15). CONCLUSION: The distribution of GOs across the United States appears to be significantly associated with ovarian cancer mortality. Efforts that facilitate outreach of GOs to certain populations may increase geographic access.

“精准医学”时代下肿瘤学住院医师规范化培训模式的思考

文章结合当前肿瘤学精准诊疗发展现状与我国肿瘤学住院医师规范化培训教学现状,分析基于内科学住培模式开展的肿瘤学住培教学在顺应肿瘤精准个体化医疗发展方面所面临的一些挑战,比如缺乏肿瘤专科基础理论学习、专科培训时间过短、专科临床诊疗知识掌握不足、无法紧密追踪肿瘤学前沿、无法满足肿瘤诊疗模式变化等问题,探索肿瘤学住培模式的优化策略,从培训计划上适当增加肿瘤科转轮时间,提高肿瘤临床知识学习效率,从教学模式上将基于问题的学习模式、基于案例的学习模式等传统教学模式应用到肿瘤精准医疗教学中,丰富且立体化肿瘤精准医学教学,培养具有精准医学思维、能够为患者提供最佳个体化治疗策略的肿瘤专科医师。

Development levels of pediatric palliative care teams and the extent of palliative care understanding and implementation among pediatric oncologists in China

Importance:Pediatric palliative care(PPC)is an interdisciplinary collaboration that focuses on the prevention and relief of patient suffering.PPC has emerged as a critical field of medical expertise and practice.However,no information is available regarding the progress of PPC in the Chinese mainland.Objective:This study investigated the geographic distribution,team structure,and services of PPC teams in the Chinese mainland.It also investigated the level of understanding and implementation among pediatric oncologists regarding PPC.Methods:The PPC subspecialty group of the Pediatrics Society of the Chinese Medical Association included 45 PPC teams.The team structure and services were investigated using questionnaires mailed to the team leader of each PPC team.In addition,we sent questionnaires regarding the level of PPC understanding and implementation of PPC practices to 170 pediatric oncologists in 11 hospitals.Results:The geographical distribution of PPC teams is uneven in China.Most PPC teams are concentrated in the eastern provincial capital of China.Most PPC teams had limited staff and services.The level of PPC understanding was considerably limited across all demographics;most pediatric oncologists reported“some understanding”(n=71,41.8%)or“poor understanding”(n=50,29.4%).Only 62.9%of pediatric oncologists had experience providing advice to family members regarding PPC matters.Interpretation:China is currently experiencing a critical shortage of PPC resources.Most pediatric oncologists had a limited understanding of PPC and reported limited practical implementation of PPC,which leads to underutilization of PPC resources.

YU Ren-cun(郁仁存)——A Famous Oncologist in Integrative Medicine

YU Ren-cun was born on August 1, 1934. After graduating from Jiangxi Medical College in 1955, he took part in the very first Western Doctors＇ Class for Learning Traditional Chinese Medicine （TCM） held in Beijing from March 1959 to December 1961. Prof. YU systematically learned TCM while taking this class. Since 1962, he has been working in the Beijing Hospital of Traditional Chinese Medicine, eventually being promoted to a Chief Physician by the Beijing Municipal Government in May of 1981. In 1997, Prof. YU was selected as a well-known veteran for the National TCM Doctor Inheritance Work by the State Administration of Traditional Chinese Medicine （SATCM）. The State Council of China has awarded him a special subsidy every month for his excellent work.

肿瘤内科医生与营养药师联合门诊的工作模式实践与效果分析

目的探讨肿瘤内科医生与营养药师联合门诊的工作模式及效果。方法通过开设肿瘤内科医生与药师联合门诊,收集联合门诊患者用药依从性、营养状态、不良反应发生情况和药师满意度评分等评价该工作模式的效果。结果经联合门诊模式干预后,肿瘤患者的营养状态、用药依从性及生存质量得到明显改善,67.6%的患者对临床药师的服务表示满意。结论肿瘤内科医生与药师联合门诊的新工作模式能够有效提高肿瘤患者的治疗效果,促进患者合理用药。

Recognition of Palliative Care in Chinese Clinicians:How They Feel and What They Know

Objective To investigate doctors'feelings when providing medical care to end-stage patients,and their understanding as well as reflection about theoretical concepts of palliative medicine.Methods Questionnaires were delivered through a social networking platform to1500clinicians of different specialties in10proviences of China.It covered issues of background information,self-assessment of familiarity to palliative care,prior training history,emotional attitude toward end-stage patients,and the reflections on clinical practice.Logistic regression analysis and chi-square test were used to analyse the categorical variables.Results There were379clinicians who completed the questionnaires and submitted successfully.Among them,66.8%(253/379)had attended palliative care training courses more than twice;66.8%(253/379)clinicians percieved powerless feeling when facing end-stage patients.We found that the education on palliative medicine was significantly associated to doctors'better comprehension on the concept of palliative care(OR=6.923,P=0.002).Doctors who were more familiar with palliative medicine were less likely to perceive powerless feelings(χ^2=13.015,P<0.001),and would be more likely to concern about patients and their family members in their clinical work(χ^2=28.754,P<0.001,χ^2=24.406,P<0.001).Conclusion The powerless feeling is prevalent in Chinese doctors when facing end-stage patients.Palliative care help them overcome the negative feelings and act more caring in clinic.More careful designed educational strategies that adapt to Chinese actual situation are needed to improve doctors'cognition on palliative care.

肿瘤专科医生职业倦怠现状及影响因素分析

目的了解肿瘤专科医生职业倦怠现状及其影响因素,探索其发生职业倦怠的规律和特点,提出干预措施。方法选取北京市某三级甲等肿瘤医院医生为研究对象,采用马斯勒职业倦怠量表(MBI-GS)和自制调查问卷对研究对象进行问卷调查。结果共有203名医生完成调查,其中40.9%的医生有一定程度的职业倦怠,24.1%的医生存在情绪衰竭,36.5%存在消极工作,2.5%存在成就感低下。不同的职称、工作环境、医院奖惩制度、药品配备、自评患者的满意度、患者对医生的信任度、患者及家属对医生的尊重度、居民对医生的尊重度、当前的执业环境、工作技术难度及社会地位对职业倦怠不同维度的平均得分差异有统计学意义(p<0.05)。结论医生的社会人口学特征、工作条件、外部环境、工作感受能够影响肿瘤专科医生职业倦怠的发生,应采取有效的应对措施,缓解其倦怠状况。

肿瘤科医生素养的整合与医患沟通

沟通对医生来说是一门艺术,与肿瘤患者能够进行良好的沟通需要肿瘤科医生素养的整合,沟通技艺更有其特殊性和复杂性。就肿瘤科医生素养整合的重要性以及在医患沟通中的应用进行了分析,并对肿瘤科医生提出了具体的要求。

广西肿瘤科医生工作满意度及影响因素研究

目的:了解广西肿瘤科医生工作满意度现状及影响因素,并就如何提高肿瘤科医生工作满意度提出建议。方法:利用随机抽样方法对广西436名肿瘤科医生进行问卷调查,对数据进行描述性统计、单因素以及逐步回归分析。结果:肿瘤科医生总体工作满意度得分为2.34±1.37,最满意的是同事关系,最不满意的为工作强度、执业环境与工资待遇;将单因素分析结果有意义的变量带入逐步回归分析中,得到肿瘤科医生工作满意度影响因素回归模型:Y=0.380X_(13)+0.174X_(10)+0.171X_(9)+0.180X_(11)+0.204X_(8)+0.123X_(7)-0.100X_(3)+0.072X_(12)。结论:肿瘤科医生对工作总体满意度不高,主要受工作强度、执业环境、个人发展、医院管理、社会地位、工资待遇、职称和同事关系的影响。建议政府与医院管理者从多方面入手切实提高肿瘤科医生的工作满意度。

Prolonged survival in patients with hand-foot skin reaction secondary to cooperative sorafenib treatment

BACKGROUND Sorafenib is an oral drug that prolongs overall survival(OS)in patients with hepatocellular carcinoma.Adverse events,including hand-foot skin reaction(HFSR),lead to permanent sorafenib discontinuation.AIM To clarify the association between interventions for adverse events and patient prognosis.METHODS We performed a retrospective,multicenter study of patients treated with sorafenib monotherapy between May 2009 and March 2018.We developed a mutual cooperation system that was initiated at the start of sorafenib treatment to effectively manage adverse events.The mutual cooperation system entailed patients receiving consultations during which pharmacists provided accurate information about sorafenib to alleviate the fear and anxiety related to adverse events.We stratified the patients into three groups:Group A,patients without HFSR but with pharmacist intervention;Group B,patients with HFSR and pharmacist interventions unreported to oncologists(nonmutual cooperation system);and Group C,patients with HFSR and pharmacist interventions known to oncologists(mutual cooperation system).OS and time to treatment failure(TTF)were evaluated using the Kaplan-Meier method.RESULTS We enrolled 134 patients(Group A,n=41;Group B,n=30;Group C,n=63).The median OS was significantly different between Groups A and C(6.2 vs 13.9 mo,p<0.01)but not between Groups A and B(6.2 vs 7.7 mo,P=0.62).Group A vs Group C was an independent OS predictor(HR,0.41;95%CI:0.25-0.66;P<0.01).In Group B alone,TTF was significantly lower and the nonadherence rate was higher(P<0.01).In addition,the Spearman’s rank correlation coefficients between OS and TTF in each group were 0.41(Group A;P<0.01),0.13(Group B;P=0.51),and 0.58(Group C;P<0.01).There was a highly significant correlation between OS and TTF in Group C.However,there was no correlation between OS and TTF in Group B.CONCLUSION The mutual cooperation system increased treatment duration and improved prognosis in patients with HFSR.Future prospective studies(e.g.,randomized controlled trials)and improved adherence could help prevent OS underestimation.

多学科综合诊治模式中肿瘤内科医生专科培养的反思与探索

肿瘤病人的增加,基础研究和临床转化的飞速发展,导致肿瘤相关科室临床医生面临的挑战越来越严峻。肿瘤的复杂性和系统性决定了多学科综合诊治(MDT)是使肿瘤患者获得最大治疗收益的正确模式。作为肿瘤多学科综合诊治中的核心组成部分,肿瘤内科医生是给患者提供先进、全面和系统服务的关键。因此,通过规范严格的入门教育和继续再教育,培养优秀、足量的肿瘤内科医生是使MDT模式达到最佳化状态的保证。