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Image-guided ablation for liver tumours – an addition to the armamentarium of multidisciplinary oncological and surgical approaches
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Biomarkers for pancreatic cancer: going beyond the impossible?
Daniel Ansari, Roland Andersson
Despite major advances in modern medicine, pancreatic cancer remains for the most part a death sentence. If we are to change the trajectory of pancreatic cancer, early diagnosis is probably the most effective tool at hand. Patients diagnosed with pancreatic cancer at an early stage have the best chance of curative treatment and long-term survival. For example, localized cancer confined to the pancreas has a 5-year survival rate of 42%1. Once the disease has spread to regional structures or lymph nodes, the 5-year survival drops to 14% and only 3% of those diagnosed with distant metastases survive beyond 5 years. However, developing early detection methods for pancreatic cancer remains an elusive task and still today, only around 13% of patients have their tumour detected at a localized stage. The striking difference in survival between early- and late stage tumours has spawned decades-long efforts to find biomarkers that will enable earlier detection of pancreatic cancer. The US National Institutes of Health (NIH) defines a biomarker as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.”2 Carbohydrate antigen 19-9 (CA 19-9), discovered in 19793, is the only FDA-approved serum biomarker for pancreatic cancer. CA 19-9 has a sensitivity of 79-81% and specificity of 82-90%4. However, CA 19-9 has a limited sensitivity in early-stage disease. False positive values may occur in patients with benign biliary obstruction and several inflammatory conditions in the pancreas and hepatobiliary system. Furthermore, approximately 5-10% of the general population are Lewis antigen negative and lack the enzyme necessary to produce CA 19-9, leading to potentially false negative results. For these reasons, CA 19-9 cannot be used for screening purposes and the indication is mainly restricted to treatment monitoring. The recent revolution in genomic, transcriptomic, proteomic and metabolomic technologies have contributed to the discovery of thousands of potential biomarker candidates for pancreatic cancer. These biomarkers are measurable in blood as liquid biopsies and have been evaluated either as single markers or as multimarker combinations, including protein panels5, 6, metabolites7, autoantibodies to tumour antigens8, 9, exosomes10, microRNAs11, nucleosomes12, circulating tumour cells13 and circulating tumour DNA14-16. Despite initial promise, no investigational biomarker has yet entered routine clinical practice. The question remains: Why do so many initially promising biomarkers fail to reach the clinic?
Widening participation in cardiothoracic healthcare: INSINC Insight
Kirstie Kirkley, Georgia R. Layton, Javeria Tariq, Heen Shamaz, Mostin Hu, Alana Atkinson, Deborah Harrington, Elizabeth Belcher, Jason Ali, Narain Moorjani, Farah Bhatti, Karen Booth
Equality, diversity and inclusion (EDI) within surgery is important.1 The recent Kennedy Review on Diversity and Inclusion, commissioned by the Royal College of Surgeons of England, made 16 recommendations to improve EDI in the surgical workforce.2 Cardiothoracic surgery in the UK lacks diversity, exemplified with only 13% of the consultant workforce being female, despite females accounting for 49% of UK doctors.3 One method of improving EDI in the specialty, is to focus on widening participation (WP) activities.
In the UK, WP activities and government policies aim to increase representation of lower socio-economic groups in higher education. Published schemes focus on peer-to-peer mentorship from medical to school students. The King’s College London scheme is a monthly seminar series offered to WP school students, publishing a 50% success rate of translation to successful application to medical school.4
Resident selection in surgery
Kristine Hagelsteen, MD PhD, Chris Mathieu
There is a global interest in and growing knowledge about how best to select residents in surgery. In 2010, Paice et al claimed that selection was “the missing link in patient safety work”1. The starting point for collegial discussions on the matter and opinions about selection are things we know and have experience of; and we know that there is a spectrum running from excellent to unsuitable surgeons. Some continue to ask, are surgeons “born or made”, i.e., is it innate talent, or their training that matters? Is competence-based education better than the apprenticeship model?2,3. Further, it is well-established that all facets of competence matter for patient outcomes, not only technical skill4-6. The detrimental effect a less competent or even dysfunctional colleague can have on patients and the workplace environment is also widely recognised7. Attrition from surgical residency programs has been reported to be up to 20%, reflecting bad investments of resources8. Another challenge is that surgery accounts for most adverse events in health care, and that up to 15 % of patients in elective surgery suffer a treatment-related injury9,10. We all want the next generation to be better than us. Selection is thus a foundational factor in raising the standard level of treatment and care, reducing adverse events, improving workplace collaboration and heightening the reputation of the profession.
Some characteristics have been found important for surgeons to be successful, such as having a strong academic background and commitment to lifelong learning; possessing sufficient manual dexterity and fine motor skills to reach proficiency; displaying emotional stability; extroversion and conscientiousness; good communication skills and ability to work in teams; critical thinking ability; situational awareness; robust decision-making and problem-solving skills11-14. A more recent addition to the list is “technical orientation”, i.e. willingness and ability to work in a technology-based environment15.
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