France : le dispositif d'annonce du cancer de l'INCa / Generalisation of the cancer diagnosis disclosure procedure

French version:

L'Institut National du Cancer (INCa) a mis en place un dispositif d'annonce du cancer, visant à promouvoir la consultation d'annonce de la maladie au patient, selon des modalités définies. Elaboré dans une volonté d'harmonisation au niveau national de cette difficile étape que constitue l'annonce du cancer au patient, ce dispositif défend l'intérêt du patient :

"L'annonce d'une maladie grave est toujours un traumatisme pour la personne malade. Elle marque l'entrée dans une vie où il faudra composer avec la maladie. L'idée que la personne malade se fait de son futur va être bouleversée. L'annonce du cancer, en particulier, va convoquer des images de mort, de souffrance, de traitements longs et pénibles. Elle va, dans la plupart des cas, provoquer la 'sidération' du patient qui va être dans l'impossibilité d'entendre ce que le médecin lui dit lors de la consultation. La personne malade passera ensuite par différentes phases de réactions psychologiques au cours desquelles son désir d'information et d'accompagnement évoluera. De nouveaux temps d'explication et de discussion sur la maladie, les traitements, permettront alors de diffuser une information adaptée, progressive, respectueuse du sujet, de sa demande et de ses ressources. Une information mieux vécue et comprise facilitera une meilleure adhésion du patient à la proposition de soins et l'aidera à bâtir des stratégies d'adaptation à la maladie. C'est dans cette optique qu'a été pensée l'organisation du dispositif d'annonce telle qu'elle est présentée (...)"

"En partenariat avec la Ligue contre le cancer et après plusieurs actions dans les établissements de soins, l'INCa continue de sensibiliser les soignants au nouveau dispositif d'annonce de la maladie. Tiré à 173 000 exemplaires, encarté dans 14 titres de la presse médicale, le document de présentation intéressera évidemment les spécialistes d'organe mais il a surtout pour objectif de mobiliser les médecins traitants, notamment les généralistes dont on sait qu'ils sont en première ligne dès l'apparition de la maladie."

Source :

L'Institut National du Cancer (INCa)

Télécharger le Dispositif au format PDF sur le site de l'INCa :
==> cliquer ici.

Néanmoins, certains médecins et chirurgiens américains sont d'avis qu'il est possible d'entamer ce processus d'annonce de la maladie par une conversation téléphonique avec le patient, ce qui bien entendu ne va pas dans le sens du dispositif d'annonce du cancer mis en place par l'INCa.

Voir l'article : "Annoncer à quelqu’un qu’il a un cancer de la prostate"
(26 janvier 2006):
==> cliquer ici.

Voir le dossier sur le cancer de l'Institut National de la Santé et de la Recherche Médicale (INSERM) :
==> cliquer ici.

==> Voir l'article paru dans le Monde du 27/04/06 : cliquer ici.

"Plan cancer, un tournant positif" :

"C'est dans le domaine de l'organisation des soins que l'empreinte des patients et de la Ligue nationale contre le cancer est le plus perceptible. 'Après une phase d'expérimentation, le dispositif d'annonce du diagnostic au malade, avec notamment une consultation longue où on prend le temps de répondre à toutes ses questions, est en cours de généralisation, explique le professeur Henri Pujol, président de la Ligue. L'objectif est qu'en 2007 tout malade bénéficie d'un soutien psychologique et social.' Dans son travail avec le département des soins de l'INCA, la Ligue a insisté sur l'introduction de critères qualitatifs comme l'existence d'un dispositif d'annonce du diagnostic, d'un travail en réseau, d'une réunion de concertation pluridisciplinaire ou de soins de support tout au long de la maladie." Un autre article du Monde cite Françoise Gestro-Speck, membre du comité de patients de l'institut Paoli-Calmettes, Marseille, qui veut "faire bouger le dispositif d'annonce, qui ne doit pas se limiter à une consultation. Ce n'est pas forcément ce jour-là qu'un patient comprend qu'il a un cancer. Il faut travailler en amont : auprès des médecins de ville, des radiologues, du personnel des laboratoires d'analyse".

© Le Monde

English version:

"The National Cancer Institute has replaced the Interministerial Cancer Taskforce and is to monitor the full implementation of the Cancer Plan and ensure its success until 2007. (...) The law has entrusted the National Cancer Institute with a permanent and ambitious task: to imagine and promote the fight against cancer in future years.

The 2005-2007 Strategic Action Plan
For the next two years, the National Cancer Institute's action plan is to focus on three priority areas:

- Promoting and coordinating cancer care policies,
- Defining and financing research policy,
- Fighting cancer in Europe and throughout the world, by placing the patient at the heart of discussion and action.

The action plan sets out measures for the application of the Cancer Plan: these must be implemented by the end of 2007. For this purpose, €1.6 billion has been allocated by the French government for the 2004/05 budget alone. Among these measures, the National Cancer Institute will primarily focus on developing the following:

- Information (Internet site www.e-cancer.fr, scientific monitoring, information stands, general interest information units, etc.),
- Screening (generalisation of cervical cancer screening, reinforcement of breast cancer screening, campaign to increase public awareness of screening etc.),
- Prevention (solar prevention campaigns, the fight against tobacco and alcohol, dietary campaigns, environmental risks, etc.),
- Healthcare organisation (generalisation of the cancer diagnosis disclosure procedure, creation of cancer care networks, home care, cancer care certification, etc.),
- Development of support care (reimbursement of medical aesthetic devices, improved organisation of home care measures, parental allowances, etc.)
- Training (enhancing the appeal of medical and paramedical cancer care professions),
- Stimulation of biological and clinical research projects (financing and coordination of the regional research hubs, the Cancéropôles, national clinical research strategy, etc.),
- Promotion of innovation (public-private sector partnerships),
- Humanities studies to improve the quality of life of patients and their families (qualitative studies: impact on family and friends, fatigue, suffering, etc.)
- Studies in social sciences to improve our knowledge of the geography of cancer (setting up of a Cancer Observatory),
- Cooperation with Europe, emerging and developing countries and international partnerships (virtual tumour bank, diagnostic and prognostic biomarkers, introduction of complex technologies, etc.),

The National Cancer Institute will carry out its first assessment in 2006. In 2007, new programmes initiated by the National Cancer Institute will be implemented in order to perpetuate national, European and international action against cancer."

Source :
©National Cancer Institute

In a previous Blog Post : "Telling a patient he has prostate cancer" (March 07/2006),I've asked Professor Laurent Boccon-Gibod, Chief of urological surgery department of Bichat - Claude Bernard Hospital, Northern University Hospital Group (Public Hospital, XVIIIth district of Paris, France): How do you tell a patient he has prostate cancer ? He answered that the generalisation of the cancer diagnosis disclosure procedure was a good thing for the patient, as he didn't think that telling a patient he has prostate cancer over the phone was the best disclosure procedure. The cancer diagnosis disclosure procedure, recently implemented in France, sets new guidelines for a set of "cancer-disclosure" consultations (these consultations will not happen over the phone). The idea is to better take into account the psychological aspects of the problem and the evolution of the understanding that the patient has about his cancer, and allow the patient to gain a better understanding of his cancer in the long run, hence gain a better cooperation from his part. This plan requests a progressive, effective, concerted and multidisciplinary communication strategy from the part of the medical community, tailored to the patients'needs.

However American physicians sometimes find that it is appropriate to get started with the diagnosis disclosure over the phone.

==> Read their arguments: click here.

==> Health information about cancer by the INSERM Institute: click here.
"Inserm is the only French public organization entirely dedicated to biological, medical and public health research".

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6 ans de chirurgie robotique au Centre Hospitalier Universitaire de Nancy (CHU nancy-Brabois)

J'ai lu avec intérêt l'article paru en octobre 2005 dans Nephrology Dialysis Transplantation (NDT), intitulé : "Robot-assisted laparoscopic and open live-donor nephrectomy: a comparison of donor morbidity and early renal allograft outcomes". Auteurs : Edith Renoult1, Jacques Hubert2, Marc Ladrière1, Nicolas Billaut2, Eric Mourey2, Benoît Feuillu2 Michèle Kessler1
1 Department of Nephrology and 2 Department of Urology, University Hospital of Nancy, France

Je me suis alors posé les questions suivantes :
- Quelle est l'importance de l'activité de prélèvement d'un rein sur donneur vivant au CHU de Nancy ?
- Les prélèvements sont-ils essentiellement effectués avec la chirurgie robotique, ou les procédés de chirurgie coelisoscopique et la chirurgie "à ciel ouvert" (chirurgie traditionnelle, invasive) sont-ils également utilisés ?
- Le prélèvement d'organe sur donneur vivant en vue de transplantation est-il un mode de prélèvement que les chirurgiens du CHU de Nancy-Brabois souhaitent développer, ou préfèrent-ils privilégier le prélèvement de reins sur donneurs en état de mort encéphalique ?

En réponse, je cite un extrait du dossier de presse du 22 avril 2005 :
"La chirurgie mini invasive par robot Da Vinci™ au CHU de Nancy-Brabois : deuxième révolution après la coelioscopie" :

"Le 4 mars 2002, Jacques Hubert réalisait pour la première fois en Europe un prélèvement rénal de donneur vivant en cœliochirurgie assistée par robot.
La cœliochirurgie, chirurgie mini-invasive n’est que très peu appliquée au domaine du prélèvement d’organes. Cependant, son intérêt semble incontestable, permettant notamment de réduire les suites opératoires. Un espoir pour patients en attente de greffe ?"

== > lire à ce sujet l'article du 02/06/05 : "Chirurgie robotique : prélèvement sur patient vivant en vue d'une transplantation rénale" : cliquer ici.

Par ailleurs, le dossier de presse du 22 avril 2005 : "La chirurgie mini invasive par robot Da Vinci™ au CHU de Nancy-Brabois : deuxième révolution après la coelioscopie" offre un tour d'horizon complet sur la chirurgie robotique multi-spécialités telle qu'elle est pratiquée au CHU de Nancy : urologie, chirurgie cardiaque, digestive, cancérologie, les perspectives techniques du "robot", ainsi qu'un glossaire des termes techniques et chirurgicaux permettant de comprendre ce dossier. Voici quelques exemples :

"Chirurgie mini-invasive : intervention chirurgicale pratiquée avec le minimum d'effraction corporelle. En pratique, il s'agit de la chirurgie coelioscopique, pratiquée avec ou sans robot chirurgical.

Circulation extra corporelle, ou CEC : circulation de suppléance, permettant le maintient d'un flux sanguin dans l'ensemble du corps humain (cerveau, rein... notamment), lors d'une intervention cardiaque qui rend temporairement le cœur incapable d'assurer sa fonction circulatoire.

Coelioscopie : examen visuel direct de la cavité abdominale, au moyen d'un endoscope introduit par de petites incisions. L'examen demande une insufflation de CO2 dans l'abdomen (pneumopéritoine) pour le distendre et permettre le déplacement de l'endoscope. Associée à un geste chirurgical, la coelioscopie prend alors l'appellation de chirurgie coelioscopique. On a ainsi pu parler de 'chirurgie par des trous de serrure'.

Laparoscopie : terme équivalent à celui de coelioscopie.

Thoracotomie : ouverture chirurgicale du thorax, pour permettre l'accès au cœur dans le cadre de la chirurgie cardiaque classique."


Pour lire ce dossier complet et actualisé sur la chirurgie robotique :
==> cliquer ici (site internet du CHU Nancy-Brabois)

==> Télécharger ce dossier au format PDF : cliquer ici.
NB : ce dossier de presse a été réalisé par le CHU de Nancy.
© CHU Nancy-Brabois.

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La chirurgie mini-invasive dans les pays d'Europe

Voici, par pays, la liste des hôpitaux équipés d'un système da Vinci™, permettant d'opérer en chirurgie mini-invasive pour les spécialités suivantes :

chirurgie cardiaque, digestive, gynécologique, pédiatrique, urologie, vasculaire :

=> Hôpitaux en Autriche :
Allgemeines Krankenhaus Wien (Vienne)
Innsbruck Medical University, Innsbruck

=> Hôpitaux en Belgique :
C.H.U. Saint-Pierre, Bruxelles
Hôpital Erasme, Bruxelles
Onze Lieve Vrouw Ziekenhuis, Aalst (Aloste)
Universitair Ziekenhuis Antwerp (Anvers)

=> Hôpitaux en France :
C.H.U. Henri-Mondor, Creteil
C.H.U. Nancy-Brabois, Vandoeuvre les Nancy
Clinique St. Augustin, Bordeaux
Hôpital Européen Georges Pompidou (HEGP), Paris 15ème
Hôpital La Pitié-Salpêtrière, Paris 13ème
Institut Mutualiste Montsouris, Paris 14ème

=> Hôpitaux en Allemagne :

Charité-Universitätkrankenhaus, Berlin
Deutsches Herzzentrum, Munich
Herzzentrum der Universität Bonn
Herzzentrum Dresden GmbH Universität Dresden (Dresde)
Herzzentrum Leipzig GmbH Leipzig
Klinikum der Johann Wolfgang Goethe-Universität Frankfurt (Francfort)
Ruprecht-Karls-Universität Heidelberg
Universitätsklinikum Hamburg-Eppendorf (Hambourg)

=> Hôpitaux en Italie :
Azienda Ospedaliera Santa Maria della Misericordia di Rilievo, Udine
Azienda Instituto Cardioreumatologico Ancona
Azienda Ospedaliera Padua
Azienda Ospedaliera Monaldi, Naples
Azienda Ospedaliera Pisana Stabilimento di Cisanello, Pisa (Pise)
Clinica Pinna Pintor, Torino (Turin)
Ospedale San Raffaele, Milano (Milan)
Ospedale Spoleto
Policlinico San Matteo, Pavia (Pavie)
Presidio Ospedaliero della Misericordia Grosseto
Presidio Ospedaliero Molinette, Torino (Turin)
Presidio Ospedliero di Camposampiero

=> Hôpitaux aux Pays-Bas :
Academisch Ziekenhuis Maastricht HX Maastricht
Universitair Medisch Centrum Utrecht

=> Hôpital en Roumanie :
Spitalul Clinic de Urgenta Floreasca, Bucaresti (Bucarest)

=> Hôpital en Espagne :
Fundacio Puigvert Barcelona (Barcelone)

=> Hôpitaux en Suisse :
Clinique Générale de Beaulieu, Genève
Klinik Hirslanden, Zürich (Zurich)
Universitätsspital Zürich (Zurich)

=> Hôpitaux en Suède :
Karolinska Sjukhuset, Stockholm
Lund University Hospital (Lund)

=> Hôpitaux en Grande-Bretagne :
Guys & St. Thomas Hospital London
St. Mary's Hospital London

Source :
www.intuitivesurgical.com

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Less-invasive procedure replaces diseased valves without cracking chest


'Closed-heart surgery' may offer new alternative

"Dr. Samuel Lichtenstein cut a two-inch hole between an elderly man's ribs. Peering inside, he poked a pencil-sized wire up into the chest, piercing the bottom of the man's heart.


Within minutes, Bud Boyer would have a new heart valve — without having his chest cracked open. Call it closed-heart surgery."

" 'I consider it some kind of magic,' said Boyer, who left the Vancouver, British Columbia, hospital a day later and was almost fully recovered in just two weeks.

In Michigan, Dr. William O'Neill slipped an artificial valve through an even tinier opening — pushing it up a patient's leg artery until it lodged in just the right spot in the still-beating heart.

The dramatic experiments, in a handful of hospitals in the U.S., Canada and Europe, are hunting easier ways to replace diseased heart valves that threaten the lives of tens of thousands of people every year — starting with the aortic valve that is the heart's key doorway to the body.

The need for a less invasive alternative is huge, and growing. Already, about 50,000 Americans undergo open-heart surgery every year to replace the aortic valve: Surgeons saw the breastbone in half, stop the heart, cut out the old valve and sew in a new one. Even the best patients spend a week in the hospital and require two or three months to recuperate.

Thousands more are turned away, deemed too ill to survive that operation and out of options. Demand is poised to skyrocket as the baby boomers gray, because the aortic valve is particularly vulnerable to rusting shut with age.

A radical new alternative?
The new experiments are a radical departure from that proven, if arduous, surgery.

The artificial valves don't even look like valves, squished inside metal cages until they're wedged into place. With barely 150 of any type implanted worldwide, most in the last year, no one knows if they'll work as well as traditional valve replacements, which last decades.

So for now, the only patients who qualify are too sick to be good candidates for regular valve replacement.

Some deaths during the earliest attempts at implanting the devices forced doctors to come up with safer techniques. Clinical trials apparently are back on track, and even the most skeptical cardiologists and heart surgeons are closely watching how these pioneers fare.

The hope is that one day, replacing a heart valve could become almost an overnight procedure.

'There's lots of technical challenges that need to be overcome,' cautioned Dr. Robert Bonow, a valve specialist at Northwestern University, who is monitoring the research for the American Heart Association. But, 'most of us do think this is the future,' he said.

O'Neill's first successful patient in March celebrated the one-year anniversary of his through-the-leg implant.

'I call it a new birthday,' chuckled Fred Grande, 78, a Richmond, Mich., car collector who took one of his beloved models for a fast spin less than a week after the procedure.

'That's the home run we want to hit with all the patients,' said O'Neill, cardiology chief at William Beaumont Hospital in Royal Oak, Mich.

'It's gratifying' to watch people once deemed beyond help bounce back, added Dr. Jeffrey Moses of New York-Presbyterian Hospital/Columbia University, who with O'Neill is leading the U.S. study. One of Moses' first patients is playing golf at age 92.

225,000 valves replaced each year
The heart has four valves, one-way swinging doors that open and close with each heartbeat to ensure blood flows in the right direction. More than 5 million Americans have moderate to severe valve disease, where at least one valve doesn't work properly, usually the aortic or mitral valves. Worldwide, roughly 225,000 valves are surgically replaced every year.

Topping that list is the aortic valve, which can become so narrowed and stiff that patients' hearts wear out trying harder and harder to push oxygen-rich blood out to the rest of the body.

Calcium deposits accumulate on its tender leaflets. Touch one chipped out of a patient, and it feels almost like a rock.

With minimally invasive valve replacement, doctors don't remove that diseased valve. Instead, they prop it open and wedge an artificial one into that rigid doorway.

'It's ironic: You use the disease process to actually help hold your valve in place,' explained Lichtenstein, of St. Paul's Hospital in Vancouver, who helped create the between-the-ribs method.

Different approaches tested
Two manufacturers — Irvine, Calif.-based Edwards LifeSciences, the biggest maker of artificial heart valves, and Paris-based CoreValve — are testing versions of a collapsible valve made of animal tissue that is folded inside a stent, a mesh-like scaffolding similar to those used to help unclog heart arteries.

The difference is how doctors get the new valve to the right spot, pop open its metal casing and make it stick:

The U.S. studies thread the Edwards valve through a leg artery up to the heart, so-called 'percutaneous valve replacement.' Unlike with open-heart surgery, doctors don't stop the patient's heart. So the trickiest part is keeping regular blood flow from washing away the new valve before it's implanted. Once the device is almost in place, doctors speed the heartbeat until normal pumping pauses for mere seconds — and quickly push the new valve inside the old one. Inflating a balloon widens the metal stent to the size of a quarter, lodging it into place and unfolding the new valve inside, which immediately funnels the resuming blood flow.

So far, 19 Americans have been implanted this way, plus more than 80 other people worldwide, most of them in France by the procedure's inventor, Dr. Alain Cribier, and in Vancouver by Lichtenstein's colleague, Dr. John Webb.

Fourteen people in Canada, Germany and Austria have received the Edwards valve through the ribs, a more direct route to the heart for patients whose leg arteries are too clogged to try the other experiment. Doctors make a tiny hole in the bottom of the heart muscle so the new valve can enter, and then use the same balloon technique to wedge it inside the old valve. Talks have begun with the Food and Drug Administration about opening a similar U.S. study later this year.

CoreValve's slightly different valve is being tested in Europe and Canada. It, too, is threaded up the leg artery. But it's made of pig tissue instead of horse tissue and, the key difference, has a self-expanding stent that requires no balloon. Doctors remove a sheath covering it and the stent's metal alloy, warmed by the body, widens until it lodges tight against the old, rocky valve. More than 45 have been implanted, and CoreValve hopes to begin a U.S. study next year. Meanwhile, lead researcher Dr. Eberhard Grube of The Heart Center in Siegburg, Germany, expects within months to begin testing a newer version small enough to thread through an artery at the collarbone, another more direct route to the heart.

Experiments pose major risks
The experiments come with some significant risks. Indeed, Edwards temporarily halted the U.S. study last year after four of the first seven U.S. patients died. Initially, doctors threaded the valve up a leg vein, not an artery, a route that required tortuous turns inside the heart that sometimes damaged a second valve, explained O'Neill.

Twelve people have been implanted since the study re-started in December using the artery route considered easier and safer; all but one have survived and are faring well, researchers say.

O'Neill and Moses — plus doctors at a third hospital, the Cleveland Clinic — have government permission to implant eight additional patients in the U.S. pilot study, which will be expanded if it goes well.

CoreValve's first four patients also died as doctors struggled to develop and learn the through-the-artery technique, Grube said.

For doctors, pushing the large valve through tiny, twisting arteries — against regular blood flow and guided by X-rays — is laborious. Occasionally, they aren't able to wedge it into position.

And because they're squeezing a round valve into an irregular-shaped opening, there's a risk that the new valve will leak blood backwards into the heart, also problematic.

Do benefits outweigh dangers?
But once researchers master how to get the valve into place safely, the question becomes how much recipients benefit: do these very ill patients live longer than expected? If not, does quality of life improve enough to warrant the procedure anyway?

It's too soon to know.

But three of French inventor Cribier's original patients have lived 2 1/2 years so far, with a 'return to normal life and no sign of heart failure,' he said. Eleven others have lived a year and counting.

CoreValve reports five patients faring well a year later.

Aside from those who didn't survive the implantation, others have died from their advanced illnesses even though their new valve was working.

It is the handful of astounding successes — people like Grande and Boyer — that have other heart specialists taking note, said Northwestern's Bonow.

'Patients have to know what they're getting into,' he stressed. Many of the seriously ill are willing to chance the experimental procedure because 'they're so debilitated and ... there have been some good examples of patients who have gotten better.'

The bigger challenge, Bonow added, is whether to expand the studies to include less sick patients who could survive open-heart valve replacement but want to avoid its rigors. Already, there are such patients clamoring to be included.

'There is a trade-off'
That's a difficult decision, because even 80- and 90-year-olds can undergo regular valve replacement successfully. When performed by the most skilled surgeons, risk of death from the operation is about 2 percent — but in less experienced hands, it can reach 15 percent, Bonow said.

Just as using a balloon to unclog heart arteries is sometimes done on patients who'd fare better with bypass surgery, eventually researchers will have to ask if patients would accept a less-than-perfect aortic valve if they got to skip surgery's pain and risks, said Dr. Michael Mack of Medical City Hospital in Dallas.

'There is a trade-off, and how you make that trade-off is a totally gray area,' he said.

But Vancouver's Boyer — who underwent two previous open-heart surgeries for clogged arteries — said avoiding that kind of pain isn't a trivial issue for patients.

'They're doing something to the field of medicine that's going to make life a hell of a lot easier to people who've got that problem,' said a grateful Boyer, describing how he could finally breathe easy after the through-the-ribs valve implant. 'I think I'll have a bunch of other parts go bad before I have a problem with this'."

Source:
www.msnbc.msn.com
Copyright 2006 The Associated Press
© 2006 MSNBC.com

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