- Email: [email protected]
ESMO committed to improving cancer education
Reflection & Reaction ESMO committed to improving cancer education The 27th Congress of the European Society for Medical Oncology (ESMO), held in October 2002, Nice, France, was an impressive demonstration of the recent exciting advances in medical oncology and the biggest meeting in ESMO’s history. In the December, 2002 issue of The Lancet Oncology, the costs for registration at ESMO and the policy of charging for tickets (€20 per session) were criticised.1 The Leading edge stated that an ESMO member attending four Challenge Your Expert (CYE) sessions would be charged a total of €230, including the registration fee. Higher costs accrue for late registration (€380) and for non-ESMO members registering on-site. Although the article acknowledges the enormous overheads associated with running such large meetings, it states that medical societies, which act as non-profit organisations, have an obligation to promote the dissemination of medical information through interaction that is not based on the ability to pay. Large meetings like the ESMO Congress enable us to offer attendees a wide range of information, such as latest developments in medical oncology, cutting edge research and educational forums, discussions on controversial topics, posters, and CYE sessions. Access to all but the latter is included in the registration fee and there are several reasons why we have chosen to charge for them. First, the sessions are deemed to be highly interactive between the lecturer and the attendees and hence there is a need for a limit on the number of participants. Furthermore, handing out tickets free of charge on a “first-come first-served basis” has, in our experience, the drawback that the attendance to individual sessions will not be 100%—a variable proportion of those who received tickets will attend. Use of this approach could preclude participation of attendees who are really interested, but for whatever reason could not get a ticket. During our Nice Congress, 8% of all participants went to the CYE sessions. The income from the sale of the tickets covered ESMO’s expenses but did not yield any surplus.
ESMO is very keen on making the information provided at the Congress widely available to the medical community. All CYE sessions are accompanied by a monograph from the presenter, which is published in the Congress educational book and distributed to all congress participants and to all members of the society. Further, the majority of sessions, including all educational sessions, are recorded and distributed free of charge to all ESMO members. These sessions are freely available to every visitor on our web site from the graphic link Virtual Meeting on our homepage (www.esmo.org). ESMO is aware that costs may preclude participation in our meetings; we therefore offer reduced registration rates to medical oncologists in training and support their participation with travel grants. Medical congresses usually make profits, but the risks of organising them should not be underestimated. Recently, several major meetings have been cancelled and many have experienced greatly reduced participation due to the events of September 11th, 2001. Actually, even ESMO was not able to find an insurance company willing to cover such risks of an eventual Congress deficit. In general, our Congress makes a profit, but these profits are not then given over to shareholders, they are returned to the society in support of our manifold extra-congressional activities. ESMO is particularly determined to support the new generation of medical oncologists. We offer fellowships, technology transfer grants, highly subsidised courses, and in June, 2003, we will host our first purely educational meeting (ESMO Summer Education Conference; ESEC) in Edinburgh, UK. Again, low registration rates will be offered to young medical oncologists and, for about 100 of them, financial support for participation will be provided. ESMO is one of the few societies that, as early as 1996, organised a specific educational programme for Central and Eastern Europe (Central and Eastern European Task Force; CEE-
THE LANCET Oncology Vol 4 February 2003
http://oncology.thelancet.com
TF). Participation of medical oncologists from these less affluent Eastern European countries is fully supported by ESMO. This programme has recently been reorganised and ESMO has committed itself to support it for the next 5 years. In addition to several educational courses organised and financially subsidised each year in western Europe, joint educational or scientific activities between ESMO and Latin American medical oncology societies have been held in the past and will continue in the future. In February 2003, a fully ESMOsupported Palliative Care Workshop will be held in Mumbai, India. All these activities require ESMO’s financial support. Other important activities include: providing ESMO Minimum Clinical Recommendations free of charge to anyone interested (with the option to download them onto a PDA); and offering the opportunity to participate in the ESMO Clinical Discussion Forum. The latter activity will be available soon and will enable ESMO members to submit rare or complicated cases to the ESMO Faculty for comments and suggestions. An expert in the field will respond and provide their considerations on the case. Noteworthy is that ESMO’s annual membership fee (€100) costs less than a year’s personal subscription to The Lancet Oncology, includes a full subscription to the society’s peerreviewed journal, Annals of Oncology, and has not changed in 5 years. The annual ESMO junior membership fee, which confers all the benefits of full membership, is €25. Overall, ESMO’s goal is to continuously improve its service to its members and to society in general. Eventual profits are reinvested in our programmes, and important information presented at our Congress is displayed free of charge to the public shortly after its presentation. As the number of participants at our Congresses steadily increases, and with additional sources of funding, we may eventually be able to expand our ‘lowcharge access programme’ for young medical oncologists and for medical
71
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Reflection & Reaction oncologists from developing countries, and certainly freeze, or even lower fees for certain categories of participants. ESMO is dedicated to serving medical oncology and medical oncologists and
is determined to contribute substantially to the improvement of prevention, diagnosis, and treatment of patients with cancer. Heinz Ludwig
President, European Society for Medical Oncology, Via la Santa 7, 6962 ViganelloLugano, Switzerland. 1 Lancet Oncology. Everything has its price. Lancet Oncol 2002; 3: 707.
Cancer prevention and delay are as important as cure The Leading Edge, “Is prevention really better than cure?”, in the November, 2002 issue of The Lancet Oncology offered considerable scepticism with respect to the value of surgical and pharmacological measures of preventing cancer.1 This scepticism was triggered in part by a recent suggestion by Bergfeldt and colleagues,2 who, on the basis of findings linking increased risk of ovarian cancer to a predisposition to breast cancer, advocated prophylactic surgical removal of breasts and/or ovaries for some women at high risk. In the editorial, The Lancet Oncology extends its discomfort with prophylactic organ removal to questioning the concept of cancer chemoprevention, another approach to reduce cancer risk. Many of the questions raised by the editorial were discussed in detail by oncologists, physicians, surgeons, basic scientists, and epidemiologists at the American Association for Cancer Research conference devoted to “Frontiers in Cancer Prevention Research” in Boston (October 14–18, 2002). The potentially negative psychological ramifications of preventive strategies and the concept of any benefit from chemoprevention being visible only on a population scale (rather than to the individual being treated) are not new issues for oncologists. Adjuvant chemotherapy after surgery is an obvious example of a clinical scenario in which oncologists discuss these issues with patients every day. For example, the majority of cancer patients in our clinics who are offered a potential 10% benefit to reduce the chances of cancer recurrence from many months of adjuvant chemotherapy, accept; with the full understanding that the percent quoted may mean that only one person out of every ten treated actually benefits from the cytotoxic chemotherapy. In general, when these
72
patients return for palliative chemotherapy for advanced disease in later months or years, the “trust” afforded to the oncologist has not been “jeopardised”, as suggested by the editorial, since the patients usually remember the odds from day 1 of adjuvant chemotherapy. Indeed, the trust may be enhanced by the continued provision of care by the same oncologist. Moreover, “prevention by delay”, a useful concept to which Hong and Lippman3 have recently drawn attention, proved to be a recurrent theme at the recent conference in Boston. The philosophy underpinning “cancer delay” is similar to that which is used to justify palliative chemotherapy or medical treatments of other incurable diseases. The Lancet Oncology editorial refers to “chemoprevention” in an undefined fashion, and appears to mean intervention strategies in healthy individuals, ie, “primary chemoprevention”. This is quite different from “secondary” and “tertiary” chemoprevention, ie, prevention of second primary cancers or treatment of preneoplasia, respectively.4 This distinction is important with respect to the assessment of risk for an individual, since the risk of developing cancer is much higher for the latter groups than it is for healthy individuals. For example, when a woman’s risk of developing breast cancer within 5 years is quantified by the Gail model (a validated mathematical model of risk, which includes factors such as age, previous breast disease, nulliparity, and family history) as being 10%, she may be more willing to accept the adverse side-effect profile of tamoxifen than a woman whose risk is determined as 1% in the same period.5 Under circumstances of risk significantly greater than that of the background population, it is a woman’s right to
consider tamoxifen therapy, prophylactic mastectomy, or even prophylactic hysterectomy before tamoxifen therapy, and it is the specialist physician’s and surgeon’s role to present her with the best available evidence for her decision. The argument, proposed in the editorial, that prevention will be taken as a “substitute” for surveillance, ie, atrisk individuals taking chemopreventive drugs will believe that they are sparing themselves from a lifetime of tests, hospital visits, and scans, is surely erroneous. In contrast to the largescale chemoprevention trial design of previous decades, recent and current chemoprevention trials involve intense levels of surveillance, greater than those offered as routine in most countries. An example is the selenium and vitamin E cancer prevention trial (SELECT), which will recruit a total of 32 400 healthy men, and accrual is currently well ahead of schedule. As part of the trial, these men are offered annual digital rectal examination and testing of serum prostate specific antigen, in addition to samples of serum, toenails, and prostate tissue being collected in some men for measurement of drug levels and biomarkers of carcinogenesis. We maintain that, in contrast to the claim made in The Lancet Oncology editorial, the development of biomarkers of screening and methods of surveillance are enriched by the field of chemoprevention and vice versa.4 Finally, the journal’s prediction that compensation claims against manufacturers of chemopreventive pharmaceuticals may be levelled by individuals in whom the remedies have failed is poorly supported by the analogy with smoking-related disease. Depending on the type of chemoprevention (see above), the scenario is more akin to the treatment of post-myocardial infarction with statins to decrease serum
THE LANCET Oncology Vol 4 February 2003
http://oncology.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
ESMO is very keen on making the information provided at the Congress widely available to the medical community. All CYE sessions are accompanied by a monograph from the presenter, which is published in the Congress educational book and distributed to all congress participants and to all members of the society. Further, the majority of sessions, including all educational sessions, are recorded and distributed free of charge to all ESMO members. These sessions are freely available to every visitor on our web site from the graphic link Virtual Meeting on our homepage (www.esmo.org). ESMO is aware that costs may preclude participation in our meetings; we therefore offer reduced registration rates to medical oncologists in training and support their participation with travel grants. Medical congresses usually make profits, but the risks of organising them should not be underestimated. Recently, several major meetings have been cancelled and many have experienced greatly reduced participation due to the events of September 11th, 2001. Actually, even ESMO was not able to find an insurance company willing to cover such risks of an eventual Congress deficit. In general, our Congress makes a profit, but these profits are not then given over to shareholders, they are returned to the society in support of our manifold extra-congressional activities. ESMO is particularly determined to support the new generation of medical oncologists. We offer fellowships, technology transfer grants, highly subsidised courses, and in June, 2003, we will host our first purely educational meeting (ESMO Summer Education Conference; ESEC) in Edinburgh, UK. Again, low registration rates will be offered to young medical oncologists and, for about 100 of them, financial support for participation will be provided. ESMO is one of the few societies that, as early as 1996, organised a specific educational programme for Central and Eastern Europe (Central and Eastern European Task Force; CEE-
THE LANCET Oncology Vol 4 February 2003
http://oncology.thelancet.com
TF). Participation of medical oncologists from these less affluent Eastern European countries is fully supported by ESMO. This programme has recently been reorganised and ESMO has committed itself to support it for the next 5 years. In addition to several educational courses organised and financially subsidised each year in western Europe, joint educational or scientific activities between ESMO and Latin American medical oncology societies have been held in the past and will continue in the future. In February 2003, a fully ESMOsupported Palliative Care Workshop will be held in Mumbai, India. All these activities require ESMO’s financial support. Other important activities include: providing ESMO Minimum Clinical Recommendations free of charge to anyone interested (with the option to download them onto a PDA); and offering the opportunity to participate in the ESMO Clinical Discussion Forum. The latter activity will be available soon and will enable ESMO members to submit rare or complicated cases to the ESMO Faculty for comments and suggestions. An expert in the field will respond and provide their considerations on the case. Noteworthy is that ESMO’s annual membership fee (€100) costs less than a year’s personal subscription to The Lancet Oncology, includes a full subscription to the society’s peerreviewed journal, Annals of Oncology, and has not changed in 5 years. The annual ESMO junior membership fee, which confers all the benefits of full membership, is €25. Overall, ESMO’s goal is to continuously improve its service to its members and to society in general. Eventual profits are reinvested in our programmes, and important information presented at our Congress is displayed free of charge to the public shortly after its presentation. As the number of participants at our Congresses steadily increases, and with additional sources of funding, we may eventually be able to expand our ‘lowcharge access programme’ for young medical oncologists and for medical
71
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Reflection & Reaction oncologists from developing countries, and certainly freeze, or even lower fees for certain categories of participants. ESMO is dedicated to serving medical oncology and medical oncologists and
is determined to contribute substantially to the improvement of prevention, diagnosis, and treatment of patients with cancer. Heinz Ludwig
President, European Society for Medical Oncology, Via la Santa 7, 6962 ViganelloLugano, Switzerland. 1 Lancet Oncology. Everything has its price. Lancet Oncol 2002; 3: 707.
Cancer prevention and delay are as important as cure The Leading Edge, “Is prevention really better than cure?”, in the November, 2002 issue of The Lancet Oncology offered considerable scepticism with respect to the value of surgical and pharmacological measures of preventing cancer.1 This scepticism was triggered in part by a recent suggestion by Bergfeldt and colleagues,2 who, on the basis of findings linking increased risk of ovarian cancer to a predisposition to breast cancer, advocated prophylactic surgical removal of breasts and/or ovaries for some women at high risk. In the editorial, The Lancet Oncology extends its discomfort with prophylactic organ removal to questioning the concept of cancer chemoprevention, another approach to reduce cancer risk. Many of the questions raised by the editorial were discussed in detail by oncologists, physicians, surgeons, basic scientists, and epidemiologists at the American Association for Cancer Research conference devoted to “Frontiers in Cancer Prevention Research” in Boston (October 14–18, 2002). The potentially negative psychological ramifications of preventive strategies and the concept of any benefit from chemoprevention being visible only on a population scale (rather than to the individual being treated) are not new issues for oncologists. Adjuvant chemotherapy after surgery is an obvious example of a clinical scenario in which oncologists discuss these issues with patients every day. For example, the majority of cancer patients in our clinics who are offered a potential 10% benefit to reduce the chances of cancer recurrence from many months of adjuvant chemotherapy, accept; with the full understanding that the percent quoted may mean that only one person out of every ten treated actually benefits from the cytotoxic chemotherapy. In general, when these
72
patients return for palliative chemotherapy for advanced disease in later months or years, the “trust” afforded to the oncologist has not been “jeopardised”, as suggested by the editorial, since the patients usually remember the odds from day 1 of adjuvant chemotherapy. Indeed, the trust may be enhanced by the continued provision of care by the same oncologist. Moreover, “prevention by delay”, a useful concept to which Hong and Lippman3 have recently drawn attention, proved to be a recurrent theme at the recent conference in Boston. The philosophy underpinning “cancer delay” is similar to that which is used to justify palliative chemotherapy or medical treatments of other incurable diseases. The Lancet Oncology editorial refers to “chemoprevention” in an undefined fashion, and appears to mean intervention strategies in healthy individuals, ie, “primary chemoprevention”. This is quite different from “secondary” and “tertiary” chemoprevention, ie, prevention of second primary cancers or treatment of preneoplasia, respectively.4 This distinction is important with respect to the assessment of risk for an individual, since the risk of developing cancer is much higher for the latter groups than it is for healthy individuals. For example, when a woman’s risk of developing breast cancer within 5 years is quantified by the Gail model (a validated mathematical model of risk, which includes factors such as age, previous breast disease, nulliparity, and family history) as being 10%, she may be more willing to accept the adverse side-effect profile of tamoxifen than a woman whose risk is determined as 1% in the same period.5 Under circumstances of risk significantly greater than that of the background population, it is a woman’s right to
consider tamoxifen therapy, prophylactic mastectomy, or even prophylactic hysterectomy before tamoxifen therapy, and it is the specialist physician’s and surgeon’s role to present her with the best available evidence for her decision. The argument, proposed in the editorial, that prevention will be taken as a “substitute” for surveillance, ie, atrisk individuals taking chemopreventive drugs will believe that they are sparing themselves from a lifetime of tests, hospital visits, and scans, is surely erroneous. In contrast to the largescale chemoprevention trial design of previous decades, recent and current chemoprevention trials involve intense levels of surveillance, greater than those offered as routine in most countries. An example is the selenium and vitamin E cancer prevention trial (SELECT), which will recruit a total of 32 400 healthy men, and accrual is currently well ahead of schedule. As part of the trial, these men are offered annual digital rectal examination and testing of serum prostate specific antigen, in addition to samples of serum, toenails, and prostate tissue being collected in some men for measurement of drug levels and biomarkers of carcinogenesis. We maintain that, in contrast to the claim made in The Lancet Oncology editorial, the development of biomarkers of screening and methods of surveillance are enriched by the field of chemoprevention and vice versa.4 Finally, the journal’s prediction that compensation claims against manufacturers of chemopreventive pharmaceuticals may be levelled by individuals in whom the remedies have failed is poorly supported by the analogy with smoking-related disease. Depending on the type of chemoprevention (see above), the scenario is more akin to the treatment of post-myocardial infarction with statins to decrease serum
THE LANCET Oncology Vol 4 February 2003
http://oncology.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.