Advancing Surgical Oncology

In his role as provincial head of surgical oncology for Cancer Care Ontario, Jon Irish works with surgeons of all specialties. His overall goal is to improve access and quality of care. He works with other strong surgical leaders: Robin McLeod, as the Lead for Quality Improvement and Knowledge Transfer; David Urbach, as the Lead for Cancer Prediction and Planning; Barry Rosen, as the Lead for Informatics; Frances Wright, as the Lead for Multidisciplinary Cancer Conference implementation; and Andy Smith in quality improvement for colorectal cancer services in the Province. Many of the quality initiatives in general surgery were initiated by Hartley Stern and Bernie Langer and continued by the new team over the last three years. These include significant advances in node sampling and tumour margin clearance for colorectal cancer. Gail Darling is active in thoracic oncology quality improvement focusing on mediastinal node staging, and there are important advances in improving margins in surgery of the prostate throughout the province with Neil Fleshner taking a major leadership role in this area. Optimizing surgical margin rates and looking at survivorship quality of life are major areas of exploration and potential for quality improvement in prostate cancer.

The general approach is to measure performance, define the standards, identify and then close the gap. Wait times for all cancers are measured regularly and then recorded. on the Ministry of Health website. (http://www.health. gov.on.ca/transformation/wait_times/public/wt_public_ mn.html#)

Jon has advocated on behalf of surgeons to provide adequate funding for surgical oncology research, and academic repair funds for academic surgeons. The effect of the repair funds over five years has recently been reported to the Ministry of Health and a position paper in preparation will be summarized in the Spotlight. Jon has been active in human resources planning for cancer care in the province. New models of care are being developed using physician extenders in anaesthesia and surgery. General practitioners specializing in oncology (GPOs) are working actively in clinics, especially in breast cancer. These human resource advances are outlined in an eight-point plan http://www.health.gov. on.ca/transformation/wait_times/providers/reports/ cancer_ep_report_0905.pdf It emphasizes human resources, quality improvement, closing the gap, and investing in technology such as laser, nanotechnology and robotics.

At UHN Jon has been engaged in the GTX (Guided Therapeutics) Program with a multidisciplinary team from interventional radiology, imaging, physics, radiation oncology and surgery. The theme of the GTX program is "create, innovate, translate, evaluate and educate." A recent example is Kazuhiro Yasufuku's minimal access endobronchial ultrasound-guided needle biopsy of mediastinal nodes. Other major initiatives employing robotics, real-time imaging and ablation are being led by Michael Jewett, John Trachtenberg and Walter Kucharczyk in the areas of prostate and kidney cancer therapeutics. Michael Fehlings, Mike Tymianski and Fred Gentili are part of the GTx programs thrust in spinal and skull base surgery. As Irish states, "Just as not all new cancer therapy drugs in development ultimately lead to an established position in the therapeutic armamentarium, it is important for interventions in surgery, radiology and other disciplines to explore similar pathways of discovery. We should not feel a sense of failure if a given innovation doesn't work, but keep exploring new approaches." Jon uses the Enabling Innovation pathway for the introduction of new technology. (http://www.surgicalspotlight.ca/Shared/PDF/ Winter06.pdf - page 15)

Jon's clinical practice is focused on head and neck surgical oncology. He practices in collaboration with other otolaryngologists as well as Lorne Rotstein from general

Jonathan Irish and family

surgery and Stefan Hofer from plastic and reconstructive surgery. He treats patients every day and loves his clinical work as much as he did when he started 18 years ago. He works in a very collaborative practice with radiation and medical oncology and allied health members such as speech-language pathologist.

His management responsibilities include the oversight of 52 surgical oncologists in all disciplines ranging from ENT to gynaecology to orthopaedics, head and neck surgery, general surgery (HPB, breast, colorectal, sarcoma), urology, and thoracic surgery. Surgical oncology has expanded rapidly in recent years thanks to the work of Sherif Hanna, Andy Smith, David McCready and other leaders across the Province.

There is a strong fellowship program in surgical oncology with 49 current fellows in all disciplines. 50% are international fellows from the US, UK, the mid-east, Australia and Asia. The strong fellowship program particularly in the area of General Surgery that has developed over the last 10 years is due to the leadership of Carol Swallow. The Royal College has approved a certificate of special competence in surgical oncology, so far only for general surgery, whereas the America boards credit several of the subspecialties.

Jon's management background is derived from the informal common sense school and from the example of role models like Pat Gullane, Bob Bell, Hartley Stern, Bryce Taylor, Bernie Langer, Alan Hudson and Robin McLeod. He felt that the physician leadership course in the Department of Health Policy, Management and Evaluation was a validation of the informal curriculum, but feels practical experience and proven competence are required as background before management training is appropriate for young surgeons. A surgeon who has earned the respect of peers and students as an educator and clinician can then consider adding management training. The natural progression through residency and staff responsibilities provides this essential background.

Jon's research includes deploying molecular biological techniques for prediction of clinical outcomes using micro-array analysis in collaboration with Dr. Suzanne Kamel-Reid. He is studying quality of life outcomes in head and neck cancer patients with the Psycho-oncology group at Princess Margaret Hospital, population-based outcome studies in collaboration with Dr. Patti Groome and Brian O`Sullivan, and a multidisciplinary approach to guided therapeutics with Dr. David Jaffray and Walter Kucharczyk.

Jon is married to Rosemary Martino, a PhD speech language pathologist and University of Toronto clinical epidemiologist who is a Professor in the Faculty of Speech Language Pathology. Their son Matthew, 22, is in law school at the University of Western Ontario; Brendan, 20, is an undergraduate at Queen's University; and daughter Liz, 16, is a high school student at the University of Toronto School.

M.M.