The building and international best practice in 2023
Luis Miguel Barros • Chief Operating Officer S+A
The essence of designing hospital equipment is anticipating the changes that are constantly occurring in the provision of healthcare, and creating a building that not only contains the basic principles of Functionality, Adaptability and Safety, but above all can serve the reality of that future moment at the time of opening, which normally implies a gap of 5 to 10 years between planning and opening to the public.
In the recent development of a proposal for an outpatient oncology treatment building, located on the campus of the Francisco Gentil Portuguese Institute of Oncology in Lisbon, we sought to investigate the latest international trends in the field of oncology treatment, oncology centre master plans and building projects.
We aimed to incorporate the best of what has already been studied and accomplished, adapting it to the reality of the proposal in question, so that this important investment is maximised to its fullest potential at the time of opening.
2. NEW CONCEPTS IN ONCOLOGY TREATMENT
Some of the biggest changes in the design of oncology centres come precisely from the enormous developments in cancer treatment, due to the effectiveness of new therapies.
Traditional treatments such as radiotherapy, chemotherapy and surgical extractions, which indiscriminately affect malignant and healthy cells by means of “brute force treatment”, are being replaced by precision medicine, which is the umbrella term for new therapies that target only cancer cells.
Many of these therapies use advanced technologies supported by machine learning to educate the patient’s own immune system to eradicate and cure cancer. These radically innovative treatments fundamentally change healthcare and – just as importantly – the supporting facilities.
In the last 20 years, the number of cancer drugs approved per year was around five. Nowadays that annual average is around 20, with around 4,000 new drugs still in the approval process. In addition, the rapid integration of artificial intelligence into both research and clinical care is evident.
A recent study by the Massachusetts Institute of Technology and the Massachusetts General Hospital compiled data from the results of all mammograms carried out over the last 20 years. It was found that an artificial intelligence algorithm can identify early signs of breast cancer five years earlier than expert human clinical technicians can – and this is one example among many. AI-guided decisions and diagnoses are emerging as an important part of cancer treatment.
This shift has implications for oncology facilities we design – from comprehensive network changes to smaller but equally critical changes to accommodate personalised medicine.
The complexity of oncology treatment is bound to increase and therefore the supporting facilities must evolve.
The biggest potential impacts on the planning and design of buildings dedicated to this activity could be the following:
2.1 NETWORK TREATMENT
With so many new treatments and therapies, there will necessarily be a greater variety in the type of facilities, systems and networks – digitally connected – to support the new continuing care.
More and more space will be needed for a greater number of users in clinical trials.
In addition to the need to expand the network of outpatient units, everyone will be entitled to remote monitoring, regardless of their ability to pay for the technology.
2.2 HOME TREATMENT
In the very near future, our clinical toolkit will include telemedicine, virtual visits and even return visits at home. For example, with a new immunotherapy, telemedicine can monitor metabolic changes.
If something goes wrong, instead of making the patient visit a 24-hour clinical service, the best option may be to treat them where they are – in their own home, thus avoiding an expensive and disruptive trip to the oncology centre. There will have to be an investment in expert emergency medical technicians to be assisted virtually and remotely by clinical specialists.
Telemedicine will certainly have a major impact on the future of care, minimising the need for patients to visit oncology centres – and reducing the distance associated with the examination.
Pre-assessment will also involve triaging to the lowest severity referral that is most convenient for the patient, which means a far less traumatic visit to the oncology centre.
2.3 COMPLEMENTARY AND ALTERNATIVE MEDICINE
Until now, the general instructions from health authorities have been to integrate clinical care, research and education into a single large comprehensive oncology centre. This goal has been challenged by the concept of continuous care, which promotes bringing the care to the patient, rather than bringing the patient to the point of care. Maintaining collaboration between doctors, researchers and educators will require adherence to virtual communication, as opposed to face-to-face communication.
Complementary and Alternative Medicine (CAM) is an increasingly valuable option as we move from simply treating cancer symptoms to substantial remission or an actual cure for the disease.
CAM is about maintaining a good life balance, promoting well-being through nutrition, exercise and good mental health, and is especially useful in the following aspects:
> In minimising side effects of oncology treatments (nausea, pain, fatigue);
> In comforting and relieving concerns associated with oncology treatments and related stress;
> In making the patient feel that they are actively contributing with their own treatment.
2.4 GENETICS AND CLINICAL TRIALS
Genetics has stimulated a transformational change in pharmacological care. With the number of cancer drugs in development increasing exponentially, more drugs will require testing, and the need for clinical trials will increase. Competition for patients participating in clinical trials will increase.
The challenge for our healthcare system is that although cancer represents only 1% of all cases, it accounts for more than 12% of the cost, a percentage that is likely to increase with the advent of new therapies. Partnerships between private companies and large, well-equipped oncology centres can generate substantial financial results.
The space for obtaining, managing and working with participants in clinical trials, given the increasing amount of clinical research required for both new therapies and combinations of therapies, will cover all types of treatment spaces. These spaces and the entire building must be prepared for this reality.
2.5 NEW TYPES OF LABORATORIES
Validating cancer through surgical extraction with laboratory-confirmed cell malignancy has been the norm for decades. However, as target therapies become exponentially more specific, diagnoses are becoming increasingly complex, involving in-vivo and ex-vivo science on a molecular and nano scale.
Combined with new methods for determining a person’s susceptibility to specific therapies, this makes personalised cancer treatment a sophisticated and complex process.
The plethora of new, widely available and improved tools (mass spectrometry, flow cytometry and genetic sequencing, to name a few), including some that are beginning to be available at the point of care, means that diagnostic laboratories are also changing. The traditional form of pathology, which takes place ex-vivo in a laboratory adjacent to the operating room, will more often be carried out in-vivo in real time, for more precise tumour resection.
Many of new therapies employ technologies that manipulate extracted cells that are placed back into the body. This takes weeks to process and requires continuous monitoring. Finally, new techniques are being developed to determine the malignancy of a cell inside the body, promising real-time diagnosis and treatment.
These new technologies and techniques will change the nature of diagnostic laboratories and supporting pathology, as well as the space for surgical procedures.
The identification of cancer cells has progressed from the tactile detection of a hard nodule.
Diagnostic and therapeutic imaging is making the transition from imaging organs and tissues to cells and molecules. All are essential for new therapies and targeted diagnostics. In addition to anatomical imaging, which records the location of cancer within the body, the size of the tumour etc., these new therapies also employ metabolic imaging to identify changes at the cellular and even molecular level – an essential part of precision medicine. Treatment is evolving from relying on anatomical imaging to using anatomical and metabolic imaging.
Targeted therapies using short-lived radioisotopes, immunotherapies triggered in-vivo and other new agents will increase the use of concomitant imaging during treatment.
In the future, dosimetry, which is necessary for all cases of solid tumours, will require less pre-planned imaging and more real-time imaging during treatment.
New proton and heavy ion therapies that promise significantly reduced tumour margins will affect the way cancer centres are designed, as will the need for cyclotrons to generate short half-life radioisotopes.
2.7 MEDICAL INFORMATION TECHNOLOGY
With all this information, aligning the best treatment with the patient’s diagnosis will be much more complex, as it will be necessary to process a large amount of data. Perhaps sometimes beyond the capacity of human beings.
AI or machine learning will help determine the best alignment, but directing this information towards the right ‘clinical pathways’ to incorporate more effectively with precision medicine will probably require new structures dedicated to decision support.
The tipping point will be reached when a secure and fully transparent digital medical record is achieved, which is compatible across all healthcare systems. It is widely known that the importance of creating these genetic records, combined with the expansion of telemedicine, could lead to super systems not unlike what Amazon has achieved in the retail market.
Oncology centres will need command centres, with robust investment in IT, data storage, telemedicine and bio repositories, which will provide the resources to confirm state-of-the-art diagnostic and treatment methodologies.
2.8 KNOWLEDGE DOES NOT COME CHEAP
With research identifying increasingly more biomarkers for genetic family cancers, and with machine learning able to locate specific markers in thousands of specimens to find matches far beyond the ability of the human mind, more patients will be able to receive early treatment, and some may be able to avoid cancer altogether.
Until now, screening has been general and based on wide-ranging but generalised risk analyses. Diagnosis has been based on biomarkers and clinical problems. Treatment has been personalised.
At the moment we are broadening the concept of screening because we can identify the genetic variability that predetermines susceptibility to specific cancers and we are getting closer to population health and preventive interventions to reduce the risk of future cancer.
When there is a new discovery – a gene, a biomarker – that is determined to affect health, there is the possibility of reviewing existing medical records to identify the patient’s susceptibility, but the questions are: who holds the key to unlocking this data? And how will the chain of custody of relevant, albeit personal, information be handled?
Personal medical records have facilitated access to patient history for decades. As our ability to track increasingly more cancers continues to broaden, how to track, who to track and where to track will become a more complex proposition, as will determining who will be responsible for medical records – including compliance with GDPR.
As increasingly more information is accessed more easily, we will see increased pressure on the healthcare system to create a ‘meaningful use’ of this newly discovered data.
2.9 IMPLICATIONS FOR HEALTHCARE INFRASTRUCTURES
There are several paths that the transformation of cancer treatment can take, but one certainty is that oncology centres which integrate doctors who use their decades of knowledge to diagnose and treat cancer will be transformed through much greater networking, using collaborative agreements to provide accurate and personalised diagnosis and treatment in locations most convenient for patients, with continuous screening and monitoring to guarantee the health and well-being of the population.
The focus on humanising spaces, on peace conveyed by a facility designed with well-being in mind, has a purpose that adds to the one demonstrated above.
Simplifying operations can impact the planning of healthcare facilities in a number of ways. For example, improving response times in operating rooms may mean building fewer operating rooms in the future, freeing up capital and space for other investments.
Consolidating services improves efficiency and creates more functional space for direct patient care.
Operational redesign – and the modern, up-to-date design of related facilities – can help healthcare institutions improve the experience of users, visitors and staff in their facilities.
3. HOSPITALS AND OTHER STRUCTURES THAT ALREADY PROMOTE PATIENT CARE
3.1 UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER – LOWRY & PEGGY MAYS AMBULATORY CLINICAL BUILDING
The challenge for the project team (KMD in association with FKP, Houston) was to create a new paradigm for cancer treatment and a plan that minimised the institutional effect of its daunting dimension, and that could adapt to technological advances in equipment and treatment of cancer patients.
The team succeeded in building a welcoming and relaxing outpatient care environment with long-term use and value. The ACB was conceived as an integral part of a campus designed similarly to an Italian town with a central square. The overall plan envisages a series of mid-rise buildings organised around the garden at the heart of the town, and the ACB is the first of four buildings that will surround a central ‘healing garden’.
An internal cascade, or ‘water wall’, establishes an aquatic theme that flows through the building on all floors in the form of aquariums and ingenious glass columns filled with bubbling water, creating a warm and serene healing environment for patients, visitors and staff.
3.2 LONDON CANCER HUB – NORDIC OFFICE OF ARCHITECTURE
The London Cancer Hub is a project with an ambitious plan to create the world’s leading life sciences and health district, specialising in cancer research and treatment.
The project team has created an open and equitable campus that offers an attractive working and leisure space for researchers, doctors and the community, while creating an excellent healing environment for patients.
A vibrant community will be created on the allocated site in Sutton, with research buildings, hospital facilities, a school, restaurants, cafés, leisure space and hotel accommodation for visitors and patients.
The guiding principles of the spatial vision are to create a flexible urban structure with a clear hierarchy of routes and public spaces, transforming the site into a welcoming, open and accessible area.
3.3 WINSHIP CANCER INSTITUTE AT EMORY MIDTOWN, ATLANTA
May Architecture, in partnership with Skidmore, Owings & Merrill (SOM), has created a revolutionary oncology treatment model for the Winship Cancer Institute at Emory Midtown. The 17-storey, 455,000 square foot facility, located in Atlanta’s Midtown neighbourhood, represents the culmination of five years of close collaboration with more than 150 end-users, patients, doctors, volunteers, surgeons, hospital staff and builders. During this extensive process, we were challenged to redefine patient care in a new world-class cancer treatment centre.
The result of the process is a unique cancer treatment model that places patients at the centre of specialised care communities, uniting outpatient and inpatient care, and integrating innovative research into prevention and treatment.
Functional services have been transformed into smaller ‘communities of care’ organised according to the type of disease. These care communities include inpatient and outpatient units, universal rooms designed for examination and infusion, diagnostics, research and procedure spaces – all designed to ensure cohesive care while offering specialised care to patients with similar needs.
The connectivity created by the two-storey communal lobbies brings together users and families who share the same experiences, providing a sense of community and comfort. The departure from typical hospital design has resulted in an environment unlike any other medical facility. It impacts patient care and profoundly impacts research and well-being among faculty, staff and trainees. Centralised layouts promote collaboration and efficiency, while well-lit and spacious corridors present abundant natural light.
Connectivity remained a goal throughout this project. It transcends the patient journey to a deeper level of interrelationship between the oncology community and the city as a whole. The patient drop-off and pick-up zone, with a large, hotel-like canopy, is a prominent feature in the busy Midtown area, and is integrated into the street level through what the team calls the ‘urban room’. Its welcoming environment promotes accessibility to resources such as shops, a pharmacy, a wellness centre, a café and other multi-use spaces designed to bridge the gap between the facility and the public.
3.4 CENTRE FOR CANCER AND HEALTH / NORD ARCHITECTS
Having cancer is like embarking on a journey, you do not know where you are going to end up. It requires strength to face the disease and take on the new identity of ‘cancer patient’. Research shows that architecture can have a positive effect on people’s recovery from illness.
A human scale and a cosy atmosphere can help people get better. Despite this, most hospitals are hardly comfortable. Finding your way from reception to the canteen can be difficult.
If we want people to get better in our hospitals, we need to deinstitutionalise and create welcoming healthcare. The Cancer and Health Centre designed by Nord Architects Copenhagen does just that.
The Centre for Cancer and Health in Copenhagen was conceived as an iconic building that creates awareness about cancer without stigmatising patients. Designed as a series of small houses combined into one volume, the centre offers the space needed for a modern healthcare facility, without losing the scale which is comfortable for the individual. The houses are connected by the raised roof in the shape of an origami of Japanese paper, which gives the building a characteristic distinction.
Upon entering the building, a comfortable lounge area run by volunteers is the first space. From here you move on to the rest of the house, which includes a courtyard for contemplation, spaces for exercise, a communal kitchen where you can learn to cook healthy food, meeting rooms for patient groups, etc.
4. LESSONS LEARNT
In all the examples investigated and information gathered, some data is constant and clearly sets trends for the near future.
Organisations will adapt to a more digital and global way of working, which in this area of oncology, paradoxically, will be reflected in a greater personalisation of treatment. This is possible because the search for the right treatment for the pathology will be based on AI algorithms that will search huge genetic databases, providing much more accurate answers.
This will make oncological treatment much less stressful and aggressive, and there is clearly a move towards attention to the well-being, balance and autonomy of the individual patient.
Healthcare infrastructures, particularly outpatient units, will play a key role in this change. They must already be designed with these concerns in mind and meet the requirements that the next 20 years will bring in the field of oncology.
Humanised, almost hotel-like spaces, with a strong social aspect and support, comfortable for both patients and clinical and support staff will be absolutely necessary.
Luis Miguel Barros