Bhgi Learning Lab 2009 Pan Arab

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Bhgi Learning Lab 2009 Pan Arab

  1. 1. Benjamin O. Anderson, M.D.
  2. 2. Recent advances in breast surgery Implications of resource limitations Guideline implementation in LMCs
  3. 3. Recent advances in breast surgery Implications of resource limitations Guideline implementation in LMCs
  4. 4. 1980s: Breast Conservation Surgery 1990s: Percutaneous Needle Biopsy 1990s: Sentinel Node Biopsy 2000s: Oncoplastic Surgery
  5. 5. RADICAL MASTECTOMY MODIFIED RADICAL MASTECTOMY
  6. 6. BREAST CONSERVING SURGERY
  7. 7. BREAST CONSERVING RADIATION THERAPY
  8. 8. NSABP B-06: Effect of Lumpectomy v. Mastectomy on Recurrence Cohort A Cohort B Cohort C DISTANT DISEASE-FREE SURVIVAL (%) YEAR No. of patients / No. of recurrences Total Mastectomy: 692/265 569/233 494/192 Lumpectomy: 699/302 634/282 520/236 Lumpectomy + XRT: 714/278 628/253 515/204
  9. 9. Fine needle aspirations Core needle biopsy Vacuum-assisted biopsy Excisional biopsy
  10. 10. Slavin, et al. Plast Reconst Surg 90:854, 1992.
  11. 11. Slavin, et al. Plast Reconst Surg 90:854, 1992
  12. 12. Slavin, et al. Plast Reconst Surg 90:854, 1992
  13. 13. Retrospective review (European Institute of Oncology) Specimen Negative Margin Volume Margins Width GROUP 1 (n=30) 200 cm3 25 / 30 8.5 mm Oncoplastic Resection GROUP 2 (n=30) 118 cm3 17 / 30 6.5 mm Standard Resection Kaur et al., Ann Surg Oncol: 12:1, 2005
  14. 14. Recent advances in breast surgery Implications of resource limitations Guideline implementation in LMCs
  15. 15. Recent advances in breast surgery Implications of resource limitations Guideline implementation in LMCs
  16. 16. Colombia
  17. 17. USA Colombia BREAST CA BREAST CA Incidence: 101 Incidence: Mortality: 19 30.3 Ratio: 19% Mortality: 12.5 Ratio: 41% Globocan 2002 (IARC)
  18. 18. 2005 2020 2050 Globocan 2002 (IARC) - Colombia
  19. 19. Globocan 2002 (IARC) - Colombia
  20. 20. India
  21. 21. 5 year DISTRIBUTION STAGE EXTENT SURVIVAL USA INDIA 0 Noninvasive 100% 16% ---- USA: 90% DCIS or early staged Early stage I disease 100% 40% 1% invasive disease at diagnosis Early stage II disease 86% 34% 23% Locally INDIA: III advanced 57% 6% 52% 76% locally advanced or Metastatic metastatic at IV disease 20% 4% 24% diagnosis Sources: SEER Survival Monograph (NCI), 2007; Chopra, Cancer Institute Chennai, India, 2001
  22. 22. Former British colony 20 million population GHANA › Two-thirds rural Literacy: › 76% male, 54% female Life expectancy: › 57 years of age › “Low level” resources 3.6% HIV positive
  23. 23. Komfo Anokye Teaching Hospital (KATH) Breast Health Center
  24. 24. Komfo Anokye Teaching Hospital (KATH) Breast Health Center
  25. 25. Komfo Anokye Teaching Hospital (KATH) Patient with breast cancer (note visible tethering of patient’s right nipple)
  26. 26. Peace and Love Hospital (Kumasi Private Hospital) T2N1 – Stage II - breast cancer (typical presentation)
  27. 27. Peace and Love Hospital (Kumasi Private Hospital) T4N1Mx – Stage IIIB -- breast cancer (common locally advanced presentation)
  28. 28. Peace and Love Hospital (Kumasi Private Hospital) Recurrent breast cancer in axillary lymph node bed
  29. 29. Breast cancer invariably fatal Cancer caused by social misbehavior › Oral / nipple contact › Dirty clothing › Wearing money in bra Mastectomy leads to death within few years
  30. 30. Recent advances in breast surgery Implications of resource limitations Guideline implementation in LMCs
  31. 31. Recent advances in breast surgery Implications of resource limitations Guideline implementation in LMCs
  32. 32. The Breast Health Global Initiative (BHGI) strives to develop, implement and study evidence-based, economically feasible, and culturally appropriate guidelines for international breast health and cancer control for low and middle income countries to improve breast health outcomes.
  33. 33. Comprehensive guidelines by selected expert panels Consensus opinions based on evidence review Publication of a) consensus and b) individual manuscripts Global Summit 2002: Health Care Disparities Global Summit 2005: Resource Stratification Global Summit 2007: Guideline Implementation
  34. 34. HEALTH PRIMARY PREVENTION SYSTEMS
  35. 35. Basic level — Core resources or fundamental services necessary for any breast health care system to function. Limited level — Second-tier resources or services that produce major improvements in outcome such as survival. Enhanced level — Third-tier resources or services that are optional but important, because they increase the number and quality of therapeutic options and patient choice. Maximal level — Highest-level resources or services used in some high resource countries that have lower priority on the basis of extreme cost and/or impracticality.
  36. 36. CONSENSUS STATEMENTS Early Detection Diagnosis Treatment Health Care Systems 8 Stratified Tables 10 Individual Manuscripts Cancer: 113 (8 suppl), 2008
  37. 37. HEALTH CARE SYSTEMS EARLY DETECTION DIAGNOSIS STAGE I STAGE II LOCALLY ADVANCED METASTATIC
  38. 38. “Health care guidelines do not improve outcome unless they are implemented.” QUESTION: How can information be disseminated such that they are implemented and sustained within a target country?
  39. 39. Dissemination & implementation (D&I) research Education and training programs Technology application and development IMPLEMENTATION STRATEGY: Create BHGI Learning Laboratories in different parts of the world to develop and test educational modules based on BHGI guidelines and to model program expansion to other LMCs.
  40. 40. HopeXchange Medical Center Oct 16, 2008, Kumasi
  41. 41. Breast Cancer Awareness March Oct 16, 2008, Kumasi
  42. 42. Breast Cancer Awareness March Oct 16, 2008, Kumasi
  43. 43. Breast Cancer Awareness March Oct 16, 2008, Kumasi
  44. 44. HopeXchange: Institute for Professional Training Training in early detection, diagnosis and treatment adjusted for low-income country resources – Curriculum based on BHGI Guidelines – International faculty to teach and learn D&I methodology applied in-country Educational outcomes assessed and reported
  45. 45. BHGI / HopeXchange Planning Team January 31, 2009, Kumasi
  46. 46. Ghana College of Physicians and Surgeons – Paul Nyame, MD Korle-Bu Teaching Hospital – Joe-Nat Clegg-Lamptey, MD Komfo Anokye Teaching Hospital (KATH) – Anthony Nsiah-Asare, MD / Baffour Awuah, MD Peace and Love Hospital – Beatrice Wiafe, MD (Kumasi) Reach for Recovery – Gladys Boateng HopeXchange Medical Center – Riccardo Massetti, MD / Mario Cappello
  47. 47. Ghana Breast Cancer Alliance (GBCA) meeting January 30, 2009, Kumasi
  48. 48. Colombia National Early Detection Program
  49. 49. Target: Middle-Income Countries BHGI Breast Early Detection Module (BSM): – Patient education – Screening (CBE + mammography) – Diagnosis (imaging / tissue sampling / pathology) – Triage to linked diagnosis and treatment programs Model early detection program for other middle- income regions of Latin America, Eastern Europe and Asia Pacific.
  50. 50. Colombian National Early Detection Program National Cancer Institute, Bogota (1934)
  51. 51. Readiness Assessment Tool Development Project NCI Director Meeting
  52. 52. Readiness Assessment Tool Development Project BHGI / NCI Research Team Meeting
  53. 53. Study Design Health Care Centers Randomization 20 HMOs Stratified by Insurance Plan Control Group Intervention Group Informed consent Enroll 7,000 women Enroll 7,000 women Training for primary care MDs, nurses, radiologists, technologists Technical skills training No intervention in health care center and breast specialists Clinical Breast Exam Screening based on Implement screening program Screening invitation, current clinical practices In health care center documentation, patient follow-up, quality control, etc Screening based on Screening mammogram with diagnostic current clinical practices Follow-up in women > age 50 Follow-up in one year Follow-up in one year Outcome Variables Clinical stage Cancer incidence Statistical Analysis Evaluation of participation Cost assessment Adverse effects
  54. 54. Breast Cancer Screening Trial Public (Regimen Contributivo) Health Care Center Visit
  55. 55. Mamografías en el estudio Pruebas Intervenciòn Control Mamografias Solicitadas 3627 100.0% 690 23.1% Mamografias Realizadas 2681 73.9% 386 55.9%
  56. 56. Instituto Nacional de Salud Publica (Public) Fundacion Mexicana para la Salud (NGO)
  57. 57. Major advances in breast surgery include breast conservation surgery, needle sampling for diagnosis, sentinel node biopsy and oncoplastic surgery Improvements in LMCs require adaptation to existing resources and require coordination of surgery with other disciplines Dissemination and implementation through BHGI Learning Laboratories can steer guideline application in LMCs
  58. 58. BHGI Executive Committee: – Gabriel N. Hortobágyi, Chair (MD Anderson) – Annetta Hewko (Komen for the Cure) – Joe Harford (NCI Office of International Affairs) BHGI Research Team: – Wenjin Li, Research Manager – David Thomas, Senior Research Advisor – Gabrielle Kane, Curriculum Specialist BHGI Program Staff: – Leslie Sullivan, Senior Program Manager – Marisa Hartman, Program Coordinator – Sandra Distelhorst, Publication Editor
  59. 59. Early Detection Panel 2007 Treatment Panel 2007 – Cheng-Har Yip, MD (Malaysia) – Alexandru Eniu, MD (Romania) – Robert Smith, PhD (USA) – Robert Carlson, MD (USA) Diagnosis Panel 2007 Health Care Systems 2007 – Roman Shyyan, MD (Ukraine) – Ed Azavedo, MD, PhD (Sweden) – Stephen Sener, MD (USA) – Joe Harford, PhD (USA) Cancer: 113 (8 suppl), 2008
  60. 60. Italy Turkey Argentina – Riccardo Masetti – Vahit Osmen – Eduardo Cazap – Alberto Costa – Nuran Bese Lebanon Egypt Colombia – Nagi El Saghir – Sharif Omar – Carlos Rada Pakistan – Ahmed Elzawawy – Raul Murillo – Zeba Aziz – Mohamed Shalan – Sandra Diaz India South Africa Austria – Raj Badwe – Justus Apffelstaedt – Raimund Jakesz – Ketayun Dinshaw Cancer: 113 (8 suppl), 2008
  61. 61. www.bhgi.info

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