Recommended
More Related Content
What's hot
What's hot (20)
Similar to Organ preservation in kenyan breast cancer patients by peter bird
Similar to Organ preservation in kenyan breast cancer patients by peter bird (20)
More from Kesho Conference
More from Kesho Conference (20)
Recently uploaded
Recently uploaded (20)
Organ preservation in kenyan breast cancer patients by peter bird
- 1. Organ Preservation in Kenyan Breast Cancer Patients Mr Peter Bird FRACS, Kijabe Hospital
- 2. World Breast Cancer Burden • Breast cancer is the second most common cancer in the world, most common cancer in women – Fifth cause of death from cancer overall • 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers) • Slightly more cases in less developed (883,000 cases) than in more developed (794,000) regions • Incidence rates vary nearly four-fold across the world regions – Rates ranging from 27 per 100,000 in Middle Africa/Eastern Asia to 96 in Western Europe • The range in mortality rates between world regions is less than that for incidence because of the more favorable survival of breast cancer in (high-incidence) developed regions – Mortality rates range from 6 per 100,000 in Eastern Asia to 20 per 100,000 in Western Africa • More breast cancer deaths in LMICs than HICs WHO IARC GLOBOCAN 2012
- 3. Estimated Breast Cancer Incidence Worldwide WHO International Agency for Research on Cancer GLOBOCAN 2012 Estimated age standardized rates per 100,000
- 4. Estimated Breast Cancer Mortality Worldwide WHO International Agency for Research on Cancer GLOBOCAN 2012 Estimated age standardized rates per 100,000
- 5. Kijabe Breast Cancer Study 2001-2007 • 125 female, 4 male between 2001 and 2007 • Excluded wazungu, non-IDC tumours • Median age 47 (range 26-76) • Mean parity 4.1 • Mean size of tumour (clinical) 6.8cm • Average length of history – 12 months • LABC 59% Bird PA, Hill AG, Houssami N. Poor Hormone Receptor Expression in East African Breast Cancer: Evidence of a Biologically Different Disease? Ann Surg Oncol., March 2008
- 6. Kijabe Breast Cancer Cases 2011-12 • 59 cases Jan 11 to Feb 12 • 48 IDC (NOS); 11 special types • Median age 45 • 62.5% under 50yo • LABC 48% 0 20 15 10 5
- 8. Halsted’s Radical Mastectomy Series Ann Surg 1894 • 50 cases of radical mastectomy (not consecutive?) • Average age 51 • All 50 with nodal disease, so Stage II or III • LABC 33/48 (68%) • 27 of 50 (54%) prognosis regarded as “hopeless or unfavourable” after surgery & path assessment • 6% local recurrence rate (“Return of the disease in the field of operation”) William Halsted 1852-1922 Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894. Ann Surg 1894 Vol 20: 497-555
- 9. Halsted’s Radical Mastectomy • Removal of skin, breast, axillary nodes to level III, pectoralis muscles • IM nodes not removed • Chest wall defect skin grafted after granulating
- 10. William Halsted operating at Johns Hopkins 1904
- 11. The Biology of Breast Cancer Fisher’s Hypothesis: Most, if not all, patients with breast cancer have disseminated disease by the time a clinical diagnosis is established; that is, breast cancer is a systemic disease at presentation and local therapies have no influence on survival Bernard Fisher 1918 - "I cannot emphasize too strongly the fact that internal metastases occur very early in cancer of the breast, and this is an additional reason for not losing a day in discussing the propriety of an operation.“ W HALSTED 1894
- 12. The Biology of Breast Cancer • Fisher’s hypothesis tested in multiple prospective RCTs in early BC in High Income Countries • Increased local recurrence in breast conserving surgery compared to RM or MRM, but no difference in survival in over 25 years of follow up • Survival has improved with less surgery, because of earlier diagnosis, and treatment with adjuvant therapies, including RT to the chest wall
- 13. Treatment Options for Breast Cancer • SURGERY – Breast conserving or mastectomy, with lymph node examination (ALND or SLNB) • CHEMOTHERAPY – Before or after surgery. Anthracyclines, taxanes etc • HORMONAL THERAPY – SERMs, AIs, LHRH analogues, oophorectomy • TARGETED BIOLOGICAL THERAPY – Trastuzumab, new dual therapies very promising • RADIOTHERAPY – Teletherapy, brachytherapy, intraop RT (TARGIT trial)
- 14. Management of Breast Cancer in Kijabe, Kenya • Patients of highly variable economic status – determines extent of surgery • Breast conserving surgery and full adjuvant therapies offered to wealthier patients with early stage disease • 30% BC pts last six months (9/30) cf. 10% in 2008 series • Poor patients get mastectomy & AD alone if the tumour can be macroscopically excised • Wide excision on the chest wall helped by flap coverage techniques, and often a Level III AD
- 15. Fifty-six Latissimus Dorsi Myocutaneous Flaps at Kijabe Hospital P Bird, 2000-2014 Indication Number of cases Pathology Complications Local recurrence Coverage of anterior chest wall defect 45 Breast malignancy, soft tissue sarcoma 3 minor flap-skin dehiscences 2 Augmentation after partial mastectomy 5 Breast cancer None 0 Delayed BR 3 Breast cancer Implant Migration N/A Coverage of posterior chest wall defect 1 Recurrent soft tissue sarcoma None 0 Neck contracture 1 Burn 1 minor flap-skin dehiscence N/A Immediate BR 1 Breast cancer None 0
- 21. NSIBR2
- 22. NSIBR1
- 23. NSIBR3
- 24. Treatment Options for Breast Cancer • SURGERY – Breast conserving or mastectomy, with lymph node examination (ALND or SLNB) • CHEMOTHERAPY – Before or after surgery. Anthracyclines, taxanes etc • HORMONAL THERAPY – SERMs, AIs, LHRH analogues, oophorectomy • TARGETED BIOLOGICAL THERAPY – Trastuzumab, new dual therapies very promising • RADIOTHERAPY – Teletherapy, brachytherapy, intraop RT (TARGIT trial) – Crucial part of BCS option!
- 25. Radiotherapy Resources in Africa 2010 Kenya and Neighbours 8 Kenya 2 (Private 7) Ethiopia 2 South Sudan 0 Somalia 0 Uganda 1 Tanzania 3 Population: 243 million Australia (public) 33 Australia (private) 26 Population: 23 million Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013
- 26. Radiotherapy Resources in Africa 2010 Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013
- 27. Treatment Options and Costs in Kijabe and Kenya Mastectomy USD700 (At Kijabe) Radiotherapy USD200 (Done at KNH. USD4-5000 in private facilities) Chemotherapy USD1000 (Done in Nairobi) Hormonal Rx USD650 (5 years of tamoxifen) TOTAL USD2550
- 28. Ethiopia (92m) Somalia (10m) Kenya (44m) South Sudan (11m) Uganda (38m) Tanzania (48m) Annual GNI per Capita 2013 Rank S Sudan $1120 139 Kenya $930 145 Tanzania $630 156 Uganda $510 162 Ethiopia $470 164 Somalia Unknown Norway $102,610 1 Australia $65,520 4 USA $53,670 8 UK $39,140 18
- 29. World Breast Cancer Burden Harford J, Personal View, Lancet Oncol 2011
- 30. Management of Breast Cancer in Kijabe, Kenya • Patients of highly variable economic status – determines extent of surgery • Breast conserving surgery and full adjuvant therapies offered to wealthier patients with early stage disease • 30% BC pts last six months (9/30) cf. 10% in 2008 series • Poor patients get mastectomy & AD alone if the tumour can be macroscopically excised • Wide excision on the chest wall helped by flap coverage techniques, and often a Level III AD
- 31. Why are Breasts Important? • Providing nourishment to our children • Allowing strong bonding between mother and child • Having two maintains a healthy body image • As a sexual organ in some (all?) cultures
- 34. Bathsheba at Her Bath Rembrandt, 1654 “One evening David got up from his bed and walked around on the roof of the palace. From the roof he saw a woman bathing. The woman was very beautiful...” 2 Samuel 11:2
- 39. Breast Conservation Surgery Loss of a breast causes significant psychosocial damage, embarrassment and loss of self-esteem. Breast surgeons strive to preserve the breast to keep the woman psychologically healthy and socially confident
- 40. Breast Conservation Surgery The best reconstructive option is no reconstruction...perform breast conserving surgery (BCS) when ever possible!
- 49. PartialLD1
- 50. PartialLD2
- 51. PartialLD3
- 52. PartialLD4
- 53. PartialLD5
- 54. PartialLD6
- 55. PartialLD7
- 56. Margins in Stage I & II Breast Conserving Surgery
- 57. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 58. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 59. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 60. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 61. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 62. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 63. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 64. Margins in Stage I & II Breast Conserving Surgery Moran et al Int J Radiation Oncol Biol Phys 2014
- 65. Conclusions • Unacceptable disparity of healthcare exists between African countries and HICs • Most BCs in Africa present locally advanced and multidisciplinary treatment is unaffordable • BC management in LMICs must be tailored to best fit the economic circumstances • Surgery is the mainstay of treatment in Kenya and Kenyan surgeons need to be taught techniques to meet this challenge
- 66. Kijabe, Kenya