Transcript
CANCERS AMONG
FEMALE: “Focusing on
Breast Cancer”
Manuaba Tjakra Wibawa
Department of General Surgery.
School of Medicine. University of Udayana
Denpasar. Bali. Indonesia
Five most common Cancers in
Women in Bali (Pathological Based, 2017)
▪Breast Cancer▪Cervix Cancer
▪Thyroid Cancer
▪Skin Cancer (non melanoma)
▪Colo-Rectal Cancer
BREAST CANCER IN BALI
Facts about Breast Cancer in
Indonesia/ Bali
▪No 1 Cancer among female
▪Affecting “younger population”
▪Majority came at “advanced stages”
▪No population based “mass screening program”
available
▪Surgeries, often became “adjunct” to Chemotherapy
▪Different surgical standards → General Surgeons,
Breast Surgical Oncologist, and Breast Surgeons
▪Advanced Stages → high cost with little results
▪Expensive Molecular Technologies → No Standard
Tissue Fixation, IHC, FISH/ CISH, Genes Profiling,
Facts about Breast Cancer and
Pregnancy in Bali
▪ 25% of Breast Cancer Population were 40 years or less
▪ 52% of our Breast Cancer Population were less than 45 years (data from 2014 up to April 2018)
▪ Risk of pregnancy
▪ No structured or regular public education about cancer in general or specifically about Breast Cancer and pregnancy even in breast cancer patients
▪ Patient information collected most of the time lack of “children’s information” such as number, ages of the youngest child → “we never ask”
▪ Pregnancy in Breast Cancer (PABC) mostly discovered by accident or from patient history
PABC CHARACTERISTICS IN SANGLAH
GENERAL HOSPITAL 2015-2017 (N: 17)
Variable n %Primary Tumor Size T1 1 5.9%
T2 3 17.6%T3 3 17.6%T4 10 58.8%
Node N0 4 23.5%N1 5 29.4%N2 5 29.4%N3 3 17.6%
Metastasis M0 13 76.5%M1 4 23.5%
Stage Stage I 1 5.9%Stage II 3 17.6%Stage III 9 52.9%Stage IV 4 23.5%
Subtype Luminal A 0 -Luminal B 8 47.1%Her2 Type 2 11.8%TNBC 4 23.5%Unknown 3 17.6%
Three years PABC in our Institution
(2015-2017. N: 17)
▪From 17 PABC patients:
▪Mean Age 33.47 ± 6.414 years
▪Youngest Age 24 years old
▪Oldest Age 44 years old
▪OS was 53.3 ± 27.4 months (Median observation 45.6 months)
▪DFS was 54.8 ± 27.9 months (Median observation 51.4 months)
▪No patient was referred by Colleagues OBGYN
EPIDEMIOLOGY
Epidemiology of Breast Cancer in
Indonesia
▪No Population Based Tumor Registry
available in Indonesia or Bali
▪Data from Hospital Based (Single Central
General Hospital Bali) about 250 -350
patients per year (under reported) → due to
health coverage →“government policy”
Number Of Cases per Year(Bali/ University of Udayana)
6762
91
125
106
99
91
N = 642
2005
2006
2007
2008
2009
2010
2011
Number Of Cases per Year(Bali/ University of Udayana)Data Tahun(2014-2018)
Tahun 2014 Tahun 2015 Tahun 2016 Tahun 2017 Tahun 2018
188
266
357
320
58
N= 1189
Tahun 2014 Tahun 2015 Tahun 2016 Tahun 2017 Tahun 2018
Age Distribution (2014-2018)(Bali/ University of Udayana)
Series1
<2020-30
31-3536-40
41-4546-50
51-5556-60
>60
121
61
110
233 241
212
155155
N=1189
Median Age of Breast Cancer Patients
2003-2007
Heri Susilo, 2008
Perbedaan Stadium Penderita
Selama Tahun 2003 - 2007
Heri Susilo, 2009. Subdivision of Surgical Oncology, UNUD
DATA JUMLAH PASIEN KANKER PAYUDARA MENURUT
STADIUM TAHUN 2012 – 2013 (n = 273)
0
10
20
30
40
50
60
70
80
90
I IIA IIB IIIA IIIB IIIC IV
Jum
lah
Stadium
STAGE(DENPASAR. 2014-2018). N = 1172
0.10%
2.90%
14.50% 14.50%
12.10%
30.30%
2%
22.80%
0.80%
Stadium 0 Stadium I Stadium IIA Stadium IIB Stadium IIIA Stadium IIIB Stadium IIIC Stadium IV Undefined
Series1
Breast cancer Subtypes (2004 – 2014)
Period
Breast Cancer Subtypes
n Total (%) n/N
Luminal A
n (%)
Luminal B
n (%)
Her-2 Type
n (%)
TNBC
n (%)
2004-2007
N = 284
8 (44.44%) 2 (11.11%) 1 (5.56%) 7 (38.89%) 18 (100%) 6.34%
2008-2011
N = 471
44 (37.29%) 9 (7.63%) 19 (16.10%) 46 (38.98%) 118 (100%) 25.05%
2012-2014
N = 344
37 (31.36%) 27 (22.88%) 30 (25.42%) 24 (20.34%) 118 (100%) 34.30%
Breast cancer Subtypes (20015 –2018)
Period
Breast Cancer Subtypes
n Total
(%)
n/N
Luminal
n (%)
Luminal
A
n (%)
Luminal
B
n (%)
Luminal
Her-2
n (%)
Her-2
Type
n (%)
TNBC
n (%)
2015-
2016
N = 499
57
(11,42%)
58
(11,62%)
94
(18,83%
)
108
(21,64%)
74
(14.82%)
108
(21,64%)
499(99.9
7%)
(100%)
2017-
2018
N = 214
3
(1,40%)
29
(13,55%)
94
(43,92%
)
33
(15,42%)
28
(13,08%)
27
(12,61%)
214 (
99.98%)
(100%)
Delayed Cases of
Breast cancer
Advanced Breast cancer (LABC, MBC)
“Time Delay”, since patient noticed the
“lump” until seeking help from Doctors
No. Jawaban Jumlah Presentase
1.
2.
3.
4.
5.
< 1 Bulan
1 Bulan – 6 Bulan
> 6 Bulan – 1 tahun
>1 Tahun – 2 tahun
> 2 Tahun
1
5
10
9
5
3.33%
16.67%
33.33%
30.00%
16.67%
Total 30 100.00%
Ariawan & Manuaba, 2006
Cause of Delay (in seeking proper
treatment)
▪Avoiding Surgery, Chemotherapy or
Radiation Therapy
▪Rumors in the community (surgery will
make cancer “more aggressive”, or
“metastasis faster”
▪The “attraction of alternative medicines” →
no surgery needed
▪Delay by doctors
Breast Cancer Management
Breast Cancer Management
▪Surgeries
▪Chemotherapy
▪Hormonal Therapy
▪Radiation Therapy
▪Targeted Therapy
SURGICAL TREATMENTS
▪ “Modified Radical Mastectomy” → standard surgery for Stage I, II
▪Breast Conserving Surgery → EBC → Frozen Section for “margin”?
▪Sentinel Lymph Node Biopsy → Methylene Blue (“Research basis only”, “dye difficult to obtain”)
▪ “Comprehensive Mastectomy” and “close huge operative defects”
▪Neo-adjuvant Chemotherapy → Standard therapy for Stage III and IV → average tumor size 9-12 cm
▪Others Adjuvant Treatment → according to Breast Cancer Subtypes (“personalized treatment”)
Breast cancer Screening
Breast Cancer Screening in Indonesia/ Bali“Individual basis”▪Breast Self Examination → trained and activated for the whole island simultaneously → to be monitored and evaluated, RCT?
▪Regular Clinical Breast Examination by doctors who are well trained (not necessarily surgeon)
▪USG for younger age for Asian Women → need for subspecialist radiologist. This is especially important because of younger age group of patient in Indonesia/ Bali (operator dependent)
▪Mammography → for older (>50 years) women; increase the availability new generation mammography machine → younger patients
▪MRI → for special case of Breast Cancer
FUTURE PLANNING FOR EARLIER
BREAST CANCER DETECTION AND IMPROVEMENT OF
OS AND DFS
▪Public Education → extensive, continuing,
and supervised
▪Screening for Breast Cancer → Population
Based or Individual; BSE, CBE and
Standard/Accredited personal and Imaging
Technology/ USG, Mammography and MRI
→ has to start
▪The role of OBGYN in early
detection of Breast Cancer during
pregnancy/ PABC?
FUTURE PLANNING FOR EARLIER BC.
DETECTION AND IMPROVEMENT OF OS
AND DFS
▪Surgical Training for Breast Cancer Surgeries → one standard and same quality/ competence → synchronized training program, “same training catalog?” → better OS, DFS
▪Toward “Organ-Oriented Training Program” →including Breast Surgery
▪Updating and modernizing medical technologies → molecular and genomic oncology → personalized treatment (government role?)
▪ Improvement of Radiotherapy services →“machines” and “Radiation Oncologist” (Government role?)
Conclusions
▪No effective and continuing public education
▪No “population based mass screening program”
▪Affecting younger populaton → germline mutation, genetic susceptability/ polymorphism?
▪ Advanced Stages in majority patients
▪Low response rate on NAC
▪Low “surgical conversion” → “comprehensive mastectomy”
▪Different standard of Breast Cancer Surgeries (Surgical Oncology>< General Surgeons>< Breast Surgeon) → OS and DFS?
Conclusions
▪RT. Centralized in big cities & not widely distributed → majority patients did not receive RT → high recurrent rate
▪“IHC” is still expensive, coverage? →personalized medicine?
▪Molecular and genomic technology →available but very expensive →personalized medicine?
Thank you
BCT/ S.
AXILLARY
DISSECTION IN
BCT/S
SLNB → “notice big incision”, dye material only →
learning curve → Safety in PABC?
LD Flap
TRAMP FLAP → TO COVER AND RECONSTRUCT
THE DEFECT
Oncoplasty in Breast
Surgery
TREATMENTS (Targeting
Therapy)
▪Transtuzumab → the most common targeted therapy used → for Her2 type Breast Cancer
▪Bevacizumab, Lapatinib, mTor Inhibitor/ Avinitor → are in the market → use for “second or third line treatment”
▪Expensive → covered by BPJS/ JKN (no longer covered since April 2018)
RADIATION THERAPY
▪Mainly distributed in big Cities (Jakarta, Surabaya, Bandung, Semarang)
▪The use of “old technologies” in many centers → Co60
▪“Long que” → Denpasar “the waiting time” up to one year
▪High percentage of Stage III or IV breast cancer → no RT → high recurrent rate
Suhartati, 2008
Look at
The Distribution
HIGH TECHNOLOGIES AND
PERSONALIZED MEDICINE
▪No Standard tissue/ tumor specimen “handling” or “fixation”
▪No Standard → tissue transport
▪No Standard → histopathology reports
▪ IHC → no quality contro/ or accreditation; no reference lab.
▪FISH or CISH → certain lab, expensive technology
▪Gene Profiling → 1 lab; expensive
Personalized Medicine, difficult to achieve
HIGH TECHNOLOGIES AND
PERSONALIZED MEDICINE
▪Routine Histo-Pathology Examination
-Cytology (no subspecialty “Breast
Cytopathologist”)
-IHC → ER, PR, Her2 (other tumor
markers → research only)
-Molecular Diagnosis → refer to
molecular lab., expensive
Problem in Advanced
Staged Breast Cancer
(LABC or MBC)
LESS RESPONSIVE TO “NAC”▪Sudarsa, 2000 → 70% (ORR)
▪Manuaba, 2006 → 40% ORR)
▪Heri Susilo (2008) → 40% (ORR)
▪Widiana (2014) → 30% (ORR)
(Regiment used → CAF, Taxane+Anthracyclines)
NSABP B-27 → higher response rate and higher complete pathological response rate (12.8-26.1%)
Smaller tumor size?
The response rate intended to decrease
was it because of “huge size tumors”, or problem
of measurement (Clinical vs MRI?)
Biological → different tumor biology?
HIGH COST and LITTLE
RESULTS
▪60-70% → Stage III (inoperable) and IV Breast Cancer
▪Less than 40% response rate
▪Surgical Conversion rate → less 30%
▪Complex surgeries (comprehensive surgeries) → radical mastectomy + reconstruction “to close huge defects”
▪“Low” 5 years” OS rate
▪High cost and wasting chemotherapy agents and expensive targeting therapies
▪Low productivity
Training of Surgeons
TRAINING OF SURGEONS
▪Breast Cancer Surgery → provided by
General Surgeons, Surgical Oncologist and
Breast Surgeon
▪Different levels of training, overlapping
training
▪Different techniques or qualities
→”personal skills/ learning curve”; “low
patient volume”
▪Multiple standards of surgical techniques →
should be “one standard” → different
phylosophy of Surgical Training?
Thank you
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