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Innovation and clinical specialities: oncology previously have a choice of either surgical or radiotherapeutic oophorectomy or luteinizing hormone-releasing hormone (LHRH) agonists with or without an antiestrogen. Endocrine therapies in postmenopausal women include selective, nonsteroidal aromatase inhibitors (anastrozole and letrozole); steroidal aromatase inhibitors (exemestane); pure antiestrogens (fulvestrant); progestin (megestrol acetate); androgens (fluoxymesterone); and high-dose estrogen (ethinyl estradiol). In premenopausal women, therapies include LHRH agonists (goserelin and luprolide); surgical or radiotherapeutic oophorectomy; progestin (megestrol acetate); androgens (fluoxymesterone); and high-dose estrogen (ethinyl estradiol). Chemotherapy is the best option in women with estrogen and progesterone receptor-negative tumors, symptomatic visceral metastasis, or endocrine therapy refractory disease. The higher rates of objective response and longer time to progression of combination chemotherapy are at the expense of increased toxicity with little survival benefit. Therefore, there is no significant advantage of combination chemotherapy over sequential single agents. Preferred first-line chemotherapies include sequential single agents or combination chemotherapy. Among preferred first-line single agents, are doxorubicin, epirubicin, pegylated liposomal doxorubicin, paclitaxel, docetaxel, capecitabine, vinorelbine (all category 2A), and gemcitabine (category 2B). Among preferred first-line combination regimens are cyclophosphamide, doxorubicin, and fluorouracil (FAC/CAF); fluorouracil, epirubicin, cyclophosphamide (FEC); doxorubicin, cyclophosphamide (AC); epirubicin, cyclophosphamide (EC); doxorubicin in combination with either docetaxel or paclitaxel (AT); cyclophosphamide, methotrexate, fluorouracil (CMF); docetaxel, capecitabine; gemcitabine, paclitaxel. Patients with tumors that are HER2-positive may derive benefit from treatment with trastuzumab as a single agent or in combination with selected chemotherapeutic agents. 27% of patients treated with a combination of Trastuzumab and doxorubicin/cyclophosphamide chemotherapy develop significant cardiac dysfunction making this regime unsafe and unpopular. 71 Treatment of complications In Africa, a good number of women present with fungating/ ulcerating masses and many of them are so ill that they can not undergo surgery or radiotherapy immediately. The following are some useful supportive measures: ✚ Dressing of the wound with honey and metronidazole cleanses and remove the odor. This measure in addition to the use of neoadjuvant chemotherapy has largely reduced the need for toilet mastectomy. ✚ Clean malignant ulcers are prone to secondary hemorrhage; topical formalin is effective in this setting. ✚ Pain is another significant problem and this may be due to the disease, therapy or depression. Optimal pain management is very crucial to improving the quality of life. If pain occurs, there should be prompt oral administration of drugs in the following order: non-opioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used. To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on demand” This three-step approach (see figure 2) of administering the right drug in the right dose at the right time is inexpensive and 80- 90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective. 109 ✚ Anemia as a result of the disease or chemotherapy is often under treated and underestimated in patients. It has a negative impact on quality of life and survival. It will require blood transfusion in some women. The introduction of recombinant human erythropoietin (epoetin) has provided an effective and convenient treatment of anemia without the risks of blood transfusion. Epoetin is also effective for the prevention of anemia and reduction of transfusion requirements in patients with a high risk of developing anemia during chemotherapy. 110-112 ✚ Lymphedema of the arm is a very distressing complication which may occur as a result of the disease itself or as a result of surgery or radiotherapy in the treatment of breast cancer. Treatment options include compression treatments (using compression bandage or garments and pneumatic compression devices), therapeutic exercises and pharmacotherapy (antibiotics, flavonoids, hyaluronidase, and selenium). Diuretics have not been found useful. 113,114 ✚ Respiratory distress in advanced breast cancer may be as a result of pleural effusion or deposits in the lungs. Closed thoracostomy tube drainage with pleurodesis using Tetracycline or Bleomycin is an effective treatment. Lung metastasis can be treated with steroids inhalers, bronchodilators, diuretics, anxiolytics, chest physiotherapy and oxygen. 5 ✚ Neurological complications include cerebral metastases, spinal, leptomeningeal, cranial and peripheral nerve metastases. 115 Treatment includes steroids, radiotherapy and surgery for localized metastases. Younger women with breast cancer are more prone to physical and psychological distress which makes them have poorer quality of life outcomes. These arise as a result of the disease and the complications of treatment. Gonadal toxicity leading to irregular menses, amenorrhea and premature menopause is especially disturbing for African patients, the majority of whom are in their reproductive age group. Other problems like Alopecia, fertility problems and the cost of treatment may severely affect relationship especially among young couples. In this context, a multi disciplinary approach is important which will involve psychologists, social welfare/support groups and various advocacy groups where survivors of breast cancer can share their experiences and support one another. 116-120 Prognosis Natural history The natural history of breast cancer in 250 untreated women revealed the following statistics; Median survival of untreated breast cancer was 2.7 years after initial diagnosis. The 5- and 10-year survival rates were 18.0 and 3.6%, respectively. Only 0.8% survived for 15 years or longer. Autopsy data confirmed that 95% of these women died of breast cancer, while the remaining 5% died of other causes. Almost 75% of the women developed ulceration of the breast during the course of the disease. The longest surviving patient died in the nineteenth year after diagnosis. 121 With modern treatment, the 5-year survival rate for stage I <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010 101
Innovation and clinical specialities: oncology Table 5: Microscopic criteria for grading of invasive carcinoma LOCAL-REGIONAL TREATMENT SYSTEMIC TREATMENT (ADJUVANT) Level of resource Surgery Radiation therphy Chemotherphy Endocrine therphy Basic Modified radical mastectomy Neoadjuvant AC, Ovarian therapy FAC or classical CMF* Tamoxifen Limited Postmasectomy irradiation of the chest wall and regional nodes Enhanced Breast-conserving theraphy** Breast-conserving whole-breast irradiation Tamoxifen Aromatese inhibitors LH-RH agonists Maximal Reconstructive surgery Growth factors Dose-dense chemotherapy *Requires blood chemistry profile and complete blodd count (CBC) testing ** Breast-conserving therapy requires mamography and reporting of margin status. AC, doxonubian and cyclosphamida; CMF, cyclophamide, methotrexate, and 5- fluorourcil; EC, epirubicin and cyclophosphamide; FAC, 5 - fluorourcil doxonubicin, and cyclophosphamide; LH+RG, lutelnizing hormone-releasing hormone patients is 94%; for stage IIa patients, 85%; and for stage IIb patients, 70%, while for stage IIIa patients the 5-year survival rate is 52%; for stage IIIb patients, 48%; and for stage IV patients, 18%. Prognostic Iindicators: Tumor size Prognosis deteriorates with increasing tumor size, which is an independent predictor of survival in node-negative patients and correlates with the incidence of nodal metastases. Staging The status of the axillary lymph nodes is one of the most useful prognostic indicators for breast cancer, with average 10-year survival rates of 60-70% for node-negative patients, dropping to 20-30% in node-positive patients. Histopathology ✚ Histologic type • Carcinoma in situ, because it is a preinvasive condition, is curable if completely removed, although 16% of patients with carcinoma in situ develop invasive recurrence after local excision of ductal carcinoma in situ, usually high grade. Similarly, 18% of patients develop invasive recurrence after lobular carcinoma in situ excision. • Well-differentiated invasive cancers have a relatively good prognosis if they are tubular, mucinous, cribriform, or secretory. • Medullary carcinoma is probably of intermediate prognosis, but different studies have used different criteria for its definition. • Invasive ductal and invasive lobular carcinomas have a less favorable prognosis but are influenced heavily by other factors. ✚ Cytologic grade • Cytologic grade is the best predictor of disease prognosis in carcinoma in situ but is dependent on the grading system used, such as the Van Nuys classification (high-grade, lowgrade comedo, low-grade noncomedo). • The grading of invasive carcinoma is also important as a prognostic indicator, with higher grades indicating a worse prognosis. Microscopic criteria for grading are shown in Table 5. ✚ Lymphovascular: Lymphatic invasion, vascular invasion, microvessel quantification, and lymphoplasmacytic infiltration are associated with a worse prognosis. ✚ Hormone receptor status: With the aid of gene expression studies using DNA microarrays and immunohistochemistry, several distinct biologic breast cancer subtypes have been identified. These subtypes differ markedly in prognosis and in the number of potential therapeutic targets they express. The intrinsic subtypes include 2 main subtypes of estrogen receptor (ER)–negative tumors (basal-likeand human epidermal growth factor receptor-2 positive/ER- [HER2_/ER-] subtype) and at least 2 types of ER+ tumors (luminal A and luminal B). The basal like subtype carries poor biologic (worse grade) and clinical prognostic indicators like positive axillary nodes. This subtype was found to be more prevalent in pre-menopausal African-American women compared to post menopausal African- American women and other races. 122 This finding may be one of the reasons why African-American women with breast cancer have high grade, late stage tumor and with poor prognosis and poor survival outcome. The similar clinical outcome of native African women with breast cancer may tempt one to extrapolate these findings seen in African-American women. To lend credence to this fact, the few studies on hormone receptor status of breast cancer in native African women show that the majority of them are Estrogen or Progesterone negative 123-125 . There are also several other provocative parallels between African-American and native African breast cancer patients which include a younger age distribution and a greater prevalence of high grade, estrogen-receptor-negative disease among breast cancer patients in the Ghanaian and Nigerian populations of western Africa similar to the patterns of breast cancer reported among African-American women. Western African populations served as the source for most of the slave trade to colonial North America, and therefore share a common ancestry with present-generation African Americans. These parallels suggest the possible contribution of founder effects. 16 However, further research needs to be done in this area before reaching any conclusion is reached as the African-Americans are 102 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
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Innovation and strategy 14 Creativi
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Innovation and strategy: creativity
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Page 133 and 134: IHF reference The International Hos
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Page 141 and 142: IHF reference JAPAN JAPAN HOSPITAL
Page 143 and 144: IHF reference KENYA THE NAIROBI HOS
Page 145 and 146: IHF Corporate Member Profiles GE He
Page 147: How Can Health Organizations Get th
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