Full document - International Hospital Federation

Innovation and clinical specialities: oncology
oestrogen receptor positivity has been reported in more than 90%
of tumours, with 92–96% being progesterone-receptor positive.
Some studies suggested that breast cancer has a worse
prognosis in men than in women, but if age- matched and stagematched
breast cancer is compared, there is no difference
between the sexes 18;134;135
Future trends and controversies
✚ Diagnosis and early detection Several new technologies,
apart from mammography are being evaluated to improve the
early detection of breast cancer. These include non ionizing
imaging techniques like Ultrasonography and MRI. Other
imaging tools being evaluated include scintimammography,
positron emission tomography, magnetic resonance
spectroscopy, optical imaging, thermo-acoustic computed
tomography, microwave imaging, Hall effect imaging etc.
✚ Molecular targets and new drugs HER-2 Pertuzumab
(also known as 2C4, Omnitarg) is a new recombinant
humanised monoclonal antibody that also binds the
extracellular portion of HER2, which causes steric hindrance
and impairs receptor dimerisation. Ongoing phase-I testing
has shown activity in patients with breast cancer that is either
HER2-negative and trastuzumab-refractory HER2-positive.
✚ Tyrosine kinase, cyclines, and proteosoma Most tyrosinekinase
inhibitors are in preclinical investigations and only a few
have been tested in patients with advanced breast cancer.
Gefitinib is an inhibitor of the tyrosine kinase of human
epidermalgrowth-factor receptor (HER1) and has shown some
antitumour activity in preclinical studies and a phase II trial of
patients heavily pretreated for metastatic breast cancer.
✚ Insulin-like growth factor (IGF) IGF is an interesting
therapeutic target in breast cancer because its ligands and
receptors are often overexpressed and are implicated in
proliferation, transformation, and metastasis. The IGF system
includes ligands IGF-I and IGF-II, receptors IGF-IR and IGF-IIR,
and six known IGF-binding proteins. These binding proteins
are promising targets for the manipulation of endocrine
responsiveness and resistance to Trastuzumab.
✚ Angiogenesis Bevacizumab is a recombinant, humanised
monoclonal antibody to vascular endothelial growth factor that
has shown some efficacy when used alone in phase II clinical
trials. Several anti-angiogenic drugs have been tested for
efficacy, including thalidomide, endostatin, angiostatin,
SU6668, SU11248, and cyclo-oxygenase 2 (COX-2) inhibitors.
COX-2 also improves the efficacy of
✚ Receptors as targets for radionuclides Efficacy of targeted
therapy depends on the biologically relevant quality and
quantity of the specific compound. This treatment needs to
reach the target efficiently and accurately and exert a selective
therapeutic effect. The development of biomarkers to assess
in-vivo responses and the ability to use such biomarkers as
targets for specific radionuclide treatment represent great
challenges in cancer medicine.
In situ ablation
In situ ablation of the primary tumour has been suggested as an
alternative to surgery. There are preliminary reports on methods
using cryosurgery, or coagulating with heat, delivered by a laser
fiberoptic technique .
Who will perform breast surgery?
Within the next decade the number of patients undergoing axillary
surgery will diminish as a result of improved staging by sentinel
node biopsy. A greater part of the patients will have only breast
resection, and these operations can be performed as day-case
surgery, even under local anaesthesia. The surgical challenges
during the next decade will be immediate breast reconstruction
and various oncoplastic procedures. Therefore breast surgery will
increasingly be performed by plastic surgeons. General surgeons
will not be so interested in carrying out all the other rather
undemanding breast procedures. 136
Controversies
✚ Relevance.
✚ The place of post mastectomy radiotherapy in early breast
cancer especially in women with T1 ,T2 and one to three
positive lymph nodes.
✚ Sequencing of post mastectomy radiotherapy and breast
reconstruction. 137
✚ The impact of mammographic screening in reduction of
mortality in breast cancer.
Conclusion
Management of breast cancer is a major challenge in resource
limited countries.
Efforts should be geared towards early diagnosis, prompt and
standardized treatment to reduce the burden of advanced disease
in African women, majority of who are worse hit in the most
productive part of their life time.
Our knowledge about breast cancer is evolving, but is still
limited with respect to its etiology and biology, and with respect to
its features in individual countries and cultures.
Further research is needed to understand the role of genetics
and environment in the etiology of breast cancer in Africa.
Recommnedations
In high-resource countries, evidence-based guidelines outlining
optimal approaches to early detection, diagnosis, and treatment of
breast cancer have been defined and disseminated. These
guidelines unfortunately are not applicable in countries with
resource constraints as they are not economically feasible or
culturally appropriate.
The following recommendations might be considered appropriate
in the resource-poor countries of Africa. Following the Breast Health
Global Initiative we have stratified the recommendations into Basic,
Limited, Enhanced and Maximal. 10-12,138
Definition of stratification terms
✚ Basic level – Core resources or fundamental services
absolutely necessary for any breast healthcare system to
function. By definition, a healthcare system lacking any basiclevel
resource would be unable to provide breast cancer care
to its patient population. Basic-level services are typically
applied in a single clinical interaction.
✚ Limited level – Second-tier resources or services that
produce major improvements in outcome, such as increased
survival, but which are attainable with limited financial means
and modest infrastructure. Limited-level services may involve
single or multiple clinical interactions.
Hospital and Healthcare Innovation Book 2009/2010 105