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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
Innovation and clinical specialities: oncology ✚ Enhanced level – Third-tier resources or services that are optional but important. Enhanced-level resources may produce minor improvements in outcome but increase the number and quality of therapeutic options and patient choice. ✚ Maximal level – High-level resources or services that may be used in some high-resource countries, but nonetheless should be considered lower priority than those in the basic, limited, or enhanced categories on the basis of cost or impracticality for limited-resource environments. In order to be useful, maximallevel resources typically depend on the existence and functionality of all lower-level resources. Our own recommendations include: ✚ Early Detection and Diagnosis: Possible less resourceintensive methods for earlier diagnosis of breast cancer like education in breast awareness, training in breast selfexamination (BSE), regular clinical breast examination (CBE) by experienced personnel and diagnostic ultrasound may be the option in resource limited countries as mammography screening may be resource intensive. 69 ✚ To improve breast pathological capacity and services in Africa, the following approaches may be explored; including training pathologists, establishing pathology services in centralized facilities, and organizing international pathology services. In particular it is important that estrogen and progesterone receptor status of tumors be identified. ✚ As staging is crucial to treatment decisions and prognosis, a thorough clinical evaluation after the diagnosis of breast cancer to check for clinically obvious indications of metastases to the lymph nodes and other areas is crucial. In addition, tests to assess the presence of metastases to the lungs, liver, and bone provide valuable information, if available. Hormone receptor testing of pathology specimens should be part of the pathology services ✚ More training for surgeons in BCT and Sentinel node biopsy. ❏ Acknowledgements Recommendations are presented in tabular form and are reproduced with permission from the BHGI. References 1. Veronesi U, Boyle P, Goldhirsch A, Orecchia R, Viale G, Veronesi U, et al. Breast cancer.[see comment]. [Review] [160 refs]. Lancet 2005 May 14;365(9472):1727-41. 2. Parkin DM, Bray F, Ferlay J, Pisani P, Parkin DM, Bray F, et al. Global cancer statistics, 2005. CA: a Cancer Journal for Clinicians 2005 Mar;55(2):74-108. Abstract Only 3. Vorobiof DA, Sitas F, Vorobiof G, Vorobiof DA, Sitas F, Vorobiof G. Breast cancer incidence in South Africa. [Review] [16 refs]. Journal of Clinical Oncology 2001 Sep 15;19(18 Suppl):125S- 7S. 4. Omar S, Khaled H, Gaafar R, Zekry AR, Eissa S, el-Khatib O, et al. Breast cancer in Egypt: a review of disease presentation and detection strategies. [Review] [44 refs]. Eastern Mediterranean Health Journal 2003 May;9(3):448-63. 5. Adebamowo CA, Ajayi OO, Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. [Review] [74 refs]. West African Journal of Medicine 2000 Jul;19(3):179-91. 6. Adesunkanmi AR, Lawal OO, Adelusola KA, Durosimi MA, Adesunkanmi ARK, Lawal OO, et al. The severity, outcome and challenges of breast cancer in Nigeria. Breast 2006 Jun;15(3):399- 409. 7. Hisham AN, Yip CH, Hisham AN, Yip CH. Overview of breast cancer in Malaysian women: a problem with late diagnosis. Asian Journal of Surgery 2004 Apr;27(2):130-3. Abstract Only 8. Parkin DM, Bray F, Ferlay J, Pisani P, Parkin DM, Bray F, et al. Global cancer statistics, 2005. CA: a Cancer Journal for Clinicians 2005 Mar;55(2):74-108. Abstract Only 9. Kirby I.Bland ea. The Breast. Schwartz’s Principles of Surgery 8th edition. 2007. Ref Type: Generic 10. Anderson BO, Shyyan R, Eniu A, Smith RA, Yip CH, Bese NS, et al. Breast Cancer in Limited- Resource Countries: An Overview of the Breast Health Global Initiative 2005 Guidelines. The Reprinted with kind permission from Surgery in Africa Monthly Review – February 2007 Charles A Adisa, MBBS, FWACS, FACS- Dr Adisa is Professor of Surgery at the Abia State University(ABSU) and a honorary Consultant Surgeon to the Abia State University Teaching Hospital (ABSUTH) . He joined the division of surgery at ABSU in 1995 where he served as the Chief of Surgery and the pioneer director of the residency training programme. He is currently the Head of the surgical oncology division in ABSUTH and the evolving minimally invasive surgical unit. His basic science research focuses on the role of pro inflammatory macrophages in breast cancer. His clinical interest is in surgical oncology especially breast, colorectal and prostatic cancers. He received his medical degree from the University of Ibadan, Nigeria with a distinction in Anatomy. He completed his general surgery residency at the University College Hospital, Ibadan and the University of Nigeria Teaching Hospital, Enugu, Nigeria. He was the best graduate in Surgery at the Fellowship examination of the West African College of Surgeons in 1995 with the award of the distinguished Jide Ajayi gold medal in Surgery.He was the American Colllege of Surgeons Guest Scholar in 2007 and the recipient of the American Society of Clinical Oncology International Development and Educational Award (IDEA) in 2008. He is an active member of several professional associations including the west African college of surgeons where he serves as an examiner, ASCO, AAS, AUA,ACS and several others. Dr Adisa’s first faculty position was as a Lecturer I (Assistant Professor) at the College of Medicine and Health Sciences, Abia State University in 1995. He is currently the Dean of Clinical Medicine at the Abia State University and the Chief Medical Director of Maranatha Specialist Hospital. Abia State University Teaching Hospital is the apex medical institution in Abia State South East Nigeria and caters for a population of over 5 million people from Abia state and the neighboring states. She was the second state funded teaching hospital in Nigeria to commence undergraduate medical education. Breast Journal 2006;12(s1):S3-S15. 11. Eniu A, Carlson RW, Aziz Z, Bines J, Hortobagyi GN, Bese NS, et al. Breast Cancer in Limited- Resource Countries: Treatment and Allocation of Resources. The Breast Journal 2006;12(s1):S38-S53. 12. Robert W.Carlson M*BOAMRCMAEEMRJMRRLM*MMaGSMP. Treatment of Breast Cancer in Countries with Limited Resources. The Breast Journal 9, 67-74. 2003. Ref Type: Generic 13. Breasted JH. The Edwin Smith Surgical Papyrus. Classics of Med Lib. Vol III., 405. 1930. Chicago, University of Chicago Press. Ref Type: Generic 14. McPherson K, Steel CM, Dixon JM, McPherson K, Steel CM, Dixon JM. ABC of breast diseases. Breast cancer-epidemiology, risk factors, and genetics.[see comment]. [Review] [16 refs]. BMJ 2000 Sep 9;321(7261):624-8. 15. Ijaduola TG, Smith EB, Ijaduola TG, Smith EB. Pattern of breast cancer among white-American, African-American, and nonimmigrant west-African women. [Review] [45 refs]. Journal of the National Medical Association 1998 Sep;90(9):547-51. Abstract Only 16. Newman LA, Newman LA. Breast cancer in African-American women. [Review] [117 refs]. Oncologist 2005 Jan;10(1):1-14. 17. Polite BN, Olopade OI, Polite BN, Olopade OI. Breast cancer and race: a rising tide does not lift all boats equally. [Review] [21 refs]. Perspectives in Biology & Medicine 2005;48(1 Suppl):S166-S175. 18. Fentiman IS, Fourquet A, Hortobagyi GN, Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. [Review] [142 refs]. Lancet 2006 Feb 18;367(9510):595-604. 19. Petrocca S, La TM, Cosenza G, Bocchetti T, Cavallini M, Di SD, et al. Male breast cancer: a case report and review of the literature. [Review] [39 refs]. Chirurgia Italiana 2005 May;57(3):365- 71. Abstract Only 106 Hospital 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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