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Innovation and clinical specialities: oncology Table 3: Treatment and allocation of resources: stage I breast Cancer LOCAL-REGIONAL TREATMENT SYSTEMIC TREATMENT (ADJUVANT) Level of resource Surgery Radiation therphy Chemotherphy Endocrine therphy Basic Modified radical mastectomy Ovarian ablation Tamoxifen Limited Breast-conserving theraphy* Breast-conserving whole-breast Classical CMF** irradiation as part of breast-conserving therapy Postmasectomy irradiation of the chest wall and regional nodes for high-risk cases AC, EC or FAC** Enhanced Taxanes Aromatase inhibitors LH-RH agonists Maximal Sentinal node biopsy Growth factors Reconstructive surgery Dose-dense chemotherapy * Breast-conserving therapy requires mamography and reporting of margin status. ** Requires blood chemistry profile and complete blodd count (CBC) testing 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 and when used alone is a poor screening test. 60,61 Magnetic Resonance Imaging is a non invasive, non radiating imaging technique. In the process of evaluating MRI as a means of characterizing mammography abnormalities, additional breast lesions have been detected. However, in the circumstance of both a negative mammogram and a negative physical examination, the probability of a breast cancer being diagnosed by MRI is extremely low. There is current interest in using MRI to screen the breasts of high-risk women and of women with a newly diagnosed breast cancer. In the first case, women with a strong family history of breast cancer or who carry known genetic mutations require screening at an early age, but mammography evaluation is limited because of the increased breast density in younger women. In the second case, a study of MRI of the contralateral breast in women with a known breast cancer showed a contralateral breast cancer in 5.7% of these women. 62-64 Plain X-rays and Bone Scan are useful in the detection and diagnosis of metastasis especially to the bones. MRI, PET, CT Scans and bone scans are not readily available in most centers in the developing world, and when available, the cost of these procedures makes them virtually unrealistic for many of the patients. Ultrasonography and X-rays are however readily available and many patients will end up with these minimal investigations and the standard history and physical examination. Table 4: Treatment and allocation of resources: stage II breast Cancer LOCAL-REGIONAL TREATMENT SYSTEMIC TREATMENT (ADJUVANT) Level of resource Surgery Radiation therphy Chemotherphy Endocrine therphy Basic Modified radical mastectomy –* Classical CMF** Ovarian therapy AC, EC or FAC** Tamoxifen Limited Breast-conserving theraphy*** Breast-conserving whole-breast irradiation as part of breast-conserving therapy Postmasectomy irradiation of the chest wall and regional nodes for high-risk cases AC, EC or FAC** Enhanced Taxanes Aromatase inhibitors LH-RH agonists Maximal Sentinal node biopsy Growth factors Reconstructive surgery Dose-dense chemotherapy * Chest wall and regional lymph node irradiation substantially decrease the risk of postmastectomy local recurrance, if available it should be used as a basic level resource ** 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 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010 95
Innovation and clinical specialities: oncology Biopsy Pathologic diagnosis of a breast lesion can be achieved using a number of biopsy techniques. With a larger biopsy sample, greater accuracy and more information are obtained, but this is at the expense of increased invasiveness. Ideally, needle biopsies should be performed after imaging to help prevent distortions of imaging due to hematoma. The various needle biopsy techniques can be divided into two groups: ✚ 1. Fine needle aspiration will provide cytology which will allow a diagnosis of malignant cells but will not differentiate between in situ or invasive disease. ✚ 2. Tissue biopsy for histology which include Tru cut biopsy, Biopty cut, Mammotome. These relatively larger tissue samples will allow the diagnosis of invasive versus in situ cancer. Table 4 compares the accuracy of needle biopsy techniques. Open Biopsy (Excision or Incision biopsy) The ultimate diagnostic biopsy is open biopsy of a lesion, normally performed under general or local anesthetic. Open excisional biopsy should be reserved for lesions for which some doubt remains regarding diagnosis after less invasive assessment or for benign lesions that the patient wants removed. A wide clearance of the lesion is usually not the goal in diagnostic biopsies, thus avoiding unnecessary distortion of the breast. It is also useful for excision of mammographic lesions when percutaneous biopsy has failed or is equivocal. Where frozen section is available, open excisional biopsy may be performed at the same time the as definitive breast cancer surgery. Incisional biopsy is used only in cases where the lesion is very large and a percutaneous biopsy has been unsuccessful. Screening Annual screening mammography has been demonstrated to reduce breast cancer mortality among women older than 50 years by 20 –39%. The benefit in younger women is not yet established. For Caucasian women aged 40–49, the results of RCTs are consistent in showing no benefits at 5–7 years after entry, a marginal benefit at 10–12 years, and unknown benefit thereafter. This is primarily because when used as a screening tool, the detection rate per screened individual is lower because of denser breasts and an overall lower incidence. The controversy over the effectiveness of screening mammography among younger women (i.e., 40–49 years) has led to varying recommendations about its use for this age group. In patients with high risk factors a yearly mammography assessment from the age of 40 years is advisable. 65-67 Considering the younger demographic pattern of Breast Cancer in Africa, it is not clear what role screening mammography should have in Africa. Other methods of early breast cancer screening like Self Breast Examination and Clinical Breast Examination have not been demonstrated to improve mortality in patients; rather SBE has resulted in more breast biopsies due to false positive results, more physician visits and apprehension in patients 68 . It is pertinent to state that most of the studies that evaluated the role of SBE and CBE have been done in developed societies where cancers are small at diagnosis and this may not be relevant in Africa where the majority of patients present late. Incorporation of Breast Awareness programmes and health education into the Primary Health Care of African countries may very well be a useful option to allow for a diagnosis at an earlier stage. Cultural attitudes play important roles in the acceptance of screening programmes. 69 Treatment Treatment strategy will depend on the stage of the disease. In situ breast cancer (DCIS and LCIS) LCIS: Observation alone with or without tamoxifen is the preferred option for women diagnosed with LCIS because their risk of developing invasive carcinoma is relatively low (approximately 21% over 15 years) and is equal in both breast.. 70 Follow-up of patients with LCIS includes physical examinations every 6 to 12 months for 5 years and then annually. Annual diagnostic mammography is recommended in patients being followed with clinical observation. DCIS: Treatment options for DCIS are mastectomy, breastconserving surgery (BCS) plus radiotherapy or BCS alone. The goal of treatment for DCIS is to reduce local recurrence, because 50% of the time that DCIS recurs it recurs as an invasive cancer. Factors that may modify treatment are: ✚ the grade of the lesion, with higher-grade lesions more likely to recur in a short time; ✚ the youth of the patient, with many more years at risk for recurrence and ✚ the size of the lesion. For years the traditional surgical management of DCIS was mastectomy, with or without axillary dissection. Breast conservation technique and irradiation is now a preferred alternative where local breast radiation is available. Only small, low grade DCIS that has been excised with a large margin may be considered for BCS alone. Axillary lymph node staging is discouraged in women with apparent pure DCIS. However, a small proportion of patients with apparent pure DCIS will be found to have invasive cancer at the time of their definitive surgical procedure which will require a further axillary dissection. 71 Addition of Tamoxifen reduces the risk of developing contralateral breast cancer. 72,73 . Follow-up of women with DCIS includes a physical examination every 6 months for 5 years and then annually, as well as yearly diagnostic mammography. Early breast cancer (stages I and II or T1-3N0-1 M0): Staging for metastatic disease is standard for most patients diagnosed with early breast cancer and include a chest X-ray, bone scan and ultrasound of the abdomen. If negative, treatment intent is curative, and involve modalities that fight the cancer locally (surgery and radiation) and systemically (chemotherapy and endocrine therapy). Loco-regional treatment: Local treatment requires the treatment of the entire breast and the axillary lymph nodes with surgery, radiation, or a combination of both. Surgery can be breast conservation therapy (BCT) and axillary staging (SLNB or axillary dissection) or simple or total mastectomy with axillary staging (modified radical mastectomy). The surgical procedure for the excision of the breast in BCT goes by several names (Partial mastectomy, tylectomy, segmental resection, quadrantectomy or lumpectomy). The goal of breast-conserving surgery is to minimize the risk of local recurrence while leaving the patient with a cosmetically acceptable breast. The selection of BCT versus mastectomy depends on the size of the tumor relative to the rest of the breast 96 <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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Innovation and stategy: Acceleratin
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Innovation and strategy: infectious
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Innovation and strategy: infectious
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Page 119 and 120: Company Profile: Wipak Medical Wipa
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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
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How Can Health Organizations Get th
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