Transcript Document

Breast Cancer in Egypt:
Does it differ ?
By
Prof Dr; Nazim Shams
Prof of Surgical Oncology
Oncology Center - Mansoura University
Great thanks to
Dr; Omar Farouk
Assistant Lecturer of surgical oncology
Oncology Center- Mansoura University
&
Dr; Adel Fathi
Senior Resident of surgical oncology
Oncology Center- Mansoura University
For their help, and for the time and effort
through out this work.
Radical Surgery
Often the less there is to
justify a traditional custom,
the harder it is to get rid of it.
Radical Surgery
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The word radical has many meanings (radix means
root in Latin).
One of the meanings is "treatment directed to the
cause" or "going to the root of a process."
It also conveys the impression in cancer surgery of
the cancer being a growth with many roots, and
radical surgery removes those roots.
The word has undergone much the same evolution
in medicine as it has in politics; so while the word
radical originally referred to "getting at the root" of
the tumor, it now often refers to extreme surgery in
which large amounts of normal tissue are removed
along with the tumor; the opposite of conservative.
Radical Surgery
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The theoretical basis for radical surgery is that if you
remove both the primary tumor and the seeds of
metastasis in the adjacent lymph nodes, there
should be a better chance of curing the disease.
The most frequently used radical operation is radical
mastectomy: the removal of the breast and a large
amount of adjacent tissue including the largest chest
muscle and the lymph nodes in the arm pit (axillary
lymph nodes).
This eighty-year old operation is the treatment of
choice for "curable" breast cancer, regardless of the
type, location or stage of invasion.
History of Radical Mastectomy
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The radical mastectomy introduced by
Halsted was the treatment of choice for
breast cancer of any size or type,
regardless of the patient’s age, for 80
years.
Halsted WS. A clinical and histological study of certain adenocarcinomata of the breast: and
a brief consideration of the supraclavicular operation and of the results of operations for
cancer of the breast from 1889 to 1898 at the Johns Hopkins Hospital. Ann Surg
1898;28:557-76.
History of Radical Mastectomy
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The Halsted radical mastectomy, an en
bloc removal of the breast, muscles of
the chest wall, and contents of the
axilla, was the “established and
standardized operation for cancer of
the breast in all stages, early or late”
for most of the 20th century.
Bloodgood JC. Problems of cancer. J Kansas Med Soc 1930;31:311- 6.
History of Radical Mastectomy
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However, by the mid-1960s,
dissatisfaction with results after radical
mastectomy and anecdotal information
regarding other procedures led some
surgeons to advocate more extensive
surgery and others to promote more
limited operations.
Fisher B. The surgical dilemma in the primary therapy of invasive breast cancer:
a critical appraisal. Curr Probl Surg 1970;October:3-53.
History of Radical Mastectomy
 New
information about tumor
metastases also suggested that less
radical surgery might be just as
effective as the more extensive
operations that were being
performed.
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Idem. Laboratory and clinical research in breast cancer — a personal adventure: the David
A. Karnofsky Memorial Lecture. Cancer Res 1980;40: 3863-74.
History of Radical Mastectomy
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Veronesi comparing the Halsted radical mastectomy
with quadrantectomy, axillary node dissection, and
breast radiotherapy (QUART).
From 1973 to 1980, a total of 701 patients with
tumors <2 cm and clinically negative axillary nodes
were accessed; the mean time on study is 8 years.
No significant differences were apparent in
local/regional recurrence, relapse-free survival, or
survival.
Conservative treatment of breast cancer with the QU.A.RT. Technique. Umberto Veronesi,
Roberto Zucali and Marcella Del Vecchio World Journal of Surgery. Volume 9, Number 5 /
October, 1985
Breast Cancer in Egypt
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Breast cancer in Egyptians is relatively
advanced at the time of presentation with
women frequently having large palpable
tumors and frequent axillary nodal
involvement.
Mean size of tumor at presentation was
estimated by 4.5 cm in Egyptian studies.
Omar S, Khaled H, Gaafar R, Zekry AR, Eissa S, el-Khatib O. Breast cancer in Egypt: a
review of disease presentation and detection strategies. East Mediterr Health J. 2003
May;9(3):448-463
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This makes mastectomy rather than
breast conservative therapy a more
frequent line of surgery in our practice.
Neoadjuvant therapy is used so little to
increase breast conservation rates in
Egypt.
Adel Denewer, Ahmed Setit and Omar Farouk. Outcome of Pectoralis Major
Myomammary Flap for Post-mastectomy Breast Reconstruction: Extended
Experience World Journal of Surgery Volume 31, Number 7 / July, 2007 13821386
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This may be attributed to many factors,
including:
1. the lack of compliance of patients
especially rural Egyptian patients with
difficulty of follow up,
2. patient phobia of cancer with preference
of mastectomy rather than breast
conservation,
3. in addition the limited quality of resources
and equipments of radiotherapy with
relatively high cost.
Adel Denewer, Ahmed Setit and Omar Farouk. Outcome of Pectoralis Major
Myomammary Flap for Post-mastectomy Breast Reconstruction: Extended
Experience World Journal of Surgery Volume 31, Number 7 / July, 2007
1382-1386
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All these factors are changing the
breast conservation rate in Egypt,
which is 15% vs. 85% for
mastectomy in the same stage.
Adel Denewer, Ahmed Setit and Omar Farouk. Outcome of Pectoralis Major
Myomammary Flap for Post-mastectomy Breast Reconstruction: Extended
Experience World Journal of Surgery Volume 31, Number 7 / July, 2007
1382-1386
Operative Technique
of
Radical Mastectomy
Risk Factors for Local Recurrence
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When deciding between RM and BCT,
the main concerns for both the
physician and the patient are the
cosmetic outcome and the risk of local
recurrence in the preserved breast.
Risk Factors for Local Recurrence
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In view of the fact that local recurrence
is a distressing experience that—in
most cases—requires salvage
mastectomy, we should identify factors
associated with the increased risk of
recurrence.
Risk Factors for Local Recurrence
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The most important factors that are
thought to be associated with local
recurrence after BCT are as follows:
 young age (i.e. 35 to 40 years),
 infiltrating tumor with an extensive
intraductal component (EIC),
 vascular invasion,
 and microscopic involvement of the
excision margins.
Risk Factors for Local Recurrence
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As a consequence, many patients with
one or a combination of these factors are
offered RM instead of BCT.
The reason is that the risk factors for local
recurrence after BCT are assumed to play
no or a much less significant role in the
development of local recurrence after RM.
Risk Factors for Local Recurrence
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However, local recurrence is also seen
after RM, the risk being equal to or only
slightly smaller than that after
conservative surgery and radiotherapy
according to randomized clinical trials.
Adri C. Voogd, Maja Nielsen, Johannes L. Peterse, Mogens Blichert-Toft, Harry Bartelink,
Marie Overgaard. Differences in Risk Factors for Local and Distant Recurrence After BreastConserving Therapy or Mastectomy for Stage I and II Breast Cancer: Pooled Results of Two
Large European Randomized Trials. Journal of Clinical Oncology, Vol 19, No 6 (March 15),
2001: pp 1688-1697
Total Number
4000
3000
2000
Total Number
1000
0
RM
MR M
SM
L + AD
R M (St I)
R M (St IIA)
R M (St IIB)
M R M (st I)
M R M (st IIA)
M R M (st IIB)
S M (St I)
S M (St IIA)
S M (St IIB)
L + A D (St I)
L + A D (St IIA)
L + A D (St
2000
1500
1000
500
0
Number of patients
5 Year Survival
Local Recurrence
(number)
Local Recurrence
(%)
LR
Distant
Metastasis
Contralateral
breast
affection
5 year
survival
(number)
5 year
survival (%)
Total
number
Incidence of Local Recurrence in the three arms
CBS
MRM
RM
800
700
600
500
400
300
200
100
0
800
600
400
200
Total 5 year 5 year Contral Distant
numbe survival survival ateral
0
LR
CBS
29
58.6
17
0
9
4
MRM
620
56.4
35
12
188
51
RM
42
53.1
25
1
17
3
Advantages of
Radical mastectomy
Cancer can be completely removed if it
has not spread beyond the breast or
nearby tissue.
 Examination of the lymph nodes
specially level III provides information
that is important in planning future
treatment.
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Advantages of
Radical mastectomy
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The findings validate earlier 10-year follow-up
results showing no advantage from radical
mastectomy and fail to demonstrate a significant
survival advantage from removing occult positive
nodes at the time of initial surgery or from
radiation therapy.
Although the Halsted radical mastectomy procedure
is now outmoded, this pioneering trial began the
trend toward less extensive surgery and led to a
vast improvement in quality-of-life for women with
breast cancer.
Fisher B, Jeong JH, Anderson S, et al. (2002). Twenty-five-year Follow-up of a Randomized
Trial Comparing Radical Mastectomy, Total Mastectomy, and Total Mastectomy followed by
Irradiation Jonathan Gabor, N Engl J Med. 347(8):567-75.
Disadvantages of
Radical mastectomy
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Removes the entire breast and chest muscles,
and leaves a long scar and a hollow chest
area.
Lymphedema (swelling of the arm), some loss
of muscle power in the arm, restricted
shoulder motion, and some numbness and
discomfort.
Breast reconstruction is also more difficult.
Disadvantages of
Radical mastectomy
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When radical and modified radical
mastectomy have been compared, there has
been no significant difference in the ultimate
survival rate.
However, the associated deformities and
limitation of limb movement following radical
mastectomy appear to be greater, a fact
which favors modified radical mastectomy.
ZvI FEIGENBERG, MICHAEL ZER, and MOSHE DINTSMAN. Comparison of
Postoperative Complications Following Radical and Modified Radical
Mastectomy. World J. Surg. 1, 207-211, 1977
Disadvantages of
Radical mastectomy
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Among the late complications, the most
common and troublesome one is edema of
the upper limb, which has been shown to be
due to obstruction of both the superficial and
deep axillary lymph channels, obstruction of
the venous pathway being exceptional.
Say, C.C., Donegan, W.: A biostatistical evaluation of complications from mastectomy.
Surg. Gynecol. Obstet. 138:370, 1974
Haagensen, C.D.: The choice of treatment for operable carcinoma of the breast. Surgery
76:685, 1974
Recommendation
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Nationalization of the treatment policy,
according to the socioeconomic &
epidemiologic standard.
Thank You