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24 -cancer breast in Egypt dose it differ - DR Nazem Shams


									Breast Cancer in Egypt:
    Does it differ ?

     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
   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
   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

   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

   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
    History of Radical Mastectomy

   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

   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
   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
   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
   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
   Breast cancer in Egyptians is relatively
    advanced at the time of presentation with
    women frequently having large palpable
    tumors and frequent axillary nodal
   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
   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

   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-
    This may be attributed to many factors,
    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
    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
   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
Operative Technique
Radical Mastectomy
Risk Factors for Local Recurrence

   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

   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
Risk Factors for Local Recurrence

   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

   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

   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 Breast-
    Conserving 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

2000                                  Total Number
       RM   MR M      SM     L + AD
     R M (St I)                         2000
   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
                                        5 Year Survival

  Local Recurrence
                     Local Recurrence
                                                          Number of patients

   5 year
 survival (%)

     5 year



                                 Incidence of Local Recurrence in the three arms





       Total 5 year 5 year Contral Distant
      numbe survival survival ateral
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
                 Advantages of
               Radical mastectomy
   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
   Removes the entire breast and chest muscles,
    and leaves a long scar and a hollow chest
   Lymphedema (swelling of the arm), some loss
    of muscle power in the arm, restricted
    shoulder motion, and some numbness and
   Breast reconstruction is also more difficult.
                Disadvantages of
               Radical mastectomy
   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.
    Postoperative Complications Following Radical and Modified Radical
    Mastectomy. World J. Surg. 1, 207-211, 1977
                   Disadvantages of
                  Radical mastectomy
   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

   Nationalization of the treatment policy,
    according to the socioeconomic &
    epidemiologic standard.
Thank You

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