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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 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 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 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 performed. 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 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 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 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 1382- 1386 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 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 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 recurrence. 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 4000 3000 2000 Total Number 1000 0 RM MR M SM L + AD 0 500 1000 1500 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 (%) (number) 5 Year Survival Local Recurrence Local Recurrence Number of patients RM CBS MRM Total number 5 year survival (%) 5 year survival (number) Contralateral breast affection Distant Metastasis LR 0 Incidence of Local Recurrence in the three arms 100 200 300 400 500 600 700 800 800 600 400 200 0 Total 5 year 5 year Contral Distant LR 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 treatment. 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 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 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 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 Nationalization of the treatment policy, according to the socioeconomic & epidemiologic standard. Thank You
"24 -cancer breast in Egypt dose it differ - DR Nazem Shams"