deputy general secretory aphfta consultant surgeon apollo medical centre dar es salaam “we can”...
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Private sector in cancer treatment and advocacy
DR NAZIR ARABMB., MS., FCS
Deputy General Secretory APHFTA Consultant Surgeon
APOLLO MEDICAL CENTRE DAR ES SALAAM
“WE CAN” CANCER OUTREACH SUMMITDar Es Salaam September 11-1`3 2014
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What is CANCER ?Cancer in the Third World
Early 1990’s ?….. new cases / year diagnosedPresently ?……. new cases / year expected
>85 % OF CANCERS SEEN AT CANCER CENTERSACROSS THE COUNTRY ARE SEEN AT STAGE III & IV
Multifactorial Causes for Cancer and it’s LATE PresentationNutritionEducationSocio Economic conditionsHygiene
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2007 DataEst. Cases Est. Cases Est. Deaths Est. Deaths
Males Females Males Females
Worldwide 6.6 M 5.7 M 4.3 M 3.3 M
Developed Countries
2.95 2.5 1.65 1.27
Developing Countries
3.6 3.2 2.65 2.0
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Approaches to Cancer Control
Prevention
Screening
Organized Treatment
AIM : Reduction of Mortality Related to Cancer
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Summary of Preventive Measures• “Lifestyle Disease”
•Avoid cancer causing agents or take
adequate precautions – Tobacco, Alcohol,
Chemical industry
• Healthy diet contains anti-cancer
substances
• Regular exercise
• Those at high risk due to familial or
inherited traits should seek appropriate
advice and possibly get on to early screening
program
• Seek appropriate medical advice early in
case of persistent symptoms
symptoms
•Vaccines
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ScreeningWomen:Cervix- visual inspection, PAP, HPV testing
Breast – examination, mammography, MRI
Otherwise – routine USG abdomen, pelvis
Colon – stool examination, colonoscopyMen:Oral - visual inspection
Prostate – DRE, PSA, TRUS,
Lungs – chest X ray, CT scan
Colon – stool examination, colonoscopy
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Cancer Treatment: Historical ErasBefore 1850 Early heroic attempts to
resect cancer1850 – 1950 Development of standard
surgical resection techniques1950 – 1960 Extended radical surgical
procedures1960 – 1980 Exploration of combined-modality
treatment 1980 – 2000 Improved organ preservation/
survival: multimodality therapy2000-present Molecular-based therapy
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Management/Treatment How are they different?- assessment,
understanding biology of individual cancers, make overall plan to combine different modalities, surgery different, studies done worldwide show difference in results
What are the modalities? – Surgery, Chemotherapy, Radiotherapy, Hormonal therapy, Biological agents, Immunotherapy, Genetic engineering?
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Principles of Cancer Therapy
History Clinical Examination
InvestigationsStage Disease
Plan of Management i.e. multidisciplinary approachAssess operability
SurgeryPathology Report
PrognosisCarry out initial plan or
reassess plan
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Cancer care requires teamwork!Primary care physicianRadiologistSurgical Pathologist Surgical oncologist (all specialties)Reconstructive surgeon AnesthesiologistMedical oncologist (adult/pediatrics) . Radiation oncologistPsycho-oncologistRehabilitation specialistsOncology nurseOncology pharmacistFamily members
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Principles of Surgical Oncology
Radical operations : Tumour with clear marginsBlood supply of tumourLymphatics at least one station beyond those involved“en bloc” concept
Conservative operations :Excision of tumour with clear marginsSeparate removal of lymphaticsNOT at the cost of Local Control
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Principles of Surgical Oncology
Debulking operations :Effective adjuvant therapy for residual diseaseLeave minimal residual disease (<1-cm)For palliating a particular symptom
Palliative operations : Palliate a specific symptomRisk - Benefit to be weighed
Excision of Metastatic :Localised to one organ Disease Long disease free interval
Risk - Benefit to be weighed
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Colorectal - anatomy
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Laparoscopy in Cancers
New way of performing surgery training in cancer surgery as well as laparoscopy
Selection of patient important for good outcomeResults equivalent to “open” surgery.
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Role of Prophylactic Surgery
MEN 2a & 2b Medullary thyroid ca Total thyroidectomy at 6 yrs if RET protooncogene mutation
Barret’s Oeso Adeno Ca Oesophagectomy for high grade dysplasia
BRCA1/BRCA2 Breast Ca Mastectomy in selected patients
Ovarian Ca Oophorectomy after child bearing
Ulcerative Colitis Colon Ca Colectomy in dysplasia, >10 years with pancolitis, diagnosed at 20
FAP Colon Ca Colectomy in teenage yrs or earlier if polyps detected
HNPCC Colon Ca surveillance colonoscopy and polypectomy
Cryptorchidism Testicular Ca Orchidectomy for non palpable undescended testis, orchidopexy for most patients
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Training in Surgical OncologyFollowing post graduation in Surgical branch
(General Surgery, ENT, Gynecology, Orthopedics, Urology)
2-3 years fellowshipAnatomical (defined areas) or Disease
oriented (across tumor types)Technical skills, Cognitive skills,
Communication skills, learn to work in MDT
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Role of the Surgical Pathologist in the
Diagnosis and Management of the
Cancer Patient
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An accurate, specific and comprehensive Surgical Pathology report helps the clinician to develop an optimal plan of treatment and to estimate prognosis
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Surgical Pathology ReportGross descriptionDetails of the type and origin of the tumor, its
differentiation Level of invasionNumbers of lymph nodes with and without metastatic
tumorResection marginsIncorporating recommendations of AJCC/UICC for TNM
staging of tumorImmunohistochemistry findings as applicable Molecular pathology
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Immunohistochemistry: To detect antigens of Therapeutic or Prognostic Significance estrogen and progesterone receptors in
breast cancersprotein products of oncogenes such as HER-
2/neu in breast cancersantigens associated with tumor cell
proliferation such as Ki-67 to measure the tumor growth fraction
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Molecular PathologyTo detect expression of specific tumor genes or
gene mutations eg EGFR (Epidermal Growth Factor Receptor)in NSLC(Non Small Cell Carcinoma) lung and Her2neu in breast carcinomas.
This determines the effectiveness of targeted therapies like geftinib and erlotinib in lung cancer and Herceptin in breast cancer
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Tumor markers used in cancerB-HCG - choriocarcinoma
GCT of testis and ovary
AFP - Hepatic CCGCT
PLAP - Seminoma testis (75%)smokers increased
CEA - colonic cancer (Gold-Friedman1965)
many other malignanciesCA 125 ovary
endometriumCA 15-3 breastCA 19-9 pancreas
colonPSA prostateCalcitonin medullary carcinoma of
thyroidThyroglobulin well differentiated thyroid cancersUrinary 5-HIAA carcinoid tumors
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PET ScanFDG scanNot meant for routine screening or for diagnosisSometimes used for stagingSometimes used for finding primary site of tumorOften used in recurrence setting for knowing extent
of disease
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Post Orchidectomy & hormonal treatment
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TESTICULAR CARCINOMA WITH LUNG AND LYMPH NODAL
METASTASES
PRE-TREATMENT POST-
TREATMENT
DIAGNOSIS
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FDG PET/CT finds primary in primary in left maxillary sinus (reported as sinusitis on CT) and also distant metastasis in right subscapularis muscle.
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Facts- Breast Cancer/Culture81% of BC occur in women, age 50 and aboveCases have been on record of Ca in teens BC does not mean deathMammography/Stereotactic biopsy used for
screening Breast feeding may decrease the risk of BCCan run in families Once knifed spreads like wild fire Shy to talk for examinationNo lump or family history1/3rd BC have no risk factorsSBE
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Breast Self ExaminationLumps, thickening, dimples Visible abnormality of the skin Retraction of nipple Discharge from the nipple Lumps in underarmsCheck breast every month
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How Often & Draw BacksMonthly SBE is optional All women starting age 20Related with menstruationCompliance of pts – anxiety levelDrop outs
Needs Health education at all levels
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Prepare a visit to Doctor
1. GP/FP/AMO/MO2. SURGEON/PHYSICIAN3. What question to ask4. Misconceptions- age, no lump, no fmly
history Note 1/3rd Ca B. no risk factors, SBEPhysical exam/screening/Lab test/biopsySpread Local/Regional/Distant
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Signs and SymptomsNo signs Swelling in the armpit areaPain or tenderness in the breastLump in the breast , 1st appearance usually painless Flattening/ indentation ( tumor not seen) Contour texture or temperature Reddish/ pitted surface of skin (machungwa) change in the nipple- indrawn/ dimpled/ itchy/ burning
or ulceration Scaling/ulcer of the nipple (Paget's disease) localized
cancerNipple discharge- clear, bloody or other color
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FiguresHospital based cancer statistics to quantify cancer survival rate and gender1. First, most vulnerable to cancer - (30-50yrs) most
productive age.2. Second, cancer – gender in males -24% &
females76% in.3. Third, cure rates of highly curable cancers is very
low (14% for cervical and 15% for breast cancer)
Cure rate of stage I cervical cancer of 21% in Tanzania- too low. There is need to improve human capacity and cancer prevention, detection and treatment facilities.
Source: P Masaki & RE Lyimo ORCI
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Cervical Cancer at different stages
The Out come
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Cancer Stage
Outcome Rate Cancer Stage
Outcome Rate
Cured 21.1%
Cured 10.1%
ONE Dead 34.1%
THREE Dead 54.1%
Absconded 1.6% Absconded 0.0
Unknown 34.1%
Unknown 35.5%
Cured 18.8%
Cured 7.1%
TWO Dead 34.4%
FOUR Dead 70.6%
Unknown 46.8%
Unknown 22.4%
Source: P Masaki & RE Lyimo ORCI
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Early Stage – Low cure rate?DiagnosedTreatment – Surgical/Staging
- Onco pathologist - Chemotherapy/Radiotherapy
Follow up - Treated Locally
- Treated Abroad
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School/Community/Religious /Clubs/Society meetings
Personal Hygiene NutritionPeriodical Medical Physical examinationScreening by simple method i.e. spatula
examinationCommunity Trained Nurse for home visitCommunity health education programmesInclude non health Private sector, i.e.
Banks/Factories
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Challenges to Private HospitalPeriodical Screening programmePatients education/pamphlets/booklets/videosGroup Lectures on CancerDiagnostics Protocols Case discussion/Tumor board presentationTreatments Protocols
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ChallengesSeminars/Symposium/WorkshopsClinical meetings intra/inter hospitalInvolve in Scientific research Cancer society / annual conference etc. Internal referral systemReferral acrossTreatment plan and implementationFollow up
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Way forwardsCorporate Hospital/Private Cancer InstituteHR (Cancer Specialists)Monitored Data collection Private Medical Research CentersAuditing of data at private hosp.Auditing of treatment of ca pts resultInvolve Private Sector in Community PPP
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Public/GovernmentAccept oncology as a separate specialty –
forming a department in medical schools, undergraduate teaching, post graduate training
Education/Awareness creation in children and general public regard preventive measures
Screening for the “endemic” cancer in the population, use of vaccines
Facilitate training of personnel – abroad and locally
Insurance Setting up radiation oncology departments with
high quality equipmentNuclear medicine equipment with requisite
isotopes sourcing
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Private EnterpriseDiagnostic services – laboratory for tumor
markers, high quality histopathology with IHC and various molecular Biological studies
Radiation set upNuclear medicine set upStem Cell therpy Corporate hospitals PPP*
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PYSCHO-SOCIAL ISSUE
Severe anxiety – fear of the “unknown”
Sense of loss
Disfigurement
Sexual life
Loss of hair
Menopause
Fear of recurrence
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GOAL
Reduce MortalityMinimum MorbidityExtensive Rehabilitation Programmes
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LET US DISCUSSThank You