BREAST CANCER CARE IN RESOURCE CONSTRAINED REGIONS BBCC 2017 DHAKA. M.J.PAUL MS,DNB, FRCS (Glasg) Professor, Endocrine Surgery CMC Vellore, India

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1 BREAST CANCER CARE IN RESOURCE CONSTRAINED REGIONS BBCC 2017 DHAKA M.J.PAUL MS,DNB, FRCS (Glasg) Professor, Endocrine Surgery CMC Vellore, India

2 BREAST CANCER THE COMING WAVE

3 THE DEMOGRAPHIC CHANGE Increase in incidence Better nutrition earlier menarche Better education later marriage Reproductive choice later childbearing A small price to pay for the individual But a large effect on the population incidence.

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8 RECOMMENDATIONS AT 4 LEVELS Basic Limited Enhanced Maximal

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10 AWARENESS AND EARLY DIAGNOSIS Methods of raising awareness Printed, multimedia Press Public forums Awareness of benign conditions Awareness about cancer and therapy Issues of delayed presentation-ayush therapies & Alternative therapies

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12 SCREENING Approach to screening Age based vs risk based (online calculators) Opportunistic Should we advocate for screening or focus on awareness only Screening method Mammography selective screening for high risk groups and opportunistic screening Clinical exam by medical or paramedical Prototype model to train health workers for cancer screening in the community Self breast exam raises awareness

13 SCREENING Who needs a mammogram? Gail model risk calculator Risk of genetic mutation BRCA? U.Penn calculator Self examination? Reporting symptoms early Treatment is effective and not so difficult The Penn II BRCA1 and BRCA2 Mutation Risk Evaluation Model Official Web Site

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15 BREAST CLINIC Clinic facility One stop service difficult and expensive to set up Two visits better to allow time for better diagnostics and counseling Diagnostic services Mammography, Ultrasound, role of MRI Stereotactic biopsy, Wire localization FNAC vs Core strategy IHC : ER/PR/HER2/Ki-67 Genetic diagnostics and counselling

16 TEAM MEMBERS IN RADIATION AND MEDICAL ONCOLOGY, RADIOLOGY AND PATHOLOGY. PLASTIC SURGERY, PALLIATIVE CARE, PHYSIOTHERAPY, BREAST CARE NURSING Multidisciplinary group for care and research in institutes Cluster of disciplines in individual practice

17 BREAST CARE NURSING Role of breast care nurse in the clinic Counselling for benign breast disease Awareness of breast cancer risks Explaining therapy protocols Perioperative wound and drain care Lymphedema prevention Radiation supportive care Chemo supportive care Coordinating support groups Health record maintenance for follow up and research

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20 SURGICAL SERVICES Diagnostic procedures wire localization Therapeutic Benign excisional, cosmetic Breast conservation / Level 1 and 2 oncoplasty Mastectomy and axillary dissection Sentinel node biopsy single / dual technique Reconstructive surgery breast /plastic surgeon Adjunctive chemoport placement Care for wound, seroma, infections, drainage, debridement

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22 CONSERVATION! SHOULD BE PATIENT DRIVEN Mosche Shein -complications

23 LEVEL 1 ONCOPLASTY Mobilize breast pillars Wide local excision For large area of DCIS Wide local excison 7 cm sectoral DCIS + INVASIVE Mobilization of breast pillars

24 LOCAL RECURRENCE INFILTRATING CHEST WALL EXCISION OF INVOLVED MUSCLE AND RIBS

25 LATISSIMUS DORSI MUSCLE FLAP AND SKIN GRAFT

26 12 years after excision of local recurrence Osteoradionecrotic Chip of rib extruding Three rib excision with mesh and LD flap reconstruction

27 FUNGATING CANCERS Treat infection Systemic therapy Palliative mastectomy Vacuum assisted closure Delayed skin grafting.

28 LYMPHEDEMA LOCAL DATA *CMC study 25.2% at one year follow up More than 2 cm increase in girth of limb Gupta S, Paul MJ et al Ind J Surg Onc 2017

29 Trial with Isosulphan blue Too expensive needs import Allergic reactions reported Node Lymphatic Channel

30 Massage 4-5 min! Methylene blue only technique for SLNB

31 SITE OF INJECTION OF THE DYE IN ARM TECHNIQUE IN PATIENTS WITH EARLY BREAST CANCER IN DEPT OF ENDOCRINE SURGERY AT CMC VELLORE Lymphatic channel and arm lymph node detected with methylene blue in patients with early breast cancer, in the ARM study at CMC Vellore AXILLARY REVERSE MAPPING

32 Usha Jesudason Writer Two Journeys

33 PATIENT SUPPORT GROUP Breast Group formed by the Departments of Radiation Oncology, Endocrine Surgery, Medical Oncology, Palliative care, Lifestyle Medicine, Dietary services and Orthotic centre.

34 THANK YOU