Centers of Excellence in Cancer BREAST CANCER DIAGNOSIS AND STAGING: A FRAMEWORK FOR PROGRESS
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1 Centers of Excellence in Cancer BREAST CANCER DIAGNOSIS AND STAGING: A FRAMEWORK FOR PROGRESS 1 Benjamin O. Anderson, M.D. Chair and Director Breast Health Global Initiative Fred Hutchinson Cancer Research Center Professor of Surgery & Global Health Medicine University of Washington Seattle, Washington
2 DIAGNOSIS AND STAGING Early Detection Tissue Sampling Cancer Staging 2
3 BREAST CANCER EPIDEMIOLOGY STAGE AT DIAGNOSIS: UNITED STATES VS. INDIA 3 STAGE EXTENT 5 year SURVIVAL DISTRIBUTION USA INDIA 0 Noninvasive 100% 16% ---- I II III IV Early stage disease 100% 40% 1% Early stage disease 86% 34% 23% Locally advanced 57% 6% 52% Metastatic disease 20% 4% 24% Sources: SEER Survival Monograph (NCI), 2007; Chopra, Cancer Institute Chennai, 2001 USA: 90% DCIS or early staged invasive disease at diagnosis INDIA: 76% locally advanced or metastatic at diagnosis 2014 BHGI. All rights reserved.
4 MAMMOGRAPHY SCREENING TRIALS BREAST CANCER MORTALITY REDUCTION 4 Nelson et al, Ann Intern Med 151:727, 2009
5 RANDOMIZED SCREENING TRIALS CANADIAN NATIONAL BREAST SCREENING STUDY BREAST CANCER SPECIFIC MORTALITY 5 Miller et al, BMJ 348:g366, BHGI. All rights reserved.
6 RANDOMIZED SCREENING TRIALS CANADIAN NATIONAL BREAST SCREENING STUDY 6 Miller et al, BMJ 348:g366, BHGI. All rights reserved.
7 CLINICAL BREAST EXAMINATION: CBE detects about 60% of mammo detected cancers WHAT DO WE KNOW? CBE finds some cancers not seen on mammography CBE necessary for any breast program, especially when ts present with advanced disease 7
8 Trivandrum Breast Cancer Screening Study (TBCS) Study design 275 clusters 115,652 women aged years 142 clusters 59,808 women Control group 133 clusters 55, women CBE once in 3 years x 3 rounds CBE +ve Triple Assessment Breast cancer cases Breast cancer deaths Breast cancer cases Breast cancer deaths Sankaranarayanan et al., J Natl Cancer Inst. 2011;103: In collaboration with Regional Cancer Centre (RCC), Trivandrum, India
9 Trivandrum Breast Cancer Screening Study (TBCS) Cumulative breast cancer incidence and mortality
10 DIAGNOSIS AND STAGING Early Detection Tissue Sampling Cancer Staging 10
11 LMC IMPLEMENTATION RESEARCH LOWER-MIDDLE INCOME COUNTRY Peru 11 Early Detection and Patient Triage
12 Breast cancer care model Regional Cancer Institute (Trujillo) Mammography Pathology Surgery Chemotherapy Radiotherapy La Fora Reference Hospital FNA Health Centers Community education CBE Photos courtesy of Ben Anderson Slide used with permission from
13 TISSUE SAMPLING OPTIONS FINE-NEEDLE ASPIRATION (FNA) VS. CORE BIOPSY FNA Low cost (<$5 per patient) Immediate result (20 minutes) Can be integrated into health system Requires expert cytologist for reading Core Needle Biopsy Histology services are mandatory in system High cost ($30-60 per single use needle) Delayed result (1 day to <1 month) 13
14 Peru Site Visit 2012 Public education about breast cancer and breast health
15 PLAN DE SUPERVISIÓN HOSPITAL REGIONAL DE LORETO JUSTIFICACIÓN OBJETIVOS METODOLOGÍA RESULTADOS INFORME Capacitación de proveedores clínicos (obstetrices y médicos) en ECM. El 1 y 2 de julio de 2011, un grupo de médicos y enfermeras de INEN, IREN Norte y PATH, asistió a un curso conjunto en ECM y BAAF celebrado en IREN-Norte. Donde ocho obstetrices de la Red de Salud de Pacasmayo y tres médicos del Hospital La Fora recibieron la formación en teoría científica, aplicación práctica y orientación de pacientes con respecto al ECM.
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19 BREAST CANCER ASSESSMENT LOW INCOME COUNTRY ` Rwanda 19 Early Detection Capacity Analysis
20 Tertiary HEALTH FACILITY OVERVIEW Anatomic pathology / Surgery Chemotherapy /hormonal therapy Radiotherapy(?) RWANDA, EAST AFRICA 4 Referral Hospitals Secondary Clinical Diagnosis Tissue Sampling Primary Clinical Breast Exam (CBE) Awareness Education 37 District Hospitals 402 Public Health Centers/Dispensaries 20 Source: MOH, 2009
21 21 Ultrasound: Kibagabaga Hospital
22 22 Dr. Ssendi Bwogi, Cytopathologist: CHUB
23 DIAGNOSIS AND STAGING Early Detection Tissue Sampling Cancer Staging 23
24 METRICS & QUALITY IMPROVEMENT Patient Factors Cancer STRUCTURE Resources (e.g. radiation) Coverage and reimbursement PROCESS Diagnosis and staging Cancer treatment Symptom management Surveillance OUTCOME Survival QOL Satisfaction 24
25 BHGI SYSTEMS METRICS 25 Cancer: 113 (8 suppl), 2008
26 BHGI SYSTEMS METRICS (2008) MEDIAN TUMOR SIZE (MTS) T is most fundamental element in TNM staging and is measured on clinical breast exam (CBE) MTS is surrogate measure of early detection success in healthcare delivery system MTS suggests early detection strategy: > 4 5cm: Awareness + CBE (no mammography) < 2cm: Image screening needed for down-staging 26 Harford, Cancer: 113 (8 suppl):2282, 2008
27 HOW DO WE DETERMINE STAGE? Staging is the process of determining how much cancer is in the body Staging is done both before and after a patient goes to operating room CLINICAL staging is pre-operative PATHOLOGIC staging is postoperative 27 SLIDE CREDIT: Gilles Erb, PhD
28 STAGING FOR BREAST CANCER = TNM AJCC-UICC Cancer 1989;63: AJCC= American Joint Committee on Cancer SLIDE CREDIT: Gilles Erb, PhD Cancer 1983;52: UICC= Union for International Cancer Control
29 BREAST CANCER FOUNDATION TNM STAGING 29 AJCC= American Joint Committee on Cancer SLIDE CREDIT: Gilles Erb, PhD UICC= Union for International Cancer Control
30 BREAST CANCER FOUNDATION TNM STAGING Early Stages Treating for Cure Metastatic Treating for Control 30 AJCC= American Joint Committee on Cancer SLIDE CREDIT: Gilles Erb, PhD UICC= Union for International Cancer Control
31 DIAGNOSIS AND STAGING SUMMARY Late-stage presentation is a fundamental obstacle to improving global breast cancer outcomes. Systematic approaches to make prompt, accurate cancer diagnoses is essential for cancer systems to work. Tissue sampling approaches with FNA and cytology can facilitate cancer patient triage. Cancer staging provides the necessary framework for determining cancer treatment as well as building cancer registration. 31
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