bhgi learning lab 2009 pan arab

Benjamin O. Anderson, M.D.Benjamin O. Anderson, M.D.

Recent advances in breast surgery

Implications of resource limitations

Guideline implementation in LMCs

1980s: Breast Conservation Surgery1980s: Breast Conservation Surgery

1990s: 1990s: PercutaneousPercutaneous Needle BiopsyNeedle Biopsy

1990s: Sentinel Node Biopsy1990s: Sentinel Node Biopsy

2000s: 2000s: OncoplasticOncoplastic SurgerySurgery

RADICAL MASTECTOMYRADICAL MASTECTOMY MODIFIED RADICAL MASTECTOMYMODIFIED RADICAL MASTECTOMY

BREAST CONSERVING SURGERYBREAST CONSERVING SURGERY

BREAST CONSERVING RADIATION THERAPYBREAST CONSERVING RADIATION THERAPY

NSABP BNSABP B--06:06: Effect of Lumpectomy v. Mastectomy on RecurrenceEffect of Lumpectomy v. Mastectomy on Recurrence

DIS

TAN

T D

ISEA

SE-F

REE

SU

RVI

VAL

(%)

Cohort A Cohort B Cohort C

Total Mastectomy: 692/265 569/233 494/192Lumpectomy: 699/302 634/282 520/236

No. of patients / No. of recurrences

YEAR

Lumpectomy + XRT: 714/278 628/253 515/204

Fine needle aspirationsFine needle aspirations

Core needle biopsyCore needle biopsy

VacuumVacuum--assisted biopsyassisted biopsy

ExcisionalExcisional biopsybiopsy

Slavin, et al. Plast Reconst Surg 90:854, 1992.

SlavinSlavin, et al. , et al. PlastPlast ReconstReconst SurgSurg 90:854, 199290:854, 1992

KaurKaur et al., Ann et al., Ann SurgSurg OncolOncol: 12:1, 2005: 12:1, 2005

Retrospective review (European Institute of Oncology)Retrospective review (European Institute of Oncology)

Specimen Specimen VolumeVolume

Negative Negative MarginsMargins

Margin Margin WidthWidth

GROUP 1 (n=30) GROUP 1 (n=30) OncoplasticOncoplastic ResectionResection

200 cm200 cm33 25 / 3025 / 30 8.5 mm8.5 mm

GROUP 2 (n=30)GROUP 2 (n=30)Standard ResectionStandard Resection

118 cm118 cm33 17 / 3017 / 30 6.5 mm6.5 mm

ColombiaColombia

GlobocanGlobocan 2002 (IARC)2002 (IARC)

ColombiaUSA

BREAST CAIncidence: 101Mortality: 19Ratio: 19%

BREAST CAIncidence: 30.3Mortality: 12.5Ratio: 41%

2005 2020 2050

GlobocanGlobocan 2002 (IARC) 2002 (IARC) -- ColombiaColombia

GlobocanGlobocan 2002 (IARC) 2002 (IARC) -- ColombiaColombia

IndiaIndia

STAGE EXTENT 5 year SURVIVAL

DISTRIBUTIONUSA INDIA

0 Noninvasive 100% 16% ----

I Early stage disease 100% 40% 1%

II Early stage disease 86% 34% 23%

III Locally advanced 57% 6% 52%

IV Metastatic disease 20% 4% 24%

INDIA:76% locally

advanced or metastatic at

diagnosis

Sources: Sources: SEER Survival Monograph (NCI), 2007;SEER Survival Monograph (NCI), 2007;Chopra, Cancer Institute Chennai, India, 2001Chopra, Cancer Institute Chennai, India, 2001

USA:90% DCIS or early staged

invasive disease at diagnosis

GH

AN

A

Former British colonyFormer British colony

20 million population20 million population›› TwoTwo--thirds ruralthirds rural

Literacy: Literacy: ›› 76% male, 54% female76% male, 54% female

Life expectancy: Life expectancy: ›› 57 years of age57 years of age

›› ““Low levelLow level”” resourcesresources

3.6% HIV positive3.6% HIV positive

Komfo Anokye Teaching Hospital (KATH)Breast Health Center

Komfo Anokye Teaching Hospital (KATH)Patient with breast cancer (note visible tethering of patient’s right nipple)

Peace and Love Hospital (Kumasi Private Hospital)T2N1 – Stage II - breast cancer (typical presentation)

Peace and Love Hospital (Kumasi Private Hospital)T4N1Mx – Stage IIIB -- breast cancer (common locally advanced presentation)

Peace and Love Hospital (Kumasi Private Hospital)Recurrent breast cancer in axillary lymph node bed

Breast cancer invariably fatalBreast cancer invariably fatal

Cancer caused by social misbehaviorCancer caused by social misbehavior›› Oral / nipple contactOral / nipple contact

›› Dirty clothingDirty clothing

›› Wearing money in braWearing money in bra

Mastectomy leads to death within few yearsMastectomy leads to death within few years

The The Breast Health Global Initiative (BHGI)Breast Health Global Initiative (BHGI) strives to strives to develop, implement and study evidencedevelop, implement and study evidence--based, based, economically feasible, and culturally appropriate economically feasible, and culturally appropriate

guidelines for international breast health and guidelines for international breast health and cancer control for low and middle income cancer control for low and middle income

countries to improve breast health outcomes.countries to improve breast health outcomes.

Comprehensive guidelinesComprehensive guidelines by selected expert panelsby selected expert panels

Consensus opinionsConsensus opinions based on evidence reviewbased on evidence review

PublicationPublication of a) consensus and b) individual manuscriptsof a) consensus and b) individual manuscripts

Global Summit 2002: Global Summit 2002: Health Care DisparitiesHealth Care Disparities

Global Summit 2005: Global Summit 2005: Resource StratificationResource Stratification

Global Summit 2007: Global Summit 2007: Guideline ImplementationGuideline Implementation

PRIMARYPRIMARYPREVENTIONPREVENTION

HEALTHHEALTHSYSTEMSSYSTEMS

Basic level Basic level —— Core resourcesCore resources or fundamental services or fundamental services necessary for any breast health care system to function. necessary for any breast health care system to function.

Limited level Limited level —— SecondSecond--tier resourcestier resources or services that or services that produce major improvements in outcome such as survival.produce major improvements in outcome such as survival.

Enhanced level Enhanced level —— ThirdThird--tier resourcestier resources or services that are or services that are optional but important, because they increase the number optional but important, because they increase the number and quality of therapeutic options and patient choice. and quality of therapeutic options and patient choice.

Maximal level Maximal level —— HighestHighest--level resourceslevel resources or services used in or services used in some high resource countries that have lower priority on some high resource countries that have lower priority on the basis of extreme cost and/or impracticality.the basis of extreme cost and/or impracticality.

Cancer: 113 (8 Cancer: 113 (8 supplsuppl), 2008 ), 2008

CONSENSUS STATEMENTSCONSENSUS STATEMENTSEarly DetectionEarly DetectionDiagnosisDiagnosisTreatmentTreatmentHealth Care SystemsHealth Care Systems8 Stratified Tables8 Stratified Tables10 Individual Manuscripts10 Individual Manuscripts

EARLY DETECTION DIAGNOSIS

STAGE I STAGE II LOCALLY ADVANCED METASTATIC

HEALTH CARE SYSTEMS

““Health care guidelines do not improve Health care guidelines do not improve outcome unless they are implemented.outcome unless they are implemented.””

QUESTION:QUESTION: How can information be How can information be disseminated such that they are disseminated such that they are implemented and sustained within a implemented and sustained within a target country?target country?

Dissemination & implementation (D&I) research Dissemination & implementation (D&I) research

Education and training programs Education and training programs

Technology application and developmentTechnology application and development

IMPLEMENTATION STRATEGY: IMPLEMENTATION STRATEGY: Create Create BHGIBHGI Learning LaboratoriesLearning Laboratories in different parts of the in different parts of the world to develop and test educational modules world to develop and test educational modules based on BHGI guidelines and to model program based on BHGI guidelines and to model program expansion to other expansion to other LMCsLMCs..

HopeXchange Medical CenterOct 16, 2008, Kumasi

Breast Cancer Awareness MarchOct 16, 2008, Kumasi

HopeXchangeHopeXchange: Institute for Professional Training: Institute for Professional Training

Training in early detection, diagnosis and treatment Training in early detection, diagnosis and treatment adjusted for lowadjusted for low--income country resourcesincome country resources–– Curriculum based on BHGI GuidelinesCurriculum based on BHGI Guidelines

–– International faculty to teach and learnInternational faculty to teach and learn

D&I methodology applied inD&I methodology applied in--countrycountry

Educational outcomes assessed and reportedEducational outcomes assessed and reported

BHGI / HopeXchange Planning Team January 31, 2009, Kumasi

Ghana College of Physicians and SurgeonsGhana College of Physicians and Surgeons–– Paul Paul NyameNyame, MD, MD

KorleKorle--Bu Teaching HospitalBu Teaching Hospital–– JoeJoe--Nat CleggNat Clegg--LampteyLamptey, MD, MD

KomfoKomfo AnokyeAnokye Teaching Hospital (KATH)Teaching Hospital (KATH)–– Anthony Anthony NsiahNsiah--AsareAsare, MD / , MD / BaffourBaffour AwuahAwuah, MD , MD

Peace and Love HospitalPeace and Love Hospital–– Beatrice Beatrice WiafeWiafe, MD (Kumasi), MD (Kumasi)

Reach for RecoveryReach for Recovery–– Gladys Gladys BoatengBoateng

HopeXchangeHopeXchange Medical CenterMedical Center–– RiccardoRiccardo MassettiMassetti, MD / Mario , MD / Mario CappelloCappello

Ghana Breast Cancer Alliance (GBCA) meetingJanuary 30, 2009, Kumasi

ColombiaColombiaNational Early Detection ProgramNational Early Detection Program

Target: MiddleTarget: Middle--Income CountriesIncome CountriesBHGI Breast Early Detection Module (BSM):BHGI Breast Early Detection Module (BSM):–– Patient educationPatient education–– Screening (CBE + mammography)Screening (CBE + mammography)–– Diagnosis (imaging / tissue sampling / pathology)Diagnosis (imaging / tissue sampling / pathology)–– Triage to linked diagnosis and treatment programsTriage to linked diagnosis and treatment programs

Model early detection program for other middleModel early detection program for other middle--income regions of Latin America, Eastern Europe income regions of Latin America, Eastern Europe and Asia Pacific.and Asia Pacific.

Colombian National Early Detection ProgramNational Cancer Institute, Bogota (1934)

Readiness Assessment Tool Development ProjectNCI Director Meeting

Readiness Assessment Tool Development ProjectBHGI / NCI Research Team Meeting

Study Design

Health Care Centers RandomizationStratified by Insurance Plan

Intervention GroupEnroll 7,000 women

Control GroupEnroll 7,000 women

Training for primary care MDs, nurses, radiologists, technologists

and breast specialistsNo intervention in health care center

Screening based oncurrent clinical practices

Implement screening programIn health care center

Screening based oncurrent clinical practices

Screening mammogram with diagnosticFollow-up in women > age 50

Follow-up in one yearFollow-up in one year

Statistical Analysis

Clinical stageCancer incidenceEvaluation of participationCost assessmentAdverse effects

Informed consent

Technical skills training Clinical Breast Exam

Screening invitation, documentation,patient follow-up, quality control, etc

Outcome Variables

20 HMOs

Breast Cancer Screening TrialPublic (Regimen Contributivo) Health Care Center Visit

Mamografías en el estudio

PruebasMamografias Solicitadas 3627 100.0% 690 23.1%Mamografias Realizadas 2681 73.9% 386 55.9%

Intervenciòn Control

Instituto Nacional de Salud Publica (Instituto Nacional de Salud Publica (PublicPublic) ) FundacionFundacion Mexicana para la Salud (NGO)Mexicana para la Salud (NGO)

Major advances in breast surgery include breast Major advances in breast surgery include breast conservation surgery, needle sampling for conservation surgery, needle sampling for diagnosis, sentinel node biopsy and diagnosis, sentinel node biopsy and oncoplasticoncoplasticsurgerysurgery

Improvements in Improvements in LMCsLMCs require adaptation to require adaptation to existing resources and require coordination of existing resources and require coordination of surgery with other disciplinessurgery with other disciplines

Dissemination and implementation through Dissemination and implementation through BHGI Learning Laboratories can steer guideline BHGI Learning Laboratories can steer guideline application in application in LMCsLMCs

BHGI Executive Committee:BHGI Executive Committee:–– Gabriel N. Gabriel N. HortobHortobáágyigyi, Chair (MD Anderson), Chair (MD Anderson)–– Annetta Hewko (Komen for the Cure)Annetta Hewko (Komen for the Cure)–– Joe Harford (NCI Office of International Affairs)Joe Harford (NCI Office of International Affairs)BHGI Research Team:BHGI Research Team:

–– WenjinWenjin Li, Research ManagerLi, Research Manager–– David Thomas, Senior Research AdvisorDavid Thomas, Senior Research Advisor–– Gabrielle Kane, Curriculum SpecialistGabrielle Kane, Curriculum SpecialistBHGI Program Staff:BHGI Program Staff:

–– Leslie Sullivan, Senior Program ManagerLeslie Sullivan, Senior Program Manager–– Marisa Hartman, Program CoordinatorMarisa Hartman, Program Coordinator–– Sandra Sandra DistelhorstDistelhorst, Publication Editor, Publication Editor

Early Detection Panel 2007Early Detection Panel 2007–– ChengCheng--HarHar Yip, MD (Malaysia)Yip, MD (Malaysia)

–– Robert Smith, PhD (USA)Robert Smith, PhD (USA)

Diagnosis Panel 2007Diagnosis Panel 2007–– Roman Roman ShyyanShyyan, MD (Ukraine), MD (Ukraine)

–– Stephen Stephen SenerSener, MD (USA), MD (USA)

Treatment Panel 2007Treatment Panel 2007–– AlexandruAlexandru EniuEniu, MD (Romania), MD (Romania)

–– Robert Carlson, MD (USA)Robert Carlson, MD (USA)

Health Care Systems 2007Health Care Systems 2007–– Ed Ed AzavedoAzavedo, MD, PhD (Sweden), MD, PhD (Sweden)

–– Joe Harford, PhD (USA)Joe Harford, PhD (USA)

Cancer: 113 (8 Cancer: 113 (8 supplsuppl), 2008), 2008

ItalyItaly–– RiccardoRiccardo MasettiMasetti–– Alberto CostaAlberto Costa

EgyptEgypt–– SharifSharif OmarOmar–– Ahmed Ahmed ElzawawyElzawawy–– Mohamed Mohamed ShalanShalan

South AfricaSouth Africa–– Justus Justus ApffelstaedtApffelstaedt

TurkeyTurkey–– VahitVahit OsmenOsmen–– NuranNuran BeseBese

ColombiaColombia–– Carlos Carlos RadaRada–– Raul MurilloRaul Murillo–– Sandra DiazSandra Diaz

AustriaAustria–– RaimundRaimund JakeszJakesz

ArgentinaArgentina–– Eduardo Eduardo CazapCazap

LebanonLebanon–– NagiNagi El El SaghirSaghir

PakistanPakistan–– ZebaZeba AzizAziz

IndiaIndia–– RajRaj BadweBadwe–– KetayunKetayun DinshawDinshaw

Cancer: 113 (8 Cancer: 113 (8 supplsuppl), 2008), 2008

www.bhgi.info

bhgi learning lab 2009 pan arab

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