WHY CANCER?WHY CANCER?

Ario Djatmiko Sub bagian Onkologi Bagian Bedah RS DR SOETOMO

Surabaya.

Health for all by the year Health for all by the year 2000 2000

Declaration of Alma Alta (1978)Declaration of Alma Alta (1978)

Health for all by the year Health for all by the year 2000 2000

Declaration of Alma Alta (1978)Declaration of Alma Alta (1978)

Primary Health Care an equitable distribution of health services. cultural and financial accessibility. epidemiological analysis that address the major health needs of community. community involvement in health decisions. a focus on prevention of diseases. the appropriate use of technology. a multicultural approach which recognizes the importance to a healthy community of adequate nutrition, education, employment, transport and housing.

Charter for Health Charter for Health Promotion Promotion

Ottawa (1986)Ottawa (1986)

Charter for Health Charter for Health Promotion Promotion

Ottawa (1986)Ottawa (1986)

Five area for action in health Five area for action in health promotionpromotion

Building healthy public policy.Building healthy public policy. Creating supportive environments.Creating supportive environments. Developing personal skill.Developing personal skill. Strengthening community action.Strengthening community action. Reorienting health services. Reorienting health services.

The philosophy of family physician describes The philosophy of family physician describes the the

role of general practitionerrole of general practitioner Care provider. Educator. Collaborator. Researcher. Controller/ evaluator.

Care provider within a care delivery system Care provider within a care delivery system that that

emphasis.emphasis. Responsibility. Accountability. Autonomy.

Health for all by the year 2000Health for all by the year 2000

Tujuan pelayanan kesehatan adalah menjaga dan meningkatkan kesehatan masyarakat, jadi fokus bukan mengobati penyakit.

Dokter umum / keluarga selalu berada ditengah masyarakat, merupakan kontak pertama setiap problem kesehatan yang timbul dimasyarakat. Rumah sakit / dokter spesialist hanya berfungsi supporting.

Hanya 15 % saja kasus-kasus (problem kesehatan) yang sebenarnya layak dirawat di RS atau dr Specialist, selebihnya (85%) seharusnya dapat ditangani dr umum / keluarga.

Dokter umum / keluarga harus mampu menjawab problema kesehatan masyarakat, dalam arti profesional, pengetahuan yang cukup dan trampil.

Membangun sistim rujukan yang baik, sehat dan transparant. Dokter umum / keluarga harus mampu melakukan professional control

pada rumah sakit / specialist rujukan, apakah sesuai standar prosedure, kualitas pelayanan, biaya? Dibangun jalur law enforcement.

Untuk kasus onkologi, peran dokter umum / keluarga > 80% dari seluruh rantai penangananan. Tidak seluruh perawatannya / follow up harus dilakukan oleh specialist.

Saat ini, keadaan terbalik: Fokus mengobati orang sakit. Health network belum terbentuk, pasien

membayar biaya kesehatannya sendiri, yang mampu langsung ke specialist. Akibatnya biaya kesehatan meningkat (medico-farmaco complex----medical abuse : biaya obat di Jakarta 43,63 %, dari total biaya pemeliharaan kesehatan, US 9,3 %).

Professional control tidak jalan. Penanganan holistik tak terjadi.

Hasil optimal penanganan kanker tak mungkin Hasil optimal penanganan kanker tak mungkin tercapai tanpa adanya health network yang tercapai tanpa adanya health network yang

baik, mengoptimalkan peran dokter baik, mengoptimalkan peran dokter umum/keluarga.umum/keluarga.

PERMASALAHAN:PERMASALAHAN: Angka kejadian penyakit kanker meningkat tajam. Ilmu pengetahuan berkembang pesat, harapan hidup

penderita kanker semakin baik bila ditangani dengan benar. 70 % penderita datang terlambat Stadium III – IV. Health network (jaringan pelayanan kesehatan) untuk

penanganan kanker secara holistik belum terbentuk. Keharusan mengikuti perkembangan ilmu untuk setiap

provider. Kenyataannya “professional education” untuk provider sangat

kurang.

Dokter umum/keluarga dan Rumah sakit/specialist seharusnya Dokter umum/keluarga dan Rumah sakit/specialist seharusnya merupakan partner yang ideal yang bertujuan sama :merupakan partner yang ideal yang bertujuan sama :

Memberi pelayanan yang memenuhi standar dan holistik serta Memberi pelayanan yang memenuhi standar dan holistik serta biaya yang rational dan terjangkau (cost containment).biaya yang rational dan terjangkau (cost containment).

““Saling mengingatkan”Saling mengingatkan”

Transformation of Diseases Transformation of Diseases PatternPattern

If : Infection DiseasesIf : Infection Diseases

CV : Cardio-Vascular DiseasesCV : Cardio-Vascular Diseases

Ca : CancerCa : Cancer

IfIf

CCVVCaCa

Medicine is the art of dealing Medicine is the art of dealing withwith

uncertaintyuncertainty

Moskowitz, 1988Moskowitz, 1988

The result of the The result of the treatmenttreatment

PatientCancer : stadiumgrade, type etc

Treatment

To<10 mminsitu

St I, II,IIIA

Advanced

Prolong survival

STADIUM AND PROGNOSIS

time

stage

Biologiconset

Preclinical diseaseUsual

diagnosis

Outcome

Detection by screening

Preclinicaldisease

inception

Symptomonset

TDLU (Terminal Duct Lobular Unit)

Wanita 41 tahun, tanpa keluhandikirim oleh dokter Jember untuk screening payudaraKlinis, taaMammography C5, dengan hook wireHasil PA: Insitu Ca ukuran 4 mm.

LOCALIZATIE

PROCEDURE

DCIS

Hook wire

KOS, 1998

Primary care physicians and specialist Primary care physicians and specialist must make a concerted effort to must make a concerted effort to educate their patients about the educate their patients about the

importance of regular mammograms.importance of regular mammograms.

Hillary Rodham ClintonA mother’s day message

(Oncology Time, vol XVII no 5/ May 1995)

Medicine is the art of dealing with uncertainty

Moskowitz, 1988

USAUSA(SOC of North America, 1994)(SOC of North America, 1994)

Female-29 years old complained thickness sensation in her left breast. Doctor : nothing wrong with her breast (PE).3 month later she got married and after 6 month pregnancy, she felt her left breast was getting bigger and harder.Hospital: Breast cancer in advanced stage.She died a month after having a baby.

Litigation: The doctor has been sentenced. Medical problem: misdiagnosed.

Diagnostic procedure? Can we exclude cancer based only on

physical examination?

SURABAYA, 2000SURABAYA, 2000 Female-45 years came with Female-45 years came with

clinically breast cancer clinically breast cancer T4N1M0 in the left breast.T4N1M0 in the left breast.11 month before she felt 11 month before she felt small lump in the left breast, small lump in the left breast, a GP send her to get USG and a GP send her to get USG and FNA, The result was Mastitis. FNA, The result was Mastitis.

She got medicine for a month, but there was no She got medicine for a month, but there was no improvement, FNA was repeated with result was improvement, FNA was repeated with result was still mastitis and the tumor was getting bigger, still mastitis and the tumor was getting bigger, after 9 months she came to KOS. Triple after 9 months she came to KOS. Triple Dx: Malignant.Dx: Malignant.The patient didn’t believe it, open biopsy: The patient didn’t believe it, open biopsy: Malignant.Malignant.

Problem: 11 months delay, late stadium.Problem: 11 months delay, late stadium.

Indonesia (Surabaya, Indonesia (Surabaya, 1997)1997)

Female-25 years old came to X Hospital with 2cm lump in the left breast. Without Imaging, surgeon send the patient to pathologist for FNAB, the result is positive adenocarcinoma.Surgeon performed mastectomy.The report of mastectomy specimen (other pathologist): Fibroadenoma no malignancy.

Problems: Legal aspect?

Did the surgeon follow right standard diagnostic procedure? How much is the value of FNA; Surgeon-pathologist communication?

Indonesia (Surabaya, 1991)Indonesia (Surabaya, 1991)

Female-23 years old with advanced breast cancer (local advanced + milliare metastase to the lung). She have been operated on by surgeon 8 months before. Surgeon : no serious thing - only small benign tumor without sending the specimen to pathologist.

She died 3 months after she came to our clinic.Problems:Diagnostic procedure?

Diagnostic Procedure PE RO LAB FNA

90%

COLLECTING DATA ERROR

ASSESSMENT

PLANNING

FINAL DIAGNOSTIC

(BIOPSY)

TREATMENT

FOLLOW UP

The arts of the treatment lies in The arts of the treatment lies in diagnostic proceduresdiagnostic procedures

Kanker payudara ?

Bagaimana sikap kita ? Apakah harus selalu berakhir dengan

kematian? Benarkah bisa disembuhkan? Apakah harus selalu kehilangan

payudara? Apakah kemajuan ilmu kedokteran

memberi harapan bagi penderita kanker payudara?

Apakah harus selalu berakhir dengan kematian?

Survival(perpanjangan hidup >5 tahun)

1920 20%

1930-40 50%

1970 70%

Saat ini tumor dini < 10 mm : 93 – 96 % dapat Saat ini tumor dini < 10 mm : 93 – 96 % dapat hidup sehat > 20 th ..... hidup sehat > 20 th ..... Peran skriningPeran skrining

1993, American cancer society:1993, American cancer society: Cancer is a curable diseasesCancer is a curable diseases

What is breast What is breast physician?physician?

General practitioner who has special General practitioner who has special training in breast problems.training in breast problems.

They must have:They must have: Proper knowledge.Proper knowledge. Appropriate skill.Appropriate skill. A Good medical record system.A Good medical record system. Network with regional breast unit.Network with regional breast unit.

The three level of cancer preventionThe three level of cancer prevention

Level of Level of preventionprevention goalgoal actionaction

PrimaryPrimaryReducing the incidence of specific cancer.

Health education & promotion, law enforcement (avoiding carcinogenic agent)

SecondarySecondaryReducing the mortality rate of specific cancer

Early detection and prompt treatment.

TertiaryTertiaryEnhancing the quality of life of cancer patients

Palliative treatment.

Type Of CancerType Of CancerAction Effectiveness Action Effectiveness

Primary LOPPrimary LOP Secondary LOPSecondary LOP Tertiary LOPTertiary LOP

SkinSkin ++ ++++ +

LungLung +++ + +

LeverLever ++ + +

CervixCervix ++ ++++ +

BreastBreast - +++ +

ST SarcomaST Sarcoma - ++ +

LeukemiaLeukemia - + +

Screening Screening IndicationIndication

High incidence of cancer.High incidence of cancer. Affect productive age.Affect productive age. Significance increase of survival Significance increase of survival

rate by screening.rate by screening.

The role of breast The role of breast physicianphysician

Active involve in all level of prevention.Active involve in all level of prevention. Health network.Health network.

building good & transparence referral building good & transparence referral system. system.

evaluating hospital performance.evaluating hospital performance. protecting patients from medical abuse or protecting patients from medical abuse or

malpractice, always concern with standard malpractice, always concern with standard operation procedure, quality of services and operation procedure, quality of services and cost. cost.

ValueValue BSEBSE BPBP MammoMammo

SensitivitySensitivity ± ++ ++++

SpecificitySpecificity ± ++ ++++

CostCost - + ++++

Procedure Procedure DifficultyDifficulty

- ++ ++++

SubjectivitySubjectivity ++++ ++ -

SizeSize > 2 cm >1,5 cm <1 cm

Breast screeningBreast screening

BSE: Breast self examination.BP : Physical Examination by Breast Physician The smallest tumor was detected at Klinik Onkologi Surabaya, 3 mm

The Role OfThe Role Of Primary LOPPrimary LOP Secondary LOPSecondary LOP Tertiary LOPTertiary LOP

PhysicianPhysician ++++ ++ ++++

HospitalHospital + ++++ ++

Lop: level of preventionLop: level of preventionGP involve in > 80 % of all LOPGP involve in > 80 % of all LOP

Cancer delay:Cancer delay: Patient delay + Doctors delay + Hospital delayPatient delay + Doctors delay + Hospital delay

Patients delay: Patients delay: • Lack of knowledge.• Economic problems.• Psychological barrier.• Misinformation.

Doctors delay :Doctors delay : • Lack of knowledge.• Lack of Network .

Hospital delay :Hospital delay : • Substandard quality services.• No Quality assurance.• Integrated delivery systems?

TUMORTUMOR(Adalah setiap pembesaran/ benjolan abnormal dalam

tubuh)

NON NEOPLASMANON NEOPLASMA ··KISTE

·RADANG ·HIPERTROPHIA ·HIPERPLASIA ·DISPLASIA ·METAPLASIA

NEOPLASMA :NEOPLASMA :

Adanya pertumbuhan dan diferensiasi abnormal akibat kerusakan gene pengaturnya

GANAS JINAK

PERBEDAAN NEOPLASMA JINAK DAN GANASPERBEDAAN NEOPLASMA JINAK DAN GANAS

NEOPLASMA JINAKNEOPLASMA JINAK A. GAMBARAN KLINISA. GAMBARAN KLINIS NEOPLASMA GANASNEOPLASMA GANAS

Adanya Tumor Keluhan Kosmetika

A.1 Keluhan Stadium dini :Tumor jinakMenyerupaiCaution/ patokan/ WaspadaStadium lanjut :VariabelTanda-tanda tumor infiltrasi gejala regional & metastase

Lambat (tahunan) Terbatas pada organ asal dan tidak mengganggu fungsi organ tersebut

A.2 Perjalanan Penyakit Progresive Umumnya lokal-Regional-metastase

Konsistensi Lunak/ padat, kenyal Tanda-tanda infiltrasi (-) Batas tegas/ teratur Tumbuh expansive Mobilitas baik Permukaan licin

A.3 PemeriksaanA.3.1 Fisik

Konsistensi padat, keras Tanda-tanda infiltrasi (+) Batas tak tegas/ tak teratur Mobilitas terbatas Tanda-tanda infiltrasi lanjut : * ulcus * perdarahan organ * retraksi kulit

NEOPLASMA JINAKNEOPLASMA JINAK A. GAMBARAN KLINISA. GAMBARAN KLINIS NEOPLASMA GANASNEOPLASMA GANAS

Well capsulated Struktur homogen Calsification (-)

A.3.2 Imaging Batas tak tegas Gambar infiltrasi stellate sign Struktur tidak homogen Micro Calsification

Capsul jelas Struktur jaringan homogen Nekrosis/ Ulcerasi (-)

Bentuk sel teratur Jaringan mempunyai gambaran homogen Hiperkromasi (-) Polikromasi (-)

B. HISTOPATOLOGIB.1 Makroskopis Capsul tak jelas

Infiltrasi Rapuh dan mudah berdarah Ada bagian-bagian yang retraktif

Pleiomorphic (+) Hiperkromasi (+) Polikromasi (+) N / C ratio mendekati 1 Struktur jaringan tak teratur (anaplasi)

PAPILOMA OR WART

PAPILOMA OF THE FACE

BENIGN NEOPLASTIC SKIN LESIONBENIGN NEOPLASTIC SKIN LESION

CONDYLOMAMOLLUSCUM CONTAGIOSUM

HAEMANGIOMA CAPILLARY

HAEMANGIOMA CAVERNOUS

(STRAWBERRY NAEVUS)

HAEMANGIOMA CAVERNOUS

MELANOTIC NAEVUS

(PIGMENTED MOLE)

KERATOACANTHOMA (MOLLUSCUM SEBACEUM)

CAVERNOUS HEAMANGIOMA

MALIGNANT SKIN LESIONMALIGNANT SKIN LESION

SQUAMOUS CELL CA

OF THE HAND

SQUAMOUS CELL CAOF THE EAR

BASAL CELL CARCINOMA

BASAL CELL CARCINOMA

OF THE FOREHEAD

MALIGNANT MELANOMA

MALIGNANT MELANOMAOF THE HEEL

MALIGNANT MELANOMA OF BIG TOE

A TYPICAL SQUAMOUS CARCINOMA

PRE & MALIGNANT SKIN PRE & MALIGNANT SKIN LESIONLESION

MALIGNANT MELANOMA

LENTIGO MALIGNANT LENTIGO

BOWEN'S DISEASE

PRE MALIGNANT LESIONPRE MALIGNANT LESION

LEUCOPLAKIA

NEUROFIBROMA

NEUROFIBROMATOSIS CAFE-AU-LAIT SPOTS

LEUCOPLAKIA

VARICOSE ULCER

LIPOMA OF THE HAND

LIPOMA OF THE NECK

CHORDOMA

BENIGN SOFT TISSUE BENIGN SOFT TISSUE TUMOURTUMOUR

NON NEOPLASTIC TUMOURNON NEOPLASTIC TUMOUR

MUCOUS CYST RHINOPHYMARANNULA DENTAL CYST

THYROGLOSSAL CYST

THYROGLOSSAL CYST

BRANCHIAL CYST EXCISED THYROGLOSSAL CYST

SEBACEOUS CYST

IMPLANTATION CYST

NON NEOPLASTIC TUMOURNON NEOPLASTIC TUMOUR

THE MIXED TUMOUR

CARCINOMA OF THE PAROTID

EXTENDED CARCINOMA

OF THE PAROTID

PAROTIS TUMOUR PAROTIS TUMOUR

PAROTIC GLAND PAROTIC GLAND TUMOURTUMOUR

MALIGNANT SOFT TISSUE MALIGNANT SOFT TISSUE SARCOMASARCOMA

FIBROSARCOMA

OSTEOSARCOMA OF THE UPPER END

OF THE HUMERUS

KAPOSI'S SARCOMA

SQUAMOUS CELL CA

OF THE TONGUE

SQUAMOUS CELL CA

IN AREA OF LEUCOPLAKIA

CARCINOMA OF THE CARCINOMA OF THE TONGUETONGUE

PAGET'S DISEASE

NIPPLE RETRACTIO

N

PEAU D'ORANGE

PEAU D'ORANGE

Signs of malignancy of the breastSigns of malignancy of the breast

Matur nuwunMatur nuwun