Breast cancer poses a significant burden in developing countries like Kenya. At Kijabe Hospital in Kenya, most breast cancer patients present with locally advanced disease and the median age of patients is younger than in Western countries. Treatment options are limited by costs and available resources. For poorer patients, treatment typically involves a mastectomy with adjuvant therapies if the tumor can be removed, while wealthier patients may receive breast conserving surgery and more comprehensive adjuvant treatment. Radiotherapy, an important part of breast conservation, is often not available locally and requires travel to Nairobi. Management strategies in low-resource settings must be tailored to the economic realities of individual patients.
Organ preservation in kenyan breast cancer patients by peter bird
1. Organ Preservation in Kenyan
Breast Cancer Patients
Mr Peter Bird FRACS, Kijabe Hospital
2. World Breast Cancer Burden
• Breast cancer is the second most common cancer in the world, most
common cancer in women
– Fifth cause of death from cancer overall
• 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers)
• Slightly more cases in less developed (883,000 cases) than in more
developed (794,000) regions
• Incidence rates vary nearly four-fold across the world regions
– Rates ranging from 27 per 100,000 in Middle Africa/Eastern Asia to 96 in
Western Europe
• The range in mortality rates between world regions is less than that
for incidence because of the more favorable survival of breast cancer
in (high-incidence) developed regions
– Mortality rates range from 6 per 100,000 in Eastern Asia to 20 per
100,000 in Western Africa
• More breast cancer deaths in LMICs than HICs
WHO IARC GLOBOCAN 2012
3. Estimated Breast Cancer Incidence Worldwide
WHO International Agency for Research on Cancer
GLOBOCAN 2012
Estimated age standardized rates per 100,000
4. Estimated Breast Cancer Mortality Worldwide
WHO International Agency for Research on Cancer
GLOBOCAN 2012
Estimated age standardized rates per 100,000
5. Kijabe Breast Cancer Study
2001-2007
• 125 female, 4 male between 2001 and 2007
• Excluded wazungu, non-IDC tumours
• Median age 47 (range 26-76)
• Mean parity 4.1
• Mean size of tumour (clinical) 6.8cm
• Average length of history – 12 months
• LABC 59%
Bird PA, Hill AG, Houssami N. Poor Hormone Receptor Expression in East African Breast
Cancer: Evidence of a Biologically Different Disease? Ann Surg Oncol., March 2008
6. Kijabe Breast Cancer Cases
2011-12
• 59 cases Jan 11 to Feb 12
• 48 IDC (NOS); 11 special types
• Median age 45
• 62.5% under 50yo
• LABC 48% 0
20
15
10
5
7.
8. Halsted’s Radical
Mastectomy Series
Ann Surg 1894
• 50 cases of radical mastectomy (not
consecutive?)
• Average age 51
• All 50 with nodal disease, so Stage II or III
• LABC 33/48 (68%)
• 27 of 50 (54%) prognosis regarded as
“hopeless or unfavourable” after surgery &
path assessment
• 6% local recurrence rate (“Return of the
disease in the field of operation”)
William Halsted 1852-1922
Halsted WS. The results of operations for the cure of cancer of the breast performed at the
Johns Hopkins Hospital from June 1889 to January 1894. Ann Surg 1894 Vol 20: 497-555
9. Halsted’s
Radical
Mastectomy
• Removal of skin,
breast, axillary
nodes to level III,
pectoralis muscles
• IM nodes not
removed
• Chest wall defect
skin grafted after
granulating
11. The Biology of Breast Cancer
Fisher’s Hypothesis:
Most, if not all, patients with breast cancer
have disseminated disease by the time a
clinical diagnosis is established; that is,
breast cancer is a systemic disease at
presentation and local therapies have no
influence on survival
Bernard Fisher 1918 -
"I cannot emphasize too strongly the fact
that internal metastases occur very early
in cancer of the breast, and this is an
additional reason for not losing a day in
discussing the propriety of an operation.“
W HALSTED 1894
12. The Biology of Breast Cancer
• Fisher’s hypothesis tested in multiple prospective RCTs
in early BC in High Income Countries
• Increased local recurrence in breast conserving surgery
compared to RM or MRM, but no difference in survival
in over 25 years of follow up
• Survival has improved with less surgery, because of
earlier diagnosis, and treatment with adjuvant
therapies, including RT to the chest wall
13. Treatment Options for
Breast Cancer
• SURGERY
– Breast conserving or mastectomy, with lymph node
examination (ALND or SLNB)
• CHEMOTHERAPY
– Before or after surgery. Anthracyclines, taxanes etc
• HORMONAL THERAPY
– SERMs, AIs, LHRH analogues, oophorectomy
• TARGETED BIOLOGICAL THERAPY
– Trastuzumab, new dual therapies very promising
• RADIOTHERAPY
– Teletherapy, brachytherapy, intraop RT (TARGIT trial)
14. Management of Breast Cancer
in Kijabe, Kenya
• Patients of highly variable economic status –
determines extent of surgery
• Breast conserving surgery and full adjuvant
therapies offered to wealthier patients with early
stage disease
• 30% BC pts last six months (9/30) cf. 10% in 2008 series
• Poor patients get mastectomy & AD alone if the
tumour can be macroscopically excised
• Wide excision on the chest wall helped by flap
coverage techniques, and often a Level III AD
15. Fifty-six Latissimus Dorsi
Myocutaneous Flaps at Kijabe Hospital
P Bird, 2000-2014
Indication Number
of cases
Pathology Complications Local recurrence
Coverage of anterior
chest wall defect
45 Breast
malignancy, soft
tissue sarcoma
3 minor flap-skin
dehiscences
2
Augmentation after
partial mastectomy
5 Breast cancer None 0
Delayed BR 3 Breast cancer Implant
Migration
N/A
Coverage of
posterior chest wall
defect
1 Recurrent soft
tissue sarcoma
None 0
Neck contracture 1 Burn 1 minor flap-skin
dehiscence
N/A
Immediate BR 1 Breast cancer None 0
24. Treatment Options for
Breast Cancer
• SURGERY
– Breast conserving or mastectomy, with lymph node examination
(ALND or SLNB)
• CHEMOTHERAPY
– Before or after surgery. Anthracyclines, taxanes etc
• HORMONAL THERAPY
– SERMs, AIs, LHRH analogues, oophorectomy
• TARGETED BIOLOGICAL THERAPY
– Trastuzumab, new dual therapies very promising
• RADIOTHERAPY
– Teletherapy, brachytherapy, intraop RT (TARGIT trial)
– Crucial part of BCS option!
25. Radiotherapy Resources
in Africa 2010
Kenya and Neighbours 8
Kenya 2 (Private 7)
Ethiopia 2
South Sudan 0
Somalia 0
Uganda 1
Tanzania 3
Population: 243 million
Australia (public) 33
Australia (private) 26
Population: 23 million
Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013
26. Radiotherapy Resources
in Africa 2010
Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013
27. Treatment Options and
Costs in Kijabe and Kenya
Mastectomy USD700
(At Kijabe)
Radiotherapy USD200
(Done at KNH. USD4-5000 in private facilities)
Chemotherapy USD1000
(Done in Nairobi)
Hormonal Rx USD650
(5 years of tamoxifen)
TOTAL USD2550
28. Ethiopia (92m)
Somalia (10m)
Kenya (44m)
South Sudan (11m)
Uganda (38m)
Tanzania (48m)
Annual GNI per Capita
2013
Rank
S Sudan $1120 139
Kenya $930 145
Tanzania $630 156
Uganda $510 162
Ethiopia $470 164
Somalia Unknown
Norway $102,610 1
Australia $65,520 4
USA $53,670 8
UK $39,140 18
30. Management of Breast Cancer
in Kijabe, Kenya
• Patients of highly variable economic status –
determines extent of surgery
• Breast conserving surgery and full adjuvant
therapies offered to wealthier patients with early
stage disease
• 30% BC pts last six months (9/30) cf. 10% in 2008 series
• Poor patients get mastectomy & AD alone if the
tumour can be macroscopically excised
• Wide excision on the chest wall helped by flap
coverage techniques, and often a Level III AD
31. Why are Breasts Important?
• Providing nourishment to our children
• Allowing strong bonding between mother
and child
• Having two maintains a healthy body image
• As a sexual organ in some (all?) cultures
32.
33.
34. Bathsheba at Her Bath
Rembrandt, 1654
“One evening
David got up
from his bed
and walked
around on the
roof of the
palace. From
the roof he
saw a woman
bathing. The
woman was
very
beautiful...”
2 Samuel 11:2
35.
36.
37.
38.
39. Breast Conservation Surgery
Loss of a breast causes significant
psychosocial damage, embarrassment
and loss of self-esteem. Breast
surgeons strive to preserve the breast
to keep the woman psychologically
healthy and socially confident
40. Breast Conservation Surgery
The best reconstructive option is no
reconstruction...perform breast
conserving surgery (BCS) when
ever possible!
57. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
58. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
59. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
60. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
61. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
62. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
63. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
64. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
65. Conclusions
• Unacceptable disparity of healthcare exists
between African countries and HICs
• Most BCs in Africa present locally advanced and
multidisciplinary treatment is unaffordable
• BC management in LMICs must be tailored to
best fit the economic circumstances
• Surgery is the mainstay of treatment in Kenya
and Kenyan surgeons need to be taught
techniques to meet this challenge