Organ Preservation in Kenyan Breast Cancer Patients

Mr Peter Bird FRACS, Kijabe Hospital

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

Estimated age standardized rates per 100,000

Estimated Breast Cancer Incidence WorldwideWHO International Agency for Research on Cancer

GLOBOCAN 2012

Estimated Breast Cancer Mortality WorldwideWHO International Agency for Research on Cancer

GLOBOCAN 2012

Estimated age standardized rates per 100,000

Kijabe Breast Cancer Study2001-2007

• 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

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

5

10

15

20

LABC, KESHO 2006 9

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”)

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

William Halsted 1852-1922

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

William Halsted operating at Johns Hopkins 1904

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

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

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)

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

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

NSIBR2

NSIBR1

NSIBR3

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!

Radiotherapy Resourcesin Africa 2010

Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013

Kenya and Neighbours 8

Kenya 2 (Private 7)Ethiopia 2South Sudan 0Somalia 0Uganda 1Tanzania 3

Population: 243 million

Australia (public) 33Australia (private) 26

Population: 23 million

Radiotherapy Resourcesin Africa 2010

Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013

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

Kenya (44m)

Somalia (10m)

Ethiopia (92m)

South Sudan (11m)

Uganda (38m)

Tanzania (48m)

Annual GNI per Capita 2013

Rank

S Sudan $1120 139Kenya $930 145Tanzania $630 156Uganda $510 162Ethiopia $470 164Somalia Unknown

Norway $102,610 1Australia $65,520 4USA $53,670 8UK $39,140 18

World Breast Cancer Burden

Harford J, Personal View, Lancet Oncol 2011

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

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

Bathsheba at Her BathRembrandt, 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

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

Breast Conservation Surgery

The best reconstructive option is no reconstruction...perform breast conserving surgery (BCS) when

ever possible!

PartialLD1

PartialLD2

PartialLD3

PartialLD4

PartialLD5

PartialLD6

PartialLD7

Margins in Stage I & II Breast Conserving Surgery

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

Margins in Stage I & II Breast Conserving Surgery

Moran et al Int J Radiation Oncol Biol Phys 2014

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

Kijabe, Kenya