Private sector in cancer treatment and advocacy

DR NAZIR ARABMB., MS., FCS

Deputy General Secretory APHFTA Consultant Surgeon

APOLLO MEDICAL CENTRE DAR ES SALAAM

“WE CAN” CANCER OUTREACH SUMMITDar Es Salaam September 11-1`3 2014

What is CANCER ?Cancer in the Third World

Early 1990’s ?….. new cases / year diagnosedPresently ?……. new cases / year expected

>85 % OF CANCERS SEEN AT CANCER CENTERSACROSS THE COUNTRY ARE SEEN AT STAGE III & IV

Multifactorial Causes for Cancer and it’s LATE PresentationNutritionEducationSocio Economic conditionsHygiene

2007 DataEst. Cases Est. Cases Est. Deaths Est. Deaths

Males Females Males Females

Worldwide 6.6 M 5.7 M 4.3 M 3.3 M

Developed Countries

2.95 2.5 1.65 1.27

Developing Countries

3.6 3.2 2.65 2.0

Approaches to Cancer Control

Prevention

Screening

Organized Treatment

AIM : Reduction of Mortality Related to Cancer

Summary of Preventive Measures• “Lifestyle Disease”

•Avoid cancer causing agents or take

adequate precautions – Tobacco, Alcohol,

Chemical industry

• Healthy diet contains anti-cancer

substances

• Regular exercise

• Those at high risk due to familial or

inherited traits should seek appropriate

advice and possibly get on to early screening

program

• Seek appropriate medical advice early in

case of persistent symptoms

symptoms

•Vaccines

ScreeningWomen:Cervix- visual inspection, PAP, HPV testing

Breast – examination, mammography, MRI

Otherwise – routine USG abdomen, pelvis

Colon – stool examination, colonoscopyMen:Oral - visual inspection

Prostate – DRE, PSA, TRUS,

Lungs – chest X ray, CT scan

Colon – stool examination, colonoscopy

Cancer Treatment: Historical ErasBefore 1850 Early heroic attempts to

resect cancer1850 – 1950 Development of standard

surgical resection techniques1950 – 1960 Extended radical surgical

procedures1960 – 1980 Exploration of combined-modality

treatment 1980 – 2000 Improved organ preservation/

survival: multimodality therapy2000-present Molecular-based therapy

Management/Treatment How are they different?- assessment,

understanding biology of individual cancers, make overall plan to combine different modalities, surgery different, studies done worldwide show difference in results

What are the modalities? – Surgery, Chemotherapy, Radiotherapy, Hormonal therapy, Biological agents, Immunotherapy, Genetic engineering?

Principles of Cancer Therapy

History Clinical Examination

InvestigationsStage Disease

Plan of Management i.e. multidisciplinary approachAssess operability

SurgeryPathology Report

PrognosisCarry out initial plan or

reassess plan

Cancer care requires teamwork!Primary care physicianRadiologistSurgical Pathologist Surgical oncologist (all specialties)Reconstructive surgeon AnesthesiologistMedical oncologist (adult/pediatrics) . Radiation oncologistPsycho-oncologistRehabilitation specialistsOncology nurseOncology pharmacistFamily members

Principles of Surgical Oncology

Radical operations : Tumour with clear marginsBlood supply of tumourLymphatics at least one station beyond those involved“en bloc” concept

Conservative operations :Excision of tumour with clear marginsSeparate removal of lymphaticsNOT at the cost of Local Control

Principles of Surgical Oncology

Debulking operations :Effective adjuvant therapy for residual diseaseLeave minimal residual disease (<1-cm)For palliating a particular symptom

Palliative operations : Palliate a specific symptomRisk - Benefit to be weighed

Excision of Metastatic :Localised to one organ Disease Long disease free interval

Risk - Benefit to be weighed

Colorectal - anatomy

Laparoscopy in Cancers

New way of performing surgery training in cancer surgery as well as laparoscopy

Selection of patient important for good outcomeResults equivalent to “open” surgery.

Role of Prophylactic Surgery

MEN 2a & 2b Medullary thyroid ca Total thyroidectomy at 6 yrs if RET protooncogene mutation

Barret’s Oeso Adeno Ca Oesophagectomy for high grade dysplasia

BRCA1/BRCA2 Breast Ca Mastectomy in selected patients

Ovarian Ca Oophorectomy after child bearing

Ulcerative Colitis Colon Ca Colectomy in dysplasia, >10 years with pancolitis, diagnosed at 20

FAP Colon Ca Colectomy in teenage yrs or earlier if polyps detected

HNPCC Colon Ca surveillance colonoscopy and polypectomy

Cryptorchidism Testicular Ca Orchidectomy for non palpable undescended testis, orchidopexy for most patients

Training in Surgical OncologyFollowing post graduation in Surgical branch

(General Surgery, ENT, Gynecology, Orthopedics, Urology)

2-3 years fellowshipAnatomical (defined areas) or Disease

oriented (across tumor types)Technical skills, Cognitive skills,

Communication skills, learn to work in MDT

Role of the Surgical Pathologist in the

Diagnosis and Management of the

Cancer Patient

An accurate, specific and comprehensive Surgical Pathology report helps the clinician to develop an optimal plan of treatment and to estimate prognosis

Surgical Pathology ReportGross descriptionDetails of the type and origin of the tumor, its

differentiation Level of invasionNumbers of lymph nodes with and without metastatic

tumorResection marginsIncorporating recommendations of AJCC/UICC for TNM

staging of tumorImmunohistochemistry findings as applicable Molecular pathology

Immunohistochemistry: To detect antigens of Therapeutic or Prognostic Significance estrogen and progesterone receptors in

breast cancersprotein products of oncogenes such as HER-

2/neu in breast cancersantigens associated with tumor cell

proliferation such as Ki-67 to measure the tumor growth fraction

 

Molecular PathologyTo detect expression of specific tumor genes or

gene mutations eg EGFR (Epidermal Growth Factor Receptor)in NSLC(Non Small Cell Carcinoma) lung and Her2neu in breast carcinomas.

This determines the effectiveness of targeted therapies like geftinib and erlotinib in lung cancer and Herceptin in breast cancer

Tumor markers used in cancerB-HCG - choriocarcinoma

GCT of testis and ovary

AFP - Hepatic CCGCT

PLAP - Seminoma testis (75%)smokers increased

CEA - colonic cancer (Gold-Friedman1965)

many other malignanciesCA 125 ovary

endometriumCA 15-3 breastCA 19-9 pancreas

colonPSA prostateCalcitonin medullary carcinoma of

thyroidThyroglobulin well differentiated thyroid cancersUrinary 5-HIAA carcinoid tumors

PET ScanFDG scanNot meant for routine screening or for diagnosisSometimes used for stagingSometimes used for finding primary site of tumorOften used in recurrence setting for knowing extent

of disease

Post Orchidectomy & hormonal treatment

TESTICULAR CARCINOMA WITH LUNG AND LYMPH NODAL

METASTASES

PRE-TREATMENT POST-

TREATMENT

DIAGNOSIS

FDG PET/CT finds primary in primary in left maxillary sinus (reported as sinusitis on CT) and also distant metastasis in right subscapularis muscle.

Facts- Breast Cancer/Culture81% of BC occur in women, age 50 and aboveCases have been on record of Ca in teens BC does not mean deathMammography/Stereotactic biopsy used for

screening Breast feeding may decrease the risk of BCCan run in families Once knifed spreads like wild fire Shy to talk for examinationNo lump or family history1/3rd BC have no risk factorsSBE

Breast Self ExaminationLumps, thickening, dimples Visible abnormality of the skin Retraction of nipple Discharge from the nipple Lumps in underarmsCheck breast every month

How Often & Draw BacksMonthly SBE is optional All women starting age 20Related with menstruationCompliance of pts – anxiety levelDrop outs

Needs Health education at all levels

Prepare a visit to Doctor

1. GP/FP/AMO/MO2. SURGEON/PHYSICIAN3. What question to ask4. Misconceptions- age, no lump, no fmly

history Note 1/3rd Ca B. no risk factors, SBEPhysical exam/screening/Lab test/biopsySpread Local/Regional/Distant

Signs and SymptomsNo signs Swelling in the armpit areaPain or tenderness in the breastLump in the breast , 1st appearance usually painless Flattening/ indentation ( tumor not seen) Contour texture or temperature Reddish/ pitted surface of skin (machungwa) change in the nipple- indrawn/ dimpled/ itchy/ burning

or ulceration Scaling/ulcer of the nipple (Paget's disease) localized

cancerNipple discharge- clear, bloody or other color

FiguresHospital based cancer statistics to quantify cancer survival rate and gender1. First, most vulnerable to cancer - (30-50yrs) most

productive age.2. Second, cancer – gender in males -24% &

females76% in.3. Third, cure rates of highly curable cancers is very

low (14% for cervical and 15% for breast cancer)

Cure rate of stage I cervical cancer of 21% in Tanzania- too low. There is need to improve human capacity and cancer prevention, detection and treatment facilities.

Source: P Masaki & RE Lyimo ORCI

Cervical Cancer at different stages

The Out come

Cancer Stage

Outcome Rate Cancer Stage

Outcome Rate

Cured 21.1%

Cured 10.1%

ONE Dead 34.1%

THREE Dead 54.1%

Absconded 1.6% Absconded 0.0

Unknown 34.1%

Unknown 35.5%

Cured 18.8%

Cured 7.1%

TWO Dead 34.4%

FOUR Dead 70.6%

Unknown 46.8%

Unknown 22.4%

Source: P Masaki & RE Lyimo ORCI

Early Stage – Low cure rate?DiagnosedTreatment – Surgical/Staging

- Onco pathologist - Chemotherapy/Radiotherapy

Follow up - Treated Locally

- Treated Abroad

School/Community/Religious /Clubs/Society meetings

Personal Hygiene NutritionPeriodical Medical Physical examinationScreening by simple method i.e. spatula

examinationCommunity Trained Nurse for home visitCommunity health education programmesInclude non health Private sector, i.e.

Banks/Factories

Challenges to Private HospitalPeriodical Screening programmePatients education/pamphlets/booklets/videosGroup Lectures on CancerDiagnostics Protocols Case discussion/Tumor board presentationTreatments Protocols

ChallengesSeminars/Symposium/WorkshopsClinical meetings intra/inter hospitalInvolve in Scientific research Cancer society / annual conference etc. Internal referral systemReferral acrossTreatment plan and implementationFollow up

Way forwardsCorporate Hospital/Private Cancer InstituteHR (Cancer Specialists)Monitored Data collection Private Medical Research CentersAuditing of data at private hosp.Auditing of treatment of ca pts resultInvolve Private Sector in Community PPP

Public/GovernmentAccept oncology as a separate specialty –

forming a department in medical schools, undergraduate teaching, post graduate training

Education/Awareness creation in children and general public regard preventive measures

Screening for the “endemic” cancer in the population, use of vaccines

Facilitate training of personnel – abroad and locally

Insurance Setting up radiation oncology departments with

high quality equipmentNuclear medicine equipment with requisite

isotopes sourcing

Private EnterpriseDiagnostic services – laboratory for tumor

markers, high quality histopathology with IHC and various molecular Biological studies

Radiation set upNuclear medicine set upStem Cell therpy Corporate hospitals PPP*

PYSCHO-SOCIAL ISSUE

Severe anxiety – fear of the “unknown”

Sense of loss

Disfigurement

Sexual life

Loss of hair

Menopause

Fear of recurrence

GOAL

Reduce MortalityMinimum MorbidityExtensive Rehabilitation Programmes

LET US DISCUSSThank You