9. NSABP B-06:
Effect of Lumpectomy v. Mastectomy on Recurrence
Cohort A Cohort B Cohort C
DISTANT DISEASE-FREE SURVIVAL (%)
YEAR
No. of patients / No. of recurrences
Total Mastectomy: 692/265 569/233 494/192
Lumpectomy: 699/302 634/282 520/236
Lumpectomy + XRT: 714/278 628/253 515/204
24. Retrospective review (European Institute of Oncology)
Specimen Negative Margin
Volume Margins Width
GROUP 1 (n=30)
200 cm3 25 / 30 8.5 mm
Oncoplastic Resection
GROUP 2 (n=30)
118 cm3 17 / 30 6.5 mm
Standard Resection
Kaur et al., Ann Surg Oncol: 12:1, 2005
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36. Recent advances in breast surgery
Implications of resource limitations
Guideline implementation in LMCs
37. Recent advances in breast surgery
Implications of resource limitations
Guideline implementation in LMCs
43. 5 year DISTRIBUTION
STAGE EXTENT
SURVIVAL USA INDIA
0 Noninvasive 100% 16% ---- USA:
90% DCIS or
early staged
Early stage
I disease 100% 40% 1% invasive disease
at diagnosis
Early stage
II disease 86% 34% 23%
Locally INDIA:
III advanced 57% 6% 52% 76% locally
advanced or
Metastatic metastatic at
IV disease 20% 4% 24% diagnosis
Sources: SEER Survival Monograph (NCI), 2007;
Chopra, Cancer Institute Chennai, India, 2001
44. Former British colony
20 million population
GHANA
› Two-thirds rural
Literacy:
› 76% male, 54% female
Life expectancy:
› 57 years of age
› “Low level” resources
3.6% HIV positive
47. Komfo Anokye Teaching Hospital (KATH)
Patient with breast cancer (note visible tethering of patient’s right nipple)
48. Peace and Love Hospital (Kumasi Private Hospital)
T2N1 – Stage II - breast cancer (typical presentation)
49. Peace and Love Hospital (Kumasi Private Hospital)
T4N1Mx – Stage IIIB -- breast cancer (common locally advanced presentation)
50. Peace and Love Hospital (Kumasi Private Hospital)
Recurrent breast cancer in axillary lymph node bed
51. Breast cancer invariably fatal
Cancer caused by social misbehavior
› Oral / nipple contact
› Dirty clothing
› Wearing money in bra
Mastectomy leads to death within few years
52. Recent advances in breast surgery
Implications of resource limitations
Guideline implementation in LMCs
53. Recent advances in breast surgery
Implications of resource limitations
Guideline implementation in LMCs
54. The Breast Health Global Initiative (BHGI) strives to
develop, implement and study evidence-based,
economically feasible, and culturally appropriate
guidelines for international breast health and
cancer control for low and middle income
countries to improve breast health outcomes.
55. Comprehensive guidelines by selected expert panels
Consensus opinions based on evidence review
Publication of a) consensus and b) individual manuscripts
Global Summit 2002: Health Care Disparities
Global Summit 2005: Resource Stratification
Global Summit 2007: Guideline Implementation
57. Basic level — Core resources or fundamental services
necessary for any breast health care system to function.
Limited level — Second-tier resources or services that
produce major improvements in outcome such as survival.
Enhanced level — Third-tier resources or services that are
optional but important, because they increase the number
and quality of therapeutic options and patient choice.
Maximal level — Highest-level resources or services used in
some high resource countries that have lower priority on
the basis of extreme cost and/or impracticality.
58. CONSENSUS STATEMENTS
Early Detection
Diagnosis
Treatment
Health Care Systems
8 Stratified Tables
10 Individual Manuscripts
Cancer: 113 (8 suppl), 2008
59. HEALTH CARE SYSTEMS EARLY DETECTION DIAGNOSIS
STAGE I STAGE II LOCALLY ADVANCED METASTATIC
60. “Health care guidelines do not improve
outcome unless they are implemented.”
QUESTION: How can information be
disseminated such that they are
implemented and sustained within a
target country?
61. Dissemination & implementation (D&I) research
Education and training programs
Technology application and development
IMPLEMENTATION STRATEGY: Create BHGI
Learning Laboratories in different parts of the
world to develop and test educational modules
based on BHGI guidelines and to model program
expansion to other LMCs.
66. HopeXchange: Institute for Professional Training
Training in early detection, diagnosis and treatment
adjusted for low-income country resources
– Curriculum based on BHGI Guidelines
– International faculty to teach and learn
D&I methodology applied in-country
Educational outcomes assessed and reported
71. Target: Middle-Income Countries
BHGI Breast Early Detection Module (BSM):
– Patient education
– Screening (CBE + mammography)
– Diagnosis (imaging / tissue sampling / pathology)
– Triage to linked diagnosis and treatment programs
Model early detection program for other middle-
income regions of Latin America, Eastern Europe
and Asia Pacific.
76. Study Design
Health Care Centers Randomization
20 HMOs
Stratified by Insurance Plan
Control Group Intervention Group Informed consent
Enroll 7,000 women Enroll 7,000 women
Training for primary care MDs,
nurses, radiologists, technologists Technical skills training
No intervention in health care center
and breast specialists Clinical Breast Exam
Screening based on Implement screening program Screening invitation,
current clinical practices In health care center documentation,
patient follow-up,
quality control, etc
Screening based on Screening mammogram with diagnostic
current clinical practices Follow-up in women > age 50
Follow-up in one year Follow-up in one year Outcome Variables
Clinical stage
Cancer incidence
Statistical Analysis Evaluation of participation
Cost assessment
Adverse effects
80. Major advances in breast surgery include breast
conservation surgery, needle sampling for
diagnosis, sentinel node biopsy and oncoplastic
surgery
Improvements in LMCs require adaptation to
existing resources and require coordination of
surgery with other disciplines
Dissemination and implementation through
BHGI Learning Laboratories can steer guideline
application in LMCs
81. BHGI Executive Committee:
– Gabriel N. Hortobágyi, Chair (MD Anderson)
– Annetta Hewko (Komen for the Cure)
– Joe Harford (NCI Office of International Affairs)
BHGI Research Team:
– Wenjin Li, Research Manager
– David Thomas, Senior Research Advisor
– Gabrielle Kane, Curriculum Specialist
BHGI Program Staff:
– Leslie Sullivan, Senior Program Manager
– Marisa Hartman, Program Coordinator
– Sandra Distelhorst, Publication Editor
82. Early Detection Panel 2007 Treatment Panel 2007
– Cheng-Har Yip, MD (Malaysia) – Alexandru Eniu, MD (Romania)
– Robert Smith, PhD (USA) – Robert Carlson, MD (USA)
Diagnosis Panel 2007 Health Care Systems 2007
– Roman Shyyan, MD (Ukraine) – Ed Azavedo, MD, PhD (Sweden)
– Stephen Sener, MD (USA) – Joe Harford, PhD (USA)
Cancer: 113 (8 suppl), 2008
83. Italy Turkey Argentina
– Riccardo Masetti – Vahit Osmen – Eduardo Cazap
– Alberto Costa – Nuran Bese Lebanon
Egypt Colombia – Nagi El Saghir
– Sharif Omar – Carlos Rada Pakistan
– Ahmed Elzawawy – Raul Murillo – Zeba Aziz
– Mohamed Shalan – Sandra Diaz
India
South Africa Austria – Raj Badwe
– Justus Apffelstaedt – Raimund Jakesz – Ketayun Dinshaw
Cancer: 113 (8 suppl), 2008
