BREAST CANCER: PRESENTATION AND LIMITATION OF TREATMENT – BANGLADESH PERSPECTIVE Professor Saif Uddin Ahmed Professor of Surgical Oncology BSM Medical

BREAST CANCER: PRESENTATION BREAST CANCER: PRESENTATION AND LIMITATION OF TREATMENT AND LIMITATION OF TREATMENT

– BANGLADESH PERSPECTIVE– BANGLADESH PERSPECTIVE

Professor Saif Uddin AhmedProfessor Saif Uddin Ahmed

Professor of Surgical OncologyProfessor of Surgical Oncology

BSM Medical University, Dhaka-BSM Medical University, Dhaka-BangladeshBangladesh

BangladeshBangladesh Population-160milion, 50% are femalePopulation-160milion, 50% are female Illiteracy- 25% But 45% female population become Illiteracy- 25% But 45% female population become

illiterateilliterate Below Poverty level- 31%, Below Poverty level- 31%, Races-Races- 99% Same99% Same

1% Tribal1% Tribal Doctors: Population= 5/10000Doctors: Population= 5/10000 Nurses: Population = 2/10000Nurses: Population = 2/10000

Health Infrastructure-in Health Infrastructure-in BangladeshBangladesh

A. Primary

B. Secondary

A. Only for primary healthcare

B. Emergency / Routine surgery

done but- Tissue diagnosis, Mammography, Radiotherapy, Chemotherapy facilities are not available

C. Almost all facilities are available for diagnosis as C. Almost all facilities are available for diagnosis as well as treatment purposewell as treatment purpose

C. Tertiary Hospital

BSM Medical university

National Cancer institute

Data of breast cancer in Data of breast cancer in BangladeshBangladesh

Approxmately 22,000 women developed breast cancer every Approxmately 22,000 women developed breast cancer every year, many of them never seek treatment. About 70% died year, many of them never seek treatment. About 70% died without treatmentwithout treatment

Second most common cancer among women in BangladeshSecond most common cancer among women in Bangladesh

Died 70% without

treatment

Data-estimated by Govt.NGO,Social Survey 2003-2009

Data of Female Cancer-in Data of Female Cancer-in BangladeshBangladesh

Whole country (Approximately) Tertiary Hospital (BSMMU)

Type of MalignancyType of Malignancy %%

Breast CarcinomaBreast Carcinoma 2525

Cervical carcinomaCervical carcinoma 2121

Gastric carcinoma Gastric carcinoma 2020

HB & Pancreatic CancerHB & Pancreatic Cancer 99

Anorectal & Colonic Anorectal & Colonic Cancer GIST Cancer GIST

99

Other MalignanciesOther Malignancies 1616

Type of MalignancyType of Malignancy %%

Lung Carcinoma Lung Carcinoma 2525

Breast CancerBreast Cancer 2121

Cervical Cancer Cervical Cancer 2020

Oro-Facial Carcinoma Oro-Facial Carcinoma 77

Gastric Carcinoma Gastric Carcinoma 66

Other MalignanciesOther Malignancies 2121

Statistic of cancer 2009

Statistics of 2014

Clinical PresentationClinical Presentation

Literally and economically below averageLiterally and economically below average

• Bangladeshi female socially and religiously conservative

Clinical Presentation..Clinical Presentation..

Lump when 1Lump when 1stst identified already attains a big size identified already attains a big size

Clinical Presentation. . . . . Clinical Presentation. . . . .

Patient do not even know- SBE-Thought social harassmentPatient do not even know- SBE-Thought social harassment No facility to do it in house or pondNo facility to do it in house or pond

Clinical Presentation. . . . .Clinical Presentation. . . . .

After identification of lump-applied –hot After identification of lump-applied –hot compression, lime, herbal medicine, “neem compression, lime, herbal medicine, “neem patha” (a leaf that causes abscess formation)patha” (a leaf that causes abscess formation)


Some times lump in breast, it is assume to be a Some times lump in breast, it is assume to be a normal phenomena which will subsequently normal phenomena which will subsequently disappear, as a result patient do not attend disappear, as a result patient do not attend health worker or health centrehealth worker or health centre


Large group with nipple discharge along with lump Large group with nipple discharge along with lump ,to attend Quak (local so called doctor) – not for the ,to attend Quak (local so called doctor) – not for the tumour but for social and personel discomfort –tumour but for social and personel discomfort –applied neem patha –causes abscess formation, applied neem patha –causes abscess formation, with the idea that discharge from abscess will with the idea that discharge from abscess will reduce lumpreduce lump

As a result disease become advancedAs a result disease become advanced


Few patient present with axillary and supra Few patient present with axillary and supra clavicular lump, fungating mass with bleeding, clavicular lump, fungating mass with bleeding, disease already become advanceddisease already become advanced


About nipple retraction they try to protrude it by About nipple retraction they try to protrude it by application of “Jelly” for curative purpose but with application of “Jelly” for curative purpose but with time disease become progressedtime disease become progressed


The patient with Paget’s disease The patient with Paget’s disease often get treated by local doctors as often get treated by local doctors as eczema, keeping the cancer ignored eczema, keeping the cancer ignored


Some patient with lump attend to field workers Some patient with lump attend to field workers and quak (so called village doctor)-treated with and quak (so called village doctor)-treated with drugs (steroid or antibiotic)- no improvement. drugs (steroid or antibiotic)- no improvement. They are psychologically upset refusing any They are psychologically upset refusing any further treatment and ultimately found to have further treatment and ultimately found to have advanced canceradvanced cancer


Nipple discharge with crust formation-as a result Nipple discharge with crust formation-as a result of application of some antiseptic, and of application of some antiseptic, and subsequently sloughing out of nipple and areola, subsequently sloughing out of nipple and areola, resulting in an ulcer with loss of nipple and areolaresulting in an ulcer with loss of nipple and areola


Another group of patient – who presented with Another group of patient – who presented with recurrent lesion after excision of lump with no recurrent lesion after excision of lump with no histopathological examination report ,no prior histopathological examination report ,no prior FNAC or mammography. They are mostly treated FNAC or mammography. They are mostly treated in primary and secondary hospitalsin primary and secondary hospitals


A very Small number of patient found to present A very Small number of patient found to present with recurrence, after partial mastectomy done, with recurrence, after partial mastectomy done, they often have no axillary dissection and has they often have no axillary dissection and has ugly scarugly scar


In tribal population, tradition of application of hot In tribal population, tradition of application of hot water on a breast lump resulting in skin sloughing water on a breast lump resulting in skin sloughing and unhealthy ugly wound. when they finally and unhealthy ugly wound. when they finally reach health centre they diagnosed as breast reach health centre they diagnosed as breast cancercancer

Some tribal population do not consider a lump to Some tribal population do not consider a lump to be significant unless they are bigbe significant unless they are big

Clinical presentation Data-Clinical presentation Data-BSMMU, 2009 to 2014 BSMMU, 2009 to 2014

n=4153n=4153Homeopathe and Herbal >62%

Lump-Big size >82%

Nipple Discharge <4%

Nipple Retraction <5%

Fumigating, Regional lump >3%

After lumpectomy Recurrences >3%

After partial mastectomy <1%

Lack of diagnostic facilityLack of diagnostic facility

We also lack of facilities to diagnose malignancy We also lack of facilities to diagnose malignancy at primary and secondary level.at primary and secondary level.

We do not have histopathology, FNAC, We do not have histopathology, FNAC, Mammography at primary & Secondary levels and Mammography at primary & Secondary levels and many patient can not go to tertiary level hospitalmany patient can not go to tertiary level hospital

The investigations like receptor study, bone scan The investigations like receptor study, bone scan are expensive and not available below tertiary are expensive and not available below tertiary level hospital. So many patients cannot afford the level hospital. So many patients cannot afford the cost and go for much less expensive treatment.cost and go for much less expensive treatment.

Lack of Investigation…….

Limitation of treatmentLimitation of treatment We are We are treating huge number treating huge number of breast cancer of breast cancer

patient in our country,our many limitations within patient in our country,our many limitations within our capacityour capacity

We are treating properly to some extent , We are treating properly to some extent , only only tertiary level tertiary level hospital, not primary and secondary hospital, not primary and secondary level hospitallevel hospital

Our patient do not come to us early, as there is Our patient do not come to us early, as there is lack of awarenesslack of awareness

Limitation of treatment…Limitation of treatment…

Skill surgeon and oncologistSkill surgeon and oncologist

We also lack of skilled surgeons at any level & We also lack of skilled surgeons at any level & female surgeons are rarityfemale surgeons are rarity

Oncologists are also lacking , not sufficient even Oncologists are also lacking , not sufficient even in tertiary level & specialized centers.in tertiary level & specialized centers.

Limitation of treatment….Limitation of treatment….Cancer boardCancer board

Many patients who get wrong treatmentMany patients who get wrong treatment We lack a Cancer Board which is essential to We lack a Cancer Board which is essential to

provide a consensus plan of treatment for each provide a consensus plan of treatment for each patient – only “Cancer board” running in tertiary patient – only “Cancer board” running in tertiary hospital in capital city, Dhaka.hospital in capital city, Dhaka.

Limitation of treatment. . . . . Limitation of treatment. . . . .

Patient fail to understand the gravity and Patient fail to understand the gravity and importance of the situationimportance of the situation

They do not consider it to be a problem, as there They do not consider it to be a problem, as there is no painis no pain

Limitation of treatment. . . . .Limitation of treatment. . . . .

our culture and religion form a conservative our culture and religion form a conservative society where the women and the family are society where the women and the family are uncomfortable to see a male doctor for breast uncomfortable to see a male doctor for breast problem. Most of our surgeons are maleproblem. Most of our surgeons are male

Limitation of treatment. . . . .Limitation of treatment. . . . .

Many take homeopathic medicines and other Many take homeopathic medicines and other indigenous medicines as they are cheap and indigenous medicines as they are cheap and widely available and also financial constrains of widely available and also financial constrains of the poor people also inhibit to see a doctorthe poor people also inhibit to see a doctor

We have patients who have lumpectomy done by We have patients who have lumpectomy done by non-certified surgeon, and no histological non-certified surgeon, and no histological examination are performed and malignancy examination are performed and malignancy remain undiagnosedremain undiagnosed

Limitations....

Some patients are treated by certified surgeons Some patients are treated by certified surgeons with partial or incomplete mastectomy. A good with partial or incomplete mastectomy. A good axillary dissection is not achieved by most axillary dissection is not achieved by most surgeons because of the lack of training.surgeons because of the lack of training.

Limitations....

Breast conserving surgery rarely practice Breast conserving surgery rarely practice because of inadequate post-operative because of inadequate post-operative radiotherapy facilities and improper post-radiotherapy facilities and improper post-operative follow up.operative follow up.

Limitations....

Sentinel node biopsy is only possible in 2/3 Sentinel node biopsy is only possible in 2/3 centers, only capital city Dhaka, and frozen centers, only capital city Dhaka, and frozen section facilities only tertiary level hospitalsection facilities only tertiary level hospital

Limitations....

After Surgery, many women do not continue After Surgery, many women do not continue chemotherapy because of fear of side effects and chemotherapy because of fear of side effects and most importantly because of it high cost. most importantly because of it high cost.

Limitations...

Facilities for radiotherapy are also very less. Only Facilities for radiotherapy are also very less. Only 2/3 centers at private level hospital have proper 2/3 centers at private level hospital have proper machines and not many can avail this. Drugs are machines and not many can avail this. Drugs are not also available everywhere, found only medical not also available everywhere, found only medical college based city area and capital city Dhaka, college based city area and capital city Dhaka, BangladeshBangladesh

Limitations...

Many patients failed to avail timely treatment or Many patients failed to avail timely treatment or discontinue treatment as they are unable to discontinue treatment as they are unable to reach to political turmoil, road blockage, strikes reach to political turmoil, road blockage, strikes and natural calamities which are common and natural calamities which are common problems in Bangladesh problems in Bangladesh

Limitations...

Treatment Data BSMMU, Treatment Data BSMMU, Dhaka n=4153 Dhaka n=4153 (2009to2014)(2009to2014)

Simple Mastectomy with ADSimple Mastectomy with AD -- >80%>80% Breast Conservative SurgeryBreast Conservative Surgery -- <1%<1% Toilet Mastectomy Toilet Mastectomy -- >12%>12% Adjuvant Therapy Adjuvant Therapy -- >5%>5% Rehabilitation andRehabilitation and

palliative carepalliative care -- <2%<2%

Confused to visit where to Confused to visit where to gogo Quak, HerbalQuak, Herbal Female Female

practitionerpractitioner GynecologistGynecologist OncologistOncologist SurgeonsSurgeons

Lack of awareness about where to seek help or whom to report.Social and religious binding.Lack of facility.

Limitations….

Unavoidable AdviceUnavoidable Advice

They have advice from various person & shuttle They have advice from various person & shuttle between surgeon, oncologist, female doctors, are between surgeon, oncologist, female doctors, are available nearer to their homeavailable nearer to their home

Fear and rejection by their surroundings and families. Fear about-organ removal, side effects of CT/RT.

Limitations....

Protocol and ScreeningProtocol and Screening There is no national management protocol and There is no national management protocol and

screening programme in Bangladesh, to screening programme in Bangladesh, to perform standard unique treatment and to perform standard unique treatment and to detect early breast cancer.detect early breast cancer.

For screening cancer

Protocol and ScreeningProtocol and Screening… … BSMMU, the only medical University of the country, BSMMU, the only medical University of the country,

has adopted a surgical treatment protocol of breast has adopted a surgical treatment protocol of breast cancer, which has followed most of the hospital and cancer, which has followed most of the hospital and health center in our countryhealth center in our country

* Separate screening program – * Separate screening program – Institutional based- BSM Medical UniversityInstitutional based- BSM Medical University Wide based national- Pilot project- along with Wide based national- Pilot project- along with

cervical cancer program from 2009, combinedly.cervical cancer program from 2009, combinedly. I worked as “Focal point” – Breast Cancer I worked as “Focal point” – Breast Cancer

Screening ProgramScreening Program

Bangladesh Govt. UNFPA BSMMUBangladesh Govt. UNFPA BSMMU

Objectives-Objectives- To trained field worker, Nurses, Paramedics and To trained field worker, Nurses, Paramedics and

doctordoctor To Overcome religious and social bindingsTo Overcome religious and social bindings

Protocol and ScreeningProtocol and Screening

BSMMU started out door based awareness and BSMMU started out door based awareness and screening program for breast cancer detection as screening program for breast cancer detection as BREAST CLINIC, as a result, the number of early BREAST CLINIC, as a result, the number of early cancer detection is easier.cancer detection is easier.

EARLY DETECTION- BY SCREENING

1. SBE- During bath - Show in Video In front of mirror On lying condition2. CBE.

3.Referal system –primary → secondary → tertiary hospital

Increase Illiteracy Go to proper place Decrease Poverty Improve facility Overcome religious bindingRemoval of ignorance

Health Education Knowledge

Bangladesh Go Ahead

More green leaf vegetable.Breast feeding.Give up –smoking, alcoholism1st child before 30yrsBalance diet and exercise

Trained manpower

Acurate diagnostic facility or referral system.proper and adequare treatmentGovernment involvement along with NGO ,socio cultural organization

Counseling & psychological support Rehabilitation.

Documents

BREAST CANCER: PRESENTATION AND LIMITATION OF TREATMENT – BANGLADESH PERSPECTIVE Professor Saif Uddin Ahmed Professor of Surgical Oncology BSM Medical