Breast Conservation Surgery; A new concept in Pakistan

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Breast Conservation Surgery A new concept in
Pakistan

• Dr. Arif R Khawaja
• FRCS (Ed),FRCS (Gen Surg)
• Consultant Surgical Oncologist,
• Shaukat Khanum Memorial Cancer Hospital and
  Research Centre, Lahore, Pakistan.

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Why Breast conservation ?

• How do you say goodbye to a breast? Ive had
  it for forty five years. I think Ill miss it.
  But I am playing it cool.
• it is more complicated than I thought. I
  wasnt going to be bothered by losing a breast. I
  am. I dont like how I look. I look amputated. I
  am different. I am a cancer patient. Will I ever
  be unaware of my chest?
• 
  Barb Sullivan
• My
  Broken Breast Book

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Difference from the West

• Incidence low (Probably 1 in every 40-50).
• Occurs in younger women.
• Histopathology more aggressive.
• Present late.
• Poor understanding of disease.
• Opinions sought from spiritual healers and
  homeopaths.
• Strong social taboos and lack of support.
• 1. Family pressure
• 2. Husband and in-laws attitude.
• 3. Negative ideas about treatment.
• Higher mortality due to late presentation.

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Breast Cancer in Pakistan

• Commonest malignancy. Between 1994-2004, 21 of
  all patients seen at our institution was Br Ca.
• 25 of all adult cancer
• 42 of all female malignancies.
• Family history is present in only 2.
• Median age is 42 years (range 19-77 yrs)
• 57 are premenopausal.

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Staging Classification of Breast Tumour
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Breast cancer 5 year survival rates (UK) by
stage at diagnosis
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Study Period

• June 2003 to May 2004
• n 64

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n 64
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n 64
No. of Patients
AGE GROUPS MENOPAUSE
Age PREMEUPAUSE 39 POSTMENOPAUSE 25
Range 24-65yrs Median 46yrs
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Tumor in different quadrants
15
04
20
11
03
02
07
02
LEFT
RIGHT
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QUADRANTS OF BREAST
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NO. of patients
TUMOR SIZE (cm)
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AXILLARY LYMPH NODE DISSECTION (ALND)

• RANGE 9 - 30
• MEDIAN 15

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METASTATIC AXILLARY NODES
No. of patients
No. of Lymph Nodes
Range 0-11 Median 01
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Histopathology
n64

• Lobular Ca 02
• DCIS 05
• IDC with
• lobular features 05
• IDC II 17
• IDC III 35

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HORMONE STATUS
Premenopausal n 39

• ER 12 (30)
• PR 12 (30)
• Her neu2 25 (62)

• ER - 27 (70)
• PR - 27 (70)
• Her neu2 - 14 (38)

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HORMONE STATUS
Postmenopausal n 25

• ER 16
• PR 16
• Her neu2 10

• ER- 9
• PR- 9
• Her neu2 - 15

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Follow up

• Follow up Mammogram n60
• Lost to Follow up n04
• Follow up Clinically n59
• Margin Positive n00
• Local recurrence n00
• Distant metastasis n05
• Death n02

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Pattern of Metastatic Disease
Pt No Age (yrs) Size (cm) L/N H/P ER PR Site of mets Out come
1 35 5 10/16 IDC III Neg Neg Lung Liver Alive
2 35 2.5 5/12 IDC III Neg Neg Brain Dead
3 35 4 8/9 IDC IV Neg Neg Lung Brain Dead
4 30 2 0/15 IDC II Neg Neg Lung Alive
5 45 3 9/9 IDCIII DCIS Neg Neg Bone Lung Alive
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CONCLUSION

• Breast conservation surgery followed by XRT is
  now an established and accepted surgical
  procedure in the management of early stage Br Ca
  all over .
• It is safe, cosmetically acceptable and easy to
  follow up.
• In Pakistan, it is still not considered to be an
  option by surgeons as there is a fear of local
  recurrence and poor follow up.
• By presenting a local study, it might be
  possible to convince colleagues and peers
  regarding its safety and may provide the
  confidence to offer patients an option of breast
  conservation in the management of this
  disfiguring disease.

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Closing Remarks

• As a surgeon, we may not be able to improve the
  quantity of life when a patient presents, but we
  can improve the quality of life of our patients.
• 4 out of 5 unmarried patients have been married
  or engaged or proposed!

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THANK YOU