CANCERS AMONG

FEMALE: “Focusing on

Breast Cancer”

Manuaba Tjakra Wibawa

Department of General Surgery.

School of Medicine. University of Udayana

Denpasar. Bali. Indonesia

Five most common Cancers in

Women in Bali (Pathological Based, 2017)

▪Breast Cancer▪Cervix Cancer

▪Thyroid Cancer

▪Skin Cancer (non melanoma)

▪Colo-Rectal Cancer

BREAST CANCER IN BALI

Facts about Breast Cancer in

Indonesia/ Bali

▪No 1 Cancer among female

▪Affecting “younger population”

▪Majority came at “advanced stages”

▪No population based “mass screening program”

available

▪Surgeries, often became “adjunct” to Chemotherapy

▪Different surgical standards → General Surgeons,

Breast Surgical Oncologist, and Breast Surgeons

▪Advanced Stages → high cost with little results

▪Expensive Molecular Technologies → No Standard

Tissue Fixation, IHC, FISH/ CISH, Genes Profiling,

Facts about Breast Cancer and

Pregnancy in Bali

▪ 25% of Breast Cancer Population were 40 years or less

▪ 52% of our Breast Cancer Population were less than 45 years (data from 2014 up to April 2018)

▪ Risk of pregnancy

▪ No structured or regular public education about cancer in general or specifically about Breast Cancer and pregnancy even in breast cancer patients

▪ Patient information collected most of the time lack of “children’s information” such as number, ages of the youngest child → “we never ask”

▪ Pregnancy in Breast Cancer (PABC) mostly discovered by accident or from patient history

PABC CHARACTERISTICS IN SANGLAH

GENERAL HOSPITAL 2015-2017 (N: 17)

Variable n %Primary Tumor Size T1 1 5.9%

T2 3 17.6%T3 3 17.6%T4 10 58.8%

Node N0 4 23.5%N1 5 29.4%N2 5 29.4%N3 3 17.6%

Metastasis M0 13 76.5%M1 4 23.5%

Stage Stage I 1 5.9%Stage II 3 17.6%Stage III 9 52.9%Stage IV 4 23.5%

Subtype Luminal A 0 -Luminal B 8 47.1%Her2 Type 2 11.8%TNBC 4 23.5%Unknown 3 17.6%

Three years PABC in our Institution

(2015-2017. N: 17)

▪From 17 PABC patients:

▪Mean Age 33.47 ± 6.414 years

▪Youngest Age 24 years old

▪Oldest Age 44 years old

▪OS was 53.3 ± 27.4 months (Median observation 45.6 months)

▪DFS was 54.8 ± 27.9 months (Median observation 51.4 months)

▪No patient was referred by Colleagues OBGYN

EPIDEMIOLOGY

Epidemiology of Breast Cancer in

Indonesia

▪No Population Based Tumor Registry

available in Indonesia or Bali

▪Data from Hospital Based (Single Central

General Hospital Bali) about 250 -350

patients per year (under reported) → due to

health coverage →“government policy”

Number Of Cases per Year(Bali/ University of Udayana)

6762

91

125

106

99

91

N = 642

2005

2006

2007

2008

2009

2010

2011

Number Of Cases per Year(Bali/ University of Udayana)Data Tahun(2014-2018)

Tahun 2014 Tahun 2015 Tahun 2016 Tahun 2017 Tahun 2018

188

266

357

320

58

N= 1189

Tahun 2014 Tahun 2015 Tahun 2016 Tahun 2017 Tahun 2018

Age Distribution (2014-2018)(Bali/ University of Udayana)

Series1

<2020-30

31-3536-40

41-4546-50

51-5556-60

>60

121

61

110

233 241

212

155155

N=1189

Median Age of Breast Cancer Patients

2003-2007

Heri Susilo, 2008

Perbedaan Stadium Penderita

Selama Tahun 2003 - 2007

Heri Susilo, 2009. Subdivision of Surgical Oncology, UNUD

DATA JUMLAH PASIEN KANKER PAYUDARA MENURUT

STADIUM TAHUN 2012 – 2013 (n = 273)

0

10

20

30

40

50

60

70

80

90

I IIA IIB IIIA IIIB IIIC IV

Jum

lah

Stadium

STAGE(DENPASAR. 2014-2018). N = 1172

0.10%

2.90%

14.50% 14.50%

12.10%

30.30%

2%

22.80%

0.80%

Stadium 0 Stadium I Stadium IIA Stadium IIB Stadium IIIA Stadium IIIB Stadium IIIC Stadium IV Undefined

Series1

Breast cancer Subtypes (2004 – 2014)

Period

Breast Cancer Subtypes

n Total (%) n/N

Luminal A

n (%)

Luminal B

n (%)

Her-2 Type

n (%)

TNBC

n (%)

2004-2007

N = 284

8 (44.44%) 2 (11.11%) 1 (5.56%) 7 (38.89%) 18 (100%) 6.34%

2008-2011

N = 471

44 (37.29%) 9 (7.63%) 19 (16.10%) 46 (38.98%) 118 (100%) 25.05%

2012-2014

N = 344

37 (31.36%) 27 (22.88%) 30 (25.42%) 24 (20.34%) 118 (100%) 34.30%

Breast cancer Subtypes (20015 –2018)

Period

Breast Cancer Subtypes

n Total

(%)

n/N

Luminal

n (%)

Luminal

A

n (%)

Luminal

B

n (%)

Luminal

Her-2

n (%)

Her-2

Type

n (%)

TNBC

n (%)

2015-

2016

N = 499

57

(11,42%)

58

(11,62%)

94

(18,83%

)

108

(21,64%)

74

(14.82%)

108

(21,64%)

499(99.9

7%)

(100%)

2017-

2018

N = 214

3

(1,40%)

29

(13,55%)

94

(43,92%

)

33

(15,42%)

28

(13,08%)

27

(12,61%)

214 (

99.98%)

(100%)

Delayed Cases of

Breast cancer

Advanced Breast cancer (LABC, MBC)

“Time Delay”, since patient noticed the

“lump” until seeking help from Doctors

No. Jawaban Jumlah Presentase

1.

2.

3.

4.

5.

< 1 Bulan

1 Bulan – 6 Bulan

> 6 Bulan – 1 tahun

>1 Tahun – 2 tahun

> 2 Tahun

1

5

10

9

5

3.33%

16.67%

33.33%

30.00%

16.67%

Total 30 100.00%

Ariawan & Manuaba, 2006

Cause of Delay (in seeking proper

treatment)

▪Avoiding Surgery, Chemotherapy or

Radiation Therapy

▪Rumors in the community (surgery will

make cancer “more aggressive”, or

“metastasis faster”

▪The “attraction of alternative medicines” →

no surgery needed

▪Delay by doctors

Breast Cancer Management

Breast Cancer Management

▪Surgeries

▪Chemotherapy

▪Hormonal Therapy

▪Radiation Therapy

▪Targeted Therapy

SURGICAL TREATMENTS

▪ “Modified Radical Mastectomy” → standard surgery for Stage I, II

▪Breast Conserving Surgery → EBC → Frozen Section for “margin”?

▪Sentinel Lymph Node Biopsy → Methylene Blue (“Research basis only”, “dye difficult to obtain”)

▪ “Comprehensive Mastectomy” and “close huge operative defects”

▪Neo-adjuvant Chemotherapy → Standard therapy for Stage III and IV → average tumor size 9-12 cm

▪Others Adjuvant Treatment → according to Breast Cancer Subtypes (“personalized treatment”)

Breast cancer Screening

Breast Cancer Screening in Indonesia/ Bali“Individual basis”▪Breast Self Examination → trained and activated for the whole island simultaneously → to be monitored and evaluated, RCT?

▪Regular Clinical Breast Examination by doctors who are well trained (not necessarily surgeon)

▪USG for younger age for Asian Women → need for subspecialist radiologist. This is especially important because of younger age group of patient in Indonesia/ Bali (operator dependent)

▪Mammography → for older (>50 years) women; increase the availability new generation mammography machine → younger patients

▪MRI → for special case of Breast Cancer

FUTURE PLANNING FOR EARLIER

BREAST CANCER DETECTION AND IMPROVEMENT OF

OS AND DFS

▪Public Education → extensive, continuing,

and supervised

▪Screening for Breast Cancer → Population

Based or Individual; BSE, CBE and

Standard/Accredited personal and Imaging

Technology/ USG, Mammography and MRI

→ has to start

▪The role of OBGYN in early

detection of Breast Cancer during

pregnancy/ PABC?

FUTURE PLANNING FOR EARLIER BC.

DETECTION AND IMPROVEMENT OF OS

AND DFS

▪Surgical Training for Breast Cancer Surgeries → one standard and same quality/ competence → synchronized training program, “same training catalog?” → better OS, DFS

▪Toward “Organ-Oriented Training Program” →including Breast Surgery

▪Updating and modernizing medical technologies → molecular and genomic oncology → personalized treatment (government role?)

▪ Improvement of Radiotherapy services →“machines” and “Radiation Oncologist” (Government role?)

Conclusions

▪No effective and continuing public education

▪No “population based mass screening program”

▪Affecting younger populaton → germline mutation, genetic susceptability/ polymorphism?

▪ Advanced Stages in majority patients

▪Low response rate on NAC

▪Low “surgical conversion” → “comprehensive mastectomy”

▪Different standard of Breast Cancer Surgeries (Surgical Oncology>< General Surgeons>< Breast Surgeon) → OS and DFS?

Conclusions

▪RT. Centralized in big cities & not widely distributed → majority patients did not receive RT → high recurrent rate

▪“IHC” is still expensive, coverage? →personalized medicine?

▪Molecular and genomic technology →available but very expensive →personalized medicine?

Thank you

BCT/ S.

AXILLARY

DISSECTION IN

BCT/S

SLNB → “notice big incision”, dye material only →

learning curve → Safety in PABC?

LD Flap

TRAMP FLAP → TO COVER AND RECONSTRUCT

THE DEFECT

Oncoplasty in Breast

Surgery

TREATMENTS (Targeting

Therapy)

▪Transtuzumab → the most common targeted therapy used → for Her2 type Breast Cancer

▪Bevacizumab, Lapatinib, mTor Inhibitor/ Avinitor → are in the market → use for “second or third line treatment”

▪Expensive → covered by BPJS/ JKN (no longer covered since April 2018)

RADIATION THERAPY

▪Mainly distributed in big Cities (Jakarta, Surabaya, Bandung, Semarang)

▪The use of “old technologies” in many centers → Co60

▪“Long que” → Denpasar “the waiting time” up to one year

▪High percentage of Stage III or IV breast cancer → no RT → high recurrent rate

Suhartati, 2008

Look at

The Distribution

HIGH TECHNOLOGIES AND

PERSONALIZED MEDICINE

▪No Standard tissue/ tumor specimen “handling” or “fixation”

▪No Standard → tissue transport

▪No Standard → histopathology reports

▪ IHC → no quality contro/ or accreditation; no reference lab.

▪FISH or CISH → certain lab, expensive technology

▪Gene Profiling → 1 lab; expensive

Personalized Medicine, difficult to achieve

HIGH TECHNOLOGIES AND

PERSONALIZED MEDICINE

▪Routine Histo-Pathology Examination

-Cytology (no subspecialty “Breast

Cytopathologist”)

-IHC → ER, PR, Her2 (other tumor

markers → research only)

-Molecular Diagnosis → refer to

molecular lab., expensive

Problem in Advanced

Staged Breast Cancer

(LABC or MBC)

LESS RESPONSIVE TO “NAC”▪Sudarsa, 2000 → 70% (ORR)

▪Manuaba, 2006 → 40% ORR)

▪Heri Susilo (2008) → 40% (ORR)

▪Widiana (2014) → 30% (ORR)

(Regiment used → CAF, Taxane+Anthracyclines)

NSABP B-27 → higher response rate and higher complete pathological response rate (12.8-26.1%)

Smaller tumor size?

The response rate intended to decrease

was it because of “huge size tumors”, or problem

of measurement (Clinical vs MRI?)

Biological → different tumor biology?

HIGH COST and LITTLE

RESULTS

▪60-70% → Stage III (inoperable) and IV Breast Cancer

▪Less than 40% response rate

▪Surgical Conversion rate → less 30%

▪Complex surgeries (comprehensive surgeries) → radical mastectomy + reconstruction “to close huge defects”

▪“Low” 5 years” OS rate

▪High cost and wasting chemotherapy agents and expensive targeting therapies

▪Low productivity

Training of Surgeons

TRAINING OF SURGEONS

▪Breast Cancer Surgery → provided by

General Surgeons, Surgical Oncologist and

Breast Surgeon

▪Different levels of training, overlapping

training

▪Different techniques or qualities

→”personal skills/ learning curve”; “low

patient volume”

▪Multiple standards of surgical techniques →

should be “one standard” → different

phylosophy of Surgical Training?

Thank you