Current global developments in breast cancer and management in Ghana

Abstract

In lieu of an abstract, here is a brief excerpt of the content: •19• Chapter 3 Current Global Developments in Breast Cancer and Management in Ghana J. N. Clegg-Lamptey and V. Vanderpuye Introduction Breast cancer is the leading female malignancy in the world with about one million new cases diagnosed annually, over 400,000 annual deaths and about 4.4 million women living with the disease.1 In Ghana it is one of the leading cancers in all institutional data, constituting 16 percent of all cancers from the pathology records of the Korle Bu Teaching hospital and 28 percent of presenting cases at the Radiotherapy Centre of the same hospital. The management of the disease is however continually changing and it is necessary to alter management strategies from time to time in the light of current clinical evidence. In this chapter we will look at some of the current developments and trends in breast cancer management. We will also discuss some established current practice that, in our view, is not yet manifest in our practice in Ghana. General developments a. Multidisciplinary team work Breast cancer used to be managed solely by the surgeon whose word was final. Currently this method is outmoded. Management decisions are now so complex, taking into consideration a variety of factors and involving other specialties, that it is not advisable to leave them in the hands of a single decision maker including the physician. It is now widely accepted that multidisciplinary teams (MDTs) form the basis for best practice in the management of breast disease.2 Multidisciplinary team work was appropriately the first key recommen- •20• Chapter 3 dation of the National Institute for Clinical Excellence (NICE) in the United Kingdom.3 Their recommendations were as follows: • All patients with breast cancer should be managed by multidisciplinary teams and all multidisciplinary teams should be actively involved in network-wide audit of processes and outcomes. • Multidisciplinary teams should consider how they might improve the effectiveness of the way they work. The recommended team is made up of all key players in the patient’s management, namely the surgeon, breast care nurse, pathologist, radiologist , radiation oncologist, medical oncologist, psychologist, clinical pharmacist, plastic/reconstruction surgeon and the social worker. Other specialties may form part of the team based on local circumstances: a clinical psychologist and clinical pharmacist play a very important role in the breast MDT at the Korle Bu Teaching Hospital. Patients should be considered members of the team and their views considered in arriving at management decisions. The guidelines by the Association of Breast Surgery, Royal College of Surgeons of England suggest two teams, a diagnostic team and a management team2 In the Korle Bu Teaching Hospital, a MDT runs a ‘Breast Clinic’ every Tuesday. A tumour board is also run at the Komfo Anokye Teaching Hospital. These teams discuss patients with breast cancer and reach consensus about treatment. Often patients are brought to the meeting, examined and discussed. b. Patient -centred care Breast cancer is a heterogeneous disease and management should be individualized, taking the circumstances of each patient into consideration . Many factors, including the pathology of the disease, stage and quality of life issues have to be considered. In developing countries, the availability of resources and sometimes the high cost of some forms of treatment influence management decisions to a large extent4 . c. Use of protocols To prevent arbitrariness, agreed protocols should guide patient management. Protocols should be based on current global clinical evidence, evidence from local practice, peculiarities of local practice •21• Current Global Developments in Breast Cancer and Management in Ghana and any on-going clinical trials as this will most likely lead to optimal outcomes5 . d. Clinical trials Breastunitsareencouragedtosupportclinicalresearchandareexpected to participate in multicentre studies aimed at improving treatment for breast cancer. There is some evidence that patients treated in clinical trials have improved outcomes.6 In spite of difficulties in obtaining funding for research, developing countries need to carry out clinical trials of their own. This is because genetic, social, demographic, environmental, and geographic attributes affect outcomes across countries and communities.7 Diagnosis of breast cancer a. Current developments in screening: Screening for cancer has become a standard of practice in contemporary health care.8 Mammographic screening has been shown to be effective. Indeed, the Cochrane 2006 report estimates a 15percent relative risk reduction following mammographic screening.9 Breast -self examination has, however, not been found to have a similar benefit in reducing mortality from breast cancer.10 The current recommendations are biennial screening mammography for women aged 50 to 74...