Quality- Concept In = The Management Of =91Breast Problems=92

&n= bsp; =20 Quality- Concept In The Management Of =91Breast Problems=92 &n= bsp; &nb= sp; &nbs= p; = ; = &= nbsp; &n= bsp; &nb= sp; =20

Speciality=20 =96 Surgery

Expert- Dr. Sheetala Prasad=20 Rai

Hospital-=20 Ufht Medical College, Haldwani - 263139 = (Ua)

Introduction=20 with change of pattern

Other=20 than acute inflammatory conditions breast is the leading site of cancer and now replacing = cervical=20 cancer in most of the urban population in = India ,=20 estimating 80,000 new = cases diagnosed annually . = There has been a steep increase till = menopause-year=20 after which the curves plateau . The =20 trend for increase was found=20 statistically significant . The diagnosis = is based on clinical examination , = imaging technique and cytology = /core-biopsy² . Fast=20 access breast clinic is avoiding unnecessary delay at first visit , assuring patients and improving public confidence in UK. Practitioner is lost in the = ocean of=20 literature and data that is available on = the=20 subject⁵ . The Core -team =20 members = include a =20 surgeon , radiologist and pathologist with laboratory =

support=20 staff etc.Excessive surgical-case-load is also likely to be=20 detrimental^3. Initial investigations are usually requested by = surgeons in developed countries. GP=92s are given referral guide = lines for suspected breast malignancy by = N H S in=20 UK². Bombay has the highest incidence of breast cancer in the country.

National Centre of health statistics , its surveillance epidemiology and end result=20 programme showed the double number of cases of DCIS^7,12=20

(=20 ductal carcinoma in situ ) from =20 1985 (7%) to 1988 = (14%) and decrease in =20 mortality rate of = breast=20 cancer by 6.8% between = 1989 to=20 1993⁶ .

Clinical=20 Pictures and Investigations

There=20 has been progressive = advancement in=20 non-invasive confirmation = and treatment of breast diseases but histopathological confirmation by different forms of biopsy techniques remains unchallenged . Benign Vs

Malignant=20 lesion remains first priority for clinicians to give initial and immediate relief to the = patient=20 proceeding to wards quick therapeutical course.

=93Number=20 of investigations is inversely proportion to the clinical sense=94. It = is cost=20 effective and time-saving . But clinical sense depends on the quality of = education , training and maximum exposure of the trainee on the patients = . These=20 things frequently lacking in peripheral institutions, small hospitals = and that too is =20 affected by = =91quack=20 interference=92 doing the things unscientifically = .

Some of=20 common problems of breast = is shown=20 below for quick clinical = judgment in most of the cases . It is =20 to help general = practitioners do =20 the

needful=20 , as they are serving the people at large . Pregnancy , lactation , = place ,=20 season and economic status with education should be kept in mind = while

making=20 decisive management . =91Cure should always be tried best to be better than the disease itself =92. Panel for = quick decisive therapy should include at least one senior surgeon , = one oncologist and one senior = radiologist=20 .

=20

Refined=20 conventional=20 x-ray chest , mammography , = ultrasound , CT ,

MRI with or without contrast agent , molecular imaging , lympho scientigraphic imaging to = measure=20 regional biochemistry and = function=20 of every organ of living individual . Advances in nuclear medicine , technologically = refined whole=20 body scanning, SPECT and PET =20 have been widely = utilized .=20 New technologies ,=20 radiopharmaceuticals = and the scope

of nuclear medicine is also continuously expanding the =20 number = of potent or promising = therapeutic=20 radionuclide preparations for the =20 treatment . This is the achievement of today=92s imaging sciences which is progressing = day by=20 day⁸. Radio labeled monoclonal antibodies (MoAb) uptake by tumor =

cells=20 denote susceptibility of the tumour to this form of therapy=20 .

SPREAD=20 BEYOND LOCAL & LYMPHNODES

Tumor positive lymph nodes in CA =20 cases appear to produce a different set of =20 proteins than do healthy nodes and a different set again from primary tumor . Scientists believe that this may be =91smoking = gun=92=20 behind the mechanism the body uses to stave off tumors . Entire protein expression and its differences may hold clues to breast cancer

development=20 and its spread⁴ . Concept of axillary-node dissection has been challenged = by=20 introduction of the sentinel node biopsy and going back again to 3-4 LN = biopsy=20 .

Treatment =96 =

Panel=20 for decisive course of =20 treatment = should include at least one senior = surgeon ,=20 one senior = radiologist and =20 one oncologist with biopsy report.Surgery = tops the list=20 of modalities in the management of carcinoma . It includes any types of = biopsy=20 to the radical removal = of the whole breast and extent of = tumor with=20 individualized and correct-surgical procedure = as needed . This is followed by radiotherapy , chemotherapy (CT) , chemo-radio therapy (CRT) hormonal and = immunotherapy=20 with vitamins , protein and minerals as required in =20 individualized = patient .

Above=20 all is the experienced clinician who = reduces=20 cost , time , risk and = mortality=20 winning the confidence of=20 the patient and thus improving professional and institutional image . Today=92s innovation in plastic surgery = has also=20 solved most of the problems of breast even after operation Wise practitioners / = patients=20 choose the expertise and hospital to give good result in breast=20 problems.

Reference:

1. =20 American=20 cancer society cost-of screening mammography issues, recommendations and = solution . &n= bsp; &nb= sp; &nbs= p; = ; Cancer=20 1987: 60(supply 7): 1694-1699

=20

=20 = 2. Jothi R. Murugesan , David Valerio , Sheena Bradley . Fast access breast=20 clinic,

&n= bsp; &nb= sp; &nbs= p; = ; = &= nbsp; &n= bsp; &nb= sp; &nbs= p; = ; =20 ISJ 2006 ; 88:142-5 &n= bsp; =20 &n= bsp; &nb= sp; &n= bsp; &nb= sp;

3. =20 S. John=20 Abraham , Recent Concepts in the management of carcionoma breast , progress in surgery , = &n= bsp; &nb= sp; &n= bsp; &nb= sp; LXI=20 ASICON 2001: 1-4

4. =20 Sainsbury=20 R , Haward B , Johnston C . Influence of clinician Work load and = patterns of=20 treatment on survival from breast Cancer . =20 &n= bsp; Lancet=20 1995: 345: 1265-70.

5. =20 Craig=20 shriver, MD , directors of the=20 clinical breast care = project WR Army Medical Center Washington DC , et al - Annual cancer Symposium of Society of Surgical Oncology-(SSO). &n= bsp; &nb= sp; Deptt = of Surgery=20 PGI CME Chandigarh.-2003

6. =20 SM=20 Bose , sabapathy PB , Alok Mazumdar and Prof N.K.Ganguli Director Gen. ICMR & director PGI = Chandigarh=20 India : &n= bsp;=20 Consensus On Breast Cancer 2000.

7. =20 Bland=20 Kl et . The National cancer data base 10 year survey of breast cancer treatment at = hospitals in=20 US report . &n= bsp; cancer=20 83 : 1262-1273 1998

8. =20 Silver=20 Jubilee celebration year of IASO Dec 2003 : News Letter = 17:2;=20 6-14 &n= bsp; &nb= sp; =20

9. =20 Faverly=20 DR Buryers L , Bult P , Holland R . Three dimensional imaging of

mammory ductal carcinoma in situ : clinical applications . =

&n= bsp;=20 &n= bsp; &nb= sp; &nbs= p; Semin Diagn=20 Pathol 1994 ; 11:193-98

10. = Silverstein=20 MJ, Blarney ED, Colburn WJ, Morin Cope L, Senofsky GM, et=20 al.

Can Intraductal breast carcinoma be excised completely by local excision=20 ?

Clinical and Pathological = predictors=20 . &n= bsp; &nb= sp; =20 Cancer 1994; 73:2985-9.

11. = Sibbering=20 DN , Blarney RW . Notting ham experience. In: Silverstein MJ, =20

editor. Ductal Carcinoma = in situ.=20 1^sted . Baltimore (MD) :

&n= bsp; =20 &n= bsp; &nb= sp; &nbs= p; Williams and=20 Wilkins; 1997 . P.367-72 .

12. = Holland=20 PA, Gandhi A, Knox WF Wilson M, Baildam AD, Bundred NJ . The=20

importance of complete excision in the = prevention of=20 local recurrence and of

&n= bsp; =20 ductal=20 carcinoma in situ . &n= bsp; &nb= sp; &nbs= p; =20 Br J Cancer 1998;77: 110-4.

13. = Steering Committee on Clinical Practice Guidelines for the Care and

Treatment of =20 Breast Cancer = .The management of ductal carcinoma in = situ (DCIS)=20 . &n= bsp; &nb= sp; =20 Can Med Assoc J 1998; 158 (3 suppl): S27-34 = .