WHY CANCER?

Ario Djatmiko Sub bagian Onkologi Bagian Bedah RS DR SOETOMO Surabaya.

Declaration of Alma Alta (1978)

Primary Health Care an equitable distribution of health services. cultural and financial accessibility. epidemiological analysis that address the major health needs of community. community involvement in health decisions. a focus on prevention of diseases. the appropriate use of technology. a multicultural approach which recognizes the importance to a healthy community of adequate nutrition, education, employment, transport and housing.

Health for all by the year 2000

Charter for Health Promotion Ottawa (1986)

Five area for action in health promotion Building healthy public policy. Creating supportive environments. Developing personal skill. Strengthening community action. Reorienting health services.

The philosophy of family physician describes the role of general practitioner Care provider. Educator. Collaborator. Researcher. Controller/ evaluator. Care provider within a care delivery system that emphasis. Responsibility. Accountability. Autonomy.

Health for all by the year 2000

Tujuan pelayanan kesehatan adalah menjaga dan meningkatkan kesehatan masyarakat, jadi fokus bukan mengobati penyakit. Dokter umum / keluarga selalu berada ditengah masyarakat, merupakan kontak pertama setiap problem kesehatan yang timbul dimasyarakat. Rumah sakit / dokter spesialist hanya berfungsi supporting. Hanya 15 % saja kasus-kasus (problem kesehatan) yang sebenarnya layak dirawat di RS atau dr Specialist, selebihnya (85%) seharusnya dapat ditangani dr umum / keluarga. Dokter umum / keluarga harus mampu menjawab problema kesehatan masyarakat, dalam arti profesional, pengetahuan yang cukup dan trampil. Membangun sistim rujukan yang baik, sehat dan transparant. Dokter umum / keluarga harus mampu melakukan professional control pada rumah sakit / specialist rujukan, apakah sesuai standar prosedure, kualitas pelayanan, biaya? Dibangun jalur law enforcement. Untuk kasus onkologi, peran dokter umum / keluarga > 80% dari seluruh rantai penangananan. Tidak seluruh perawatannya / follow up harus dilakukan oleh specialist.

Saat ini, keadaan terbalik: Fokus mengobati orang sakit. Health network belum terbentuk, pasien membayar biaya kesehatannya sendiri, yang mampu langsung ke specialist. Akibatnya biaya kesehatan meningkat (medico-farmaco complex----medical abuse : biaya obat di Jakarta 43,63 %, dari total biaya pemeliharaan kesehatan, US 9,3 %). Professional control tidak jalan. Penanganan holistik tak terjadi. Hasil optimal penanganan kanker tak mungkin tercapai tanpa adanya health network yang baik, mengoptimalkan peran dokter umum/keluarga.

PERMASALAHAN:

Angka kejadian penyakit kanker meningkat tajam. Ilmu pengetahuan berkembang pesat, harapan hidup penderita kanker semakin baik bila ditangani dengan benar. 70 % penderita datang terlambat Stadium III IV. Health network (jaringan pelayanan kesehatan) untuk penanganan kanker secara holistik belum terbentuk. Keharusan mengikuti perkembangan ilmu untuk setiap provider. Kenyataannya professional education untuk provider sangat kurang.

Dokter umum/keluarga dan Rumah sakit/specialist seharusnya merupakan partner yang ideal yang bertujuan sama : Memberi pelayanan yang memenuhi standar dan holistik serta biaya yang rational dan terjangkau (cost containment). Saling mengingatkan

Transformation of Diseases Pattern

If
CV Ca

If

: Infection Diseases

CV : Cardio-Vascular Diseases Ca : Cancer

Medicine is the art of dealing with uncertainty

Moskowitz, 1988

The result of the treatment

Patient

Cancer : stadium grade, type etc

Treatment

STADIUM AND PROGNOSIS

stage To<10 mm insitu St I, II, IIIA Advanced Prolong survival time

Detection by screening

Biologic onset

Preclinical disease

Usual diagnosis

O u t c o m e

Preclinical disease inception

Symptom onset

TDLU (Terminal Duct Lobular Unit)

Wanita 41 tahun, tanpa keluhan dikirim oleh dokter Jember untuk screening payudara Klinis, taa Mammography C5, dengan hook wire Hasil PA: Insitu Ca ukuran 4 mm.

Hook wire

DCIS

KOS, 1998

L O C A L I Z A T I E

P R O C E D U R E

Primary care physicians and specialist must make a concerted effort to educate their patients about the importance of regular mammograms.

Hillary Rodham Clinton

A mothers day message (Oncology Time, vol XVII no 5/ May 1995)

Medicine is the art of dealing with uncertainty

Moskowitz, 1988

USA (SOC of North America, 1994)

Female-29 years old complained thickness sensation in her left breast. Doctor : nothing wrong with her breast (PE). 3 month later she got married and after 6 month pregnancy, she felt her left breast was getting bigger and harder. Hospital: Breast cancer in advanced stage. She died a month after having a baby. Litigation: The doctor has been sentenced. Medical problem: misdiagnosed. Diagnostic procedure? Can we exclude cancer based only on physical examination?

SURABAYA, 2000 Female-45 years came with clinically breast cancer T4N1M0 in the left breast. 11 month before she felt small lump in the left breast, a GP send her to get USG and FNA, The result was Mastitis.
She got medicine for a month, but there was no improvement, FNA was repeated with result was still mastitis and the tumor was getting bigger, after 9 months she came to KOS. Triple Dx: Malignant. The patient didnt believe it, open biopsy: Malignant. Problem: 11 months delay, late stadium.

Indonesia (Surabaya, 1997)

Female-25 years old came to X Hospital with 2cm lump in the left breast. Without Imaging, surgeon send the patient to pathologist for FNAB, the result is positive adenocarcinoma. Surgeon performed mastectomy. The report of mastectomy specimen (other pathologist): Fibroadenoma no malignancy. Problems: Legal aspect? Did the surgeon follow right standard diagnostic procedure? How much is the value of FNA; Surgeon-pathologist communication?

Indonesia (Surabaya, 1991)

Female-23 years old with advanced breast cancer (local advanced + milliare metastase to the lung). She have been operated on by surgeon 8 months before. Surgeon : no serious thing - only small benign tumor without sending the specimen to pathologist. She died 3 months after she came to our clinic. Problems: Diagnostic procedure?

Diagnostic Procedure
PE RO LAB FNA 90% COLLECTING DATA ASSESSMENT PLANNING FINAL DIAGNOSTIC ERROR

(BIOPSY)
TREATMENT FOLLOW UP
The arts of the treatment lies in diagnostic procedures

Kanker payudara ?

Bagaimana sikap kita ? Apakah harus selalu berakhir dengan kematian? Benarkah bisa disembuhkan? Apakah harus selalu kehilangan payudara? Apakah kemajuan ilmu kedokteran memberi harapan bagi penderita kanker payudara?

Apakah harus selalu berakhir dengan kematian?

Survival (perpanjangan hidup >5 tahun) 1920 1930-40 20% 50%

1970

70%

Saat ini tumor dini < 10 mm : 93 96 % dapat hidup sehat > 20 th .....

Peran skrining

1993, American cancer society:

Cancer is a curable diseases

What is breast physician?

General practitioner who has special training in breast problems. They must have: Proper knowledge. Appropriate skill. A Good medical record system. Network with regional breast unit.

The three level of cancer prevention

Level of prevention
Primary

goal
Reducing the incidence of specific cancer.

action
Health education & promotion, law enforcement (avoiding carcinogenic agent) Early detection and prompt treatment.

Secondary

Reducing the mortality rate of specific cancer

Enhancing the quality of life of cancer patients

Tertiary

Palliative treatment.

Action Effectiveness Type Of Cancer Primary LOP Skin Lung Lever Cervix ++ +++ ++ ++ Secondary LOP ++++ + + ++++ Tertiary LOP + + + +

Breast
ST Sarcoma Leukemia

+++
++ +

+
+ +

Screening Indication

High incidence of cancer. Affect productive age. Significance increase of survival rate by screening.

The role of breast physician

Active involve in all level of prevention. Health network.

building good & transparence referral system. evaluating hospital performance. protecting patients from medical abuse or malpractice, always concern with standard operation procedure, quality of services and cost.

Breast screening
Value
Sensitivity Specificity Cost Procedure Difficulty Subjectivity Size

BSE
++++ > 2 cm

BP
++ ++ + ++ ++ >1,5 cm

Mammo
++++ ++++ ++++ ++++ <1 cm

BSE: Breast self examination. BP : Physical Examination by Breast Physician The smallest tumor was detected at Klinik Onkologi Surabaya, 3 mm

The Role Of Physician Hospital

Primary LOP ++++ +

Secondary LOP ++ ++++

Tertiary LOP ++++ ++

Lop: level of prevention GP involve in > 80 % of all LOP

Cancer delay:
Patient delay + Doctors delay + Hospital delay
Patients delay: Lack of knowledge. Economic problems. Psychological barrier. Misinformation. Doctors delay : Lack of knowledge. Lack of Network .

Hospital delay : Substandard quality services. No Quality assurance. Integrated delivery systems?

TUMOR
(Adalah setiap pembesaran/ benjolan abnormal dalam tubuh) NON NEOPLASMA KISTE RADANG HIPERTROPHIA HIPERPLASIA DISPLASIA METAPLASIA
NEOPLASMA : Adanya pertumbuhan dan diferensiasi abnormal akibat kerusakan gene pengaturnya

GANAS

JINAK

PERBEDAAN NEOPLASMA JINAK DAN GANAS

NEOPLASMA JINAK
Adanya Tumor Keluhan Kosmetika

A. GAMBARAN KLINIS
A.1 Keluhan

NEOPLASMA GANAS
Stadium dini : Tumor jinak Menyerupai Caution/ patokan/ Waspada Stadium lanjut : Variabel Tanda-tanda tumor infiltrasi gejala regional & metastase Progresive Umumnya lokalRegional-metastase

Lambat (tahunan) Terbatas pada organ asal dan tidak mengganggu fungsi organ tersebut Konsistensi Lunak/ padat, kenyal Tanda-tanda infiltrasi (-) Batas tegas/ teratur Tumbuh expansive Mobilitas baik Permukaan licin

A.2 Perjalanan Penyakit

A.3 Pemeriksaan A.3.1 Fisik

Konsistensi padat, keras Tanda-tanda infiltrasi (+) Batas tak tegas/ tak teratur Mobilitas terbatas Tanda-tanda infiltrasi lanjut : * ulcus * perdarahan organ * retraksi kulit

NEOPLASMA JINAK

A. GAMBARAN KLINIS
A.3.2 Imaging

NEOPLASMA GANAS

Well capsulated Struktur homogen Calsification (-)

Batas tak tegas Gambar infiltrasi stellate sign Struktur tidak homogen Micro Calsification

B. HISTOPATOLOGI

Capsul jelas Struktur jaringan homogen Nekrosis/ Ulcerasi (-)

B.1 Makroskopis

Capsul tak jelas Infiltrasi Rapuh dan mudah berdarah Ada bagian-bagian yang retraktif

Bentuk sel teratur Jaringan mempunyai gambaran homogen Hiperkromasi (-) Polikromasi (-)

Pleiomorphic (+) Hiperkromasi (+) Polikromasi (+) N / C ratio mendekati 1 Struktur jaringan tak teratur (anaplasi)

BENIGN NEOPLASTIC SKIN LESION

PAPILOMA OR WART

PAPILOMA OF THE FACE

MOLLUSCUM CONTAGIOSUM

CONDYLOMA

HAEMANGIOMA CAPILLARY

KERATOACANTHOMA (MOLLUSCUM SEBACEUM)

CAVERNOUS HEAMANGIOMA

HAEMANGIOMA CAVERNOUS (STRAWBERRY NAEVUS)

HAEMANGIOMA CAVERNOUS

MELANOTIC NAEVUS (PIGMENTED MOLE)

MALIGNANT SKIN LESION

A TYPICAL SQUAMOUS CARCINOMA

SQUAMOUS CELL CA OF THE HAND

SQUAMOUS CELL CA OF THE EAR

BASAL CELL CARCINOMA

BASAL CELL CARCINOMA OF THE FOREHEAD

MALIGNANT MELANOMA

MALIGNANT MELANOMA OF THE HEEL

MALIGNANT MELANOMA OF BIG TOE

PRE & MALIGNANT SKIN LESION

MALIGNANT MELANOMA

LENTIGO

MALIGNANT LENTIGO

BOWEN'S DISEASE

PRE MALIGNANT LESION

LEUCOPLAKIA

LEUCOPLAKIA

VARICOSE ULCER

NEUROFIBROMA

NEUROFIBROMATOSIS

CAFE-AU-LAIT SPOTS

BENIGN SOFT TISSUE TUMOUR

LIPOMA OF THE NECK

LIPOMA OF THE HAND

CHORDOMA

NON NEOPLASTIC TUMOUR

MUCOUS CYST

RANNULA

DENTAL CYST

RHINOPHYMA

BRANCHIAL CYST

THYROGLOSSAL CYST

THYROGLOSSAL CYST

EXCISED THYROGLOSSAL CYST

NON NEOPLASTIC TUMOUR

SEBACEOUS CYST

IMPLANTATION CYST

PAROTIC GLAND TUMOUR

THE MIXED TUMOUR

CARCINOMA OF THE PAROTID

EXTENDED CARCINOMA OF THE PAROTID

PAROTIS TUMOUR

PAROTIS TUMOUR

MALIGNANT SOFT TISSUE SARCOMA

KAPOSI'S SARCOMA

FIBROSARCOMA

OSTEOSARCOMA OF THE UPPER END OF THE HUMERUS

CARCINOMA OF THE TONGUE

SQUAMOUS CELL CA OF THE TONGUE

SQUAMOUS CELL CA IN AREA OF LEUCOPLAKIA

Signs of malignancy of the breast

PAGET'S DISEASE

NIPPLE RETRACTION

PEAU D'ORANGE

PEAU D'ORANGE

Matur nuwun