News

Patients’ School: all about breast cancer

02.12.2013

This always important issue was discussed at the meeting at NI Pirogov National Medical Surgical Center.

Source: “Meditcinskaya Gazeta” (Medical Newspaper), October 25, 2013, No. 81 (7407), page 11

This free educational event helped patients, their relatives and doctors to get the most current information on timely diagnosis and treatment of breast cancer, methods of psychological support and rehabilitation. Such Schools are organized for both patients and doctors.

How expert can help?
The School began with a presentation “Modern methods of diagnosis and treatment of breast cancer, rehabilitation after treatment” made by Vladislav Sarzhevskiy, Associate Professor of the Department of Hematology and Cell Therapy of NI Pirogov National Medical Surgical Center. The presenter managed to cover in plain language one of the most complex issues in oncology. On average, 50-80 new cases of BC per 100,000 women are diagnosed every year globally. Unfortunately, in Russia this figure is higher: in 2002 there were 266 cases per 100,000 women; in 2012 the figure reached 380 and ranked first among all cancers. For breast cancer, major risk factors include female gender (actually, this disease rarely occurs in men) and old age. Additional risk factors are family history, early menarche, late menopause, late first birth. Prolonged intensive hormone therapy, when gynecologist prescribes drugs containing female hormones, may also increase the risk of breast cancer. The main methods to detect the disease are medical examinations, assessment of risk factors, mammography, breast ultrasound and magnetic resonance imaging. Mammography remains the most affordable way of detection and assessment of the spread of the tumor. As for MRI, due to its high cost it is not used widely in Russia, but for example in the USA this method is included in the standard screening.
If breast cancer is suspected, the patient must have additional examinations and tests. A woman is further examined not only by her general practitioner, but also by oncologist and breast physician, and biopsy is performed in addition to mammography. The biopsy is a method of obtaining samples of tumor tissues; it is divided into thin-needle aspiration biopsy, needle core biopsy and obtaining biological material from lymph nodes located near mammary gland. Thin (or fine) needle aspiration biopsy is a fairly simple method of obtaining tumor cells, which are then placed on a slide and laboratory specialist makes a conclusion about the presence or absence of malignancy. The needle core biopsy is a more sophisticated, but also more informative method. Using special devices a column of breast tumor tissue is obtained; it is treated in a special way, allowing a more thorough diagnosis of malignancy. But the most accurate diagnosis requires an incision of tissue above the tumor.

Biochemical blood tests are conducted; breast tumor markers are determined SL15-3 and Carcinoembryionic Antigen (CEA). It is necessary to understand the genetic nature of the disease, because different types of treatment are used depending on it. Non-invasive treatment for BC (in siti) is possible when the tumor has not yet spread beyond the duct or breast lobule. A test for hormone receptors is also mandatory. Genetic analysis for all malignant neoplasms is also conducted: if one of the her 2 neu genes is activated, the tumor will grow faster.

As we know, breast cancer cells can, after they appeared in the body, affect any organ - the liver, pelvis and spine. Based on this, the TNM breast cancer staging system was developed and the treatment plan depends on the stage of the disease. A consultation of specialists is needed, not the decision of one doctor only. This is at least the oncosurgeon, oncologist-chemotherapeutist and radiologist. In case of conserving surgery, a small incision of the skin is made and the tumor and part of the normal breast tissue are removed; after surgery the cosmetic defect is not so obvious. On the other hand, mastectomy means a wide incision and removal of almost all mammary gland affected by tumor.

Current approach in oncology requires removal of adjacent lymph nodes – lymph node dissection. This removes malignant cells which may be located in lymph nodes. As for chemotherapy, it is divided into neoadjuvant (before surgery) and adjuvant (after surgery). For late stages of breast cancer palliative chemotherapy is conducted.

Breast reconstruction after surgery can be carried out in two ways: introduction of the implant under the muscle or reconstruction using patient’s own tissues, for example, when the abdominal skin is transplanted to the breast area.

How legal expert can help?

The legal unit of Patients’ School was delivered by Lidiya Sergeevna Moskvina, who is a secretary of the branch of the Public Council for the Protection of Patients' Rights at Roszdravnadzor Administration in Moscow and Moscow region. She reminded that it is planned primary health care that is the most complex taking into account the whole set of measures, because it includes therapeutic, surgical and oncologic aspects. If cancer is suspected in a patient, he or she is referred to the room of primary oncological care and then, with the purpose to clarify the diagnosis and treatment tactics, to a specialized medical institution (cancer center). Currently in the Russian Federation there are four provisions for free medical care for cancer patients: federal benefits, regional benefits, high-tech medical care and special programs in the regions. More information about these programs can be found on a website of regional health authority.

Social package for disabled with diagnosis of cancer consists of three parts: free drugs, spa treatment and travel to the place of treatment. The list of medications that can be provided for federal benefit recipients is contained in the Order No. 665 of the former Russian Ministry of Health and Social Development, which can be found on the website of the Russian Ministry of Health. The disability status is assigned during the medical and social expertise provided the three conditions are met: health disorder with persistent disorder of body functions, physical dysfunction and the need for social protection measures. If a patient does not agree with the decision made by social security medical assessment board, then he or she may appeal to the higher authority or to the court within a month. The Decree 890 (approved in 1994) of the Russian Government contains a list of diseases and categories of patients eligible for free medicines; cancer patients are included in this list. Federal benefit recipients may monetize their social packages, that means receive money instead of free drugs and purchase drugs for their own expense.

With regard to high-tech medical care (HTMC), it involves unique methods of treatment – there are 137 types of such methods for 20 categories of diseases including cancer. The need for HTMC is primarily determined by the physician in charge of the case, who submits its conclusion in the medical commission of the healthcare organization where a patient is treated, which shall review the documents within three days and, if necessary, send them to the commission in patient’s community, which makes the final decision. If the decision is positive, patient receives a voucher and organization is determined that will have to provide HTMC.

Antitumor drugs are prescribed by oncologists and hematologists. If the patient is being treated in non-specialized medical institution, then the decision on prescribing is made by his or her doctor in charge. Expensive drugs are prescribed by medical commission and only in the following two cases: patient’s hypersensitivity and for vital indications. If in a particular pharmacy necessary drug is not in stock, than the prescription has to be included in the waiting list. The pharmacy must provide the drug within 10-15 days.

How psychotherapy can help?
Irina Morkovkina, psychiatrist and psychotherapist at Mental Health Research Center of the Russian Academy of Medical Sciences devoted her report to psychological aspects of treatment and rehabilitation of breast cancer patients. It is clear that patients cannot beat breast cancer by their own, help can be offered by a doctor, not by an alternative medicine practitioner or quacks of any type. A patient, for his or her part, has to fight for a better quality of life, having available the necessary information. Psychological care in oncology is aimed primarily at resolving emotional problems. The role of psychotherapy in oncology has long been known, for example there is a remarkable experience in the past century, where Scandinavian specialists divided a group of 100 people with a predisposition to lung cancer (smoking, alcohol consumption) into two subgroups matched by age and gender. People in the first group were subjected to psychotherapeutic monitoring standard in western countries, while in another group there were no communications with psychologist or psychotherapist. The study was quite lengthy and costly, as a result in the second group cancer mortality was order of magnitude higher, 13 study participants of 50 died.

Today, thanks to modern medicine, cancer diseases in the early stages can be cured 100%. But even if a person is incurable, it does not mean that it is not possible to help. And sometimes such assistance is provided for decades. Being under stress after the announcement of the diagnosis, at first the patient experiences shock, which can be manifested in various forms. At that moment doctor may “lose a patient”, who may opt to rely on unconventional treatment; only advancing of disease makes patients to return thereafter. The patient may feel anger, usually directed inside, but it is mirrored on those who sincerely want to help. At the “negotiation” phase the patient looks for a compromise:
 “I will do anything just to make disease recede”. All those reactions are normal for a person who is under stress. The last phase is “acceptance” when all the blinkers are opened and the person starts to perceive the real situation, what is happening and what to expect.

When the disease returns and in case of metastatic disease, all stages of patient’s experiences are identical. Here, under no circumstances doctor or relatives have to use the so-called “tyranny of positive thinking” of the sort “why you're moaning, you're all right.” In this situation the patient immediately begins to feel the he or she is a burden to others, under the pressure of "maintaining optimism". The best way out of this is the awareness of the patient about the type of tumor, the histology, necessary drugs. And this is up to the patient to allow the doctor to talk about his or her condition to relatives, and not vice versa.
Family therapy is very important in cancer treatment. In particularly it is applicable to rehabilitation of women with breast cancer, when often a "loving" husband leaves his chosen one after surgery. Rehabilitation may include, for example, classes in breathing, relaxing exercises, hypnosis and even dance therapy. Art therapy proved to be helpful, when the patient first depicts a diseased organ in gloomy dark colors, but then paints of lighter colors are used in the drawings when curing is reached.

The concept of “caregiver burnout”, which we cannot overlook, applies to doctors and nurses, as well as all patient’s relatives and loved ones. The patient often perceives it as a cynical disregard, but it is only a superficial phenomenon. The patient should be aware that doctor is always thinking how to help, but he or she is also a human being and can get tired. Often relatives do not understand how to approach to always crying and aggrieved woman, the more so it is normal in her situation to cry and feel aggrieved. What is abnormal is when, as it often happens, a woman predisposed to BC is totally unprepared to give answers on such questions as how will she live with it, where will she get money for treatment if she contract the disease? It is especially true if we recall that cancer is becoming younger rapidly. The treatment and rehabilitation can result in the amount of 300,000 to 2.7 million rubles. May be the way out is the voluntarily cancer insurance, which is already being discussed at the state level?

Vyacheslav Svalnov, correspondent of “Meditcinskaya Gazeta” (Medical Newspaper), Moscow.