Electronic Health Records (EHR) – A necessity for Indian Doctors? 

The latest edition of eHealth Magazine highlighted my views regarding Electronic Health Records ( EHR’s). I have been regularly using EHR’s since I entered practice and I personally feel that all doctors should use it, as they simplify data collection and analysis.

   
 Another big advantage in our country is that patients often forget or lose their medical documents. In that case EHR’s can help doctors in retrieving the patient’s medical information and treat them in a better manner. 

BRASCON 2015 – International Breast Surgery Conference

The Pink City (Jaipur) hosted BRASCON 2015, an international breast surgery conference which attracted leading breast surgeons from not only India but also UK. It included a live operative workshop and was attended by more than 400 delegates.

I had the pleasure of presenting an invited talk on “Management of Non Palpable Breast Lesions”, which is a very interesting topic because with the increase in opportunistic screening in our country, we are seeing more and more non palpable lesions and there are special techniques required to manage these lesions.

In my talk, I spoke about my experience regarding wire guided localization (WGT) and ROLL (radio-guided occult lesion localization), both of which are the standard techniques to manage such lesions.

Many British Breast Surgeons were happy to see that we were performing such surgeries in India as well and they appreciated my operative videos.

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Social Issues faced by Breast Cancer patients – Livemint article

Ever since I started writing my blog, I have been stressing on the social issues faced by Breast Cancer patients in India and that it is as important an issue as treating their cancer. It is nice to know that my views have been shared in an article on Livemint.

You can read the article by clicking on the link – Being alone with cancer

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End of the South Indian Sojourn

Leaving Bangalore after the end of my fellowship turned out to be quite an emotional affair. This was the first time I was away from home for so long and my seniors and colleagues in the department made me feel quite comfortable during the tenure of my course.

Working with each one of them turned out to be an amazing experience in which I learned the necessary skills in the best possible atmosphere and I am definitely going to miss all of them in the future.

Now looking forward to my next stint in America. 🙂

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With Dr. Anthony - one of the best surgeons I have worked under...cool, calm and composed

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With Dr. Archana - who was always willing to teach and help

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Meera ma'am - who was an important link between the doctors and the patients. Learnt a lot about life from her.

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Breast care nurses - the most dedicated lot I have seen. They were responsible for the seamless functioning of the unit.

Shocking case – Mastectomy done for an 11 yr old girl!!

Every day brings a new surprise in the life of a doctor but there are some cases which just make you feel angry & helpless and today’s case was exactly the same. Our receptionist had fixed an appointment and when she told me that it is for a 11 year old girl, I probably thought that she is going to turn out be a case of juvenile hypertrophy (enlargement) of the breast but what I saw when I examined the patient left me in a state of shock.

This sweet looking 11 year old kid walked in with her parents and they started telling me the history that she underwent a surgery of the right breast to remove a benign lesion (fibroadenoma) 2 months back and they came to our unit because the girl had noticed another lesion on the left side. Breast surgery at 11 years is usually not recommended as it hampers with the development of the breast during puberty and I immediately knew that something will not be right when I examine the patient. Examination of the girl turned out to be quite shocking. The surgeon (who was actually a gynecologist in a rural set-up) removed not only the lump but also the entire breast tissue on the right side leaving behind just a long scar on the chest (image). It took me a couple of minutes to get in terms with what I was seeing and multiple thoughts started running through my head after that:

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1. My initial reaction was that of anger towards the doctor who had done such a surgery without properly examining the patient or documenting it. Her notes before surgery mentioned no examination findings and the only thing written was ”work-up for surgery”. She had fortunately not examined the other breast, which also had a small lump and I am sure had she examined it, she would have done the same thing on the left side as well.

2. I felt sad for the girl & her parents very well knowing that there is going to be no development of the breast of the right side and the patient will probably have to go for an implant later on in her life.

3. This case reinforced the fact that breast surgery needs to come up as a dedicated branch in India, in order to prevent such cases. Also more awareness needs to be created among people regarding this branch and the fact that it does not deal with only breast cancer. Benign breast diseases are often ignored by patients and they usually approach local doctors for their treatment.

4. This case also reinforced the point regarding proper notes & documentation in all patients. This patient can easily take the doctor who did such a surgery to court and that doctor will have nothing in her defense

5. This case was a real eye opener with regards to the lack of knowledge which general practitioners/ general surgeons / gynecologists have regarding breast disorders and this needs to be addressed by proper refresher courses for these doctors.

 

New blog to spread the right information about Holistic Medicine

India is probably the birth place of Holistic Medicine and all branches of holistic medicine are widely practiced in India. The problem is that practitioners of some of these branches don’t disseminate the correct information about their branch and give false hope of cure to suffering patients.

During my medical career, I have come across many patients who have become a victim of such practice and have had to pay dearly for following these quacks. Personally, I feel that all branches have a role to play in today’s healthcare system, provided the practitioners know their limitations and they refer patients to the proper doctors, if the disease is beyond the scope of their branch.

In an effort to spread the right information about Holistic Medicine, we have started a new blog – The Holistic RxThis website will feature articles pertaining to all branches of medicine and will be backed by scientific evidence.

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Contraindications to Breast Conserving Surgery

Breast conserving surgery (BCS) is fast becoming popular but one should be aware of the the contraindications of this procedure in order to avoid high recurrence rates & complications.

Breast conserving surgery in simple words is lumptectomy (removal of the tumor with a normal rim of tissue). All patients following BCS require radiotherapy. Some of the contraindications of this procedure are related to the surgical aspect whereas others are contraindications for radiotherapy.

 

Absolute Contraindications

  1. Pregnancy – is a contraindication for radiotherapy, as it can lead to teratogenic effects.
  2. Two or more primary tumors in separate quadrants (multicentric tumors). Patients with multifocal tumors (two or more primaries in the same quadrant) can undergo BCS. [Fig 1]
  3. Diffuse malignant-appearing calcifications on mammogram 
  4. History of prior radiation to the breast area
  5. Persistent positive margins
  6. Inflammatory breast cancer

multifocal vs multicentric

 

Relative Contraindications

  1. History of collagen vascular disease – leads to increased radiotherapy associated complications
  2. Breast size to tumor size ratio [Fig 2] – Instead of the absolute size of the tumor, tumor/ breast ratio is a better indicator of whether the patient is eligible for BCS or not. Fig 2 – highlights two patients, both with identical tumor sizes but one patient has a large breast (leading to a small tumor/ breast ratio) whereas the other patient has a small breast (leading to a large tumor/ breast ratio). BCS is avoided in patients with large tumor to breast ratio as it leads to poor cosmetic outcome.

tumorbreastratio

 

Following are NOT contraindications to BCS:

  • Family history of breast cancer
  • Positive lymph nodes
  • Bilateral breast cancer
  • Lobular histology
  • Central quadrant tumor

Importance of regular follow-up after Breast Cancer Treatment

It was quite sad to see this 68 year old lady come to the clinic yesterday. She was diagnosed with left breast cancer two years back and was treated with MRM, adjuvant chemotherapy and hormonal therapy at a private hospital. After her treatment was completed, she did not visit the oncologist again thinking that she has been cured and for the last 6 months she had been harboring this growth over the chest wall, which turned out to be a local recurrence.

Local recurrence after mastectomy

Local recurrence after mastectomy

Patients tend to think that when the treatment is over, they are cured of the disease, but that is not the case. Patients need to visit their oncologists/ doctors regularly after the completion of their treatment and this case points out the importance of correct and regular follow-up after breast cancer treatment.

The current guidelines regarding follow-up of breast cancer patients are:

  1. History & physical examination: Every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter.
  2. Mammography: If mastectomy has been done, then annual mammograms of the opposite breast. If  breast conservation has been done, then B/L mammography should be done annually.
  3.  Breast self-examination. Perform a breast self-examination every month. This procedure is not a substitute for a mammogram.
  4. Pelvic examination. If the patient is on Tamoxifen, annual gynecological check-up should be done because tamoxifen can increase the chances of uterine cancer.

One reason which deters patients from going on regular follow-ups is the fact that some doctors order unnecessary tests during these visits. One should be aware that the following tests are NOT recommended for regular follow-up care of breast cancer patients:

  • Blood tests like CBC, LFT, KFT
  • Chest x-ray
  • Bone scan
  • CT scan
  • FDG PET scan
  • Breast MRI
  • Breast cancer tumor markers – CA 15-3, CA. 27.29, CEA

Paget’s disease of the Breast

Paget’s disease of the breast or nipple is an eczematous condition involving the nipple and areolar skin, which is histologically characterized by the presence of malignant cells interspersed within the keratinocytes of the epidermis (cells of the skin). In approximately 90% of cases, the condition is associated with an in situ or invasive breast carcinoma.

Symptoms:

  • Chronic eczematous lesion involving the nipple (most common presentation) [highlighted in the image]
  • Nipple erythema or ulceration
  • Nipple inversion
  • Nipple discharge
  • Pruritus
  • As many as 40% of women have a palpable mass on presentation, and some may present with enlarged axillary lymph nodes.
Ulceration of the nipple

Ulceration of the nipple

Imaging:

90% patients who present with an underlying breast lump along with Paget’s have abnormal findings on mammography but only 50% patients who present with Paegt’s without a breast lump show mammographic abnormalities. Magnetic resonance imaging (MRI) is increasingly being used, particularly in cases without a palpable mass. MRI is particularly useful to establish extent of disease in patients in which breast-conserving surgery is being contemplated.

Pathology: The hallmark of Paget’s is the presence of neoplastic cells within the epidermis that show abundant clear cytoplasm and tend to spread individually in between the native keratinocytes (Image). They tend to display prominent nucleoli and frequent mitoses. In addition, they commonly show intracytoplasmic mucin-filled vacuoles, which are stained with a periodic-acid-Schiff or mucicarmine stain.

Paget cells seen in the epidermis

Paget cells seen in the epidermis

Paget cells are usually positive for markers of breast epithelium differentiation like:

  • Cytokeratin 7
  • CAM 5.2
  • Low-molecular-weight cytokeratins (negative for high-molecular-weight cytokeratins)
  • Vast majority of cases show strong overexpression of the HER2/neu proteinion of the gene
  • Positive for mucin
  • 18-20% of Paget’s cells express S100 protein but contrary to melanoma cells, HMB45 is consistently negative.

Toker cells are immunophenotypically similar to Paget cells, sharing expression of cytokeratin 7 and CAM 5.2, absence of high-molecular-weight cytokeratin expression, and negative S100- and HMB45-expression. They differ in the negative expression of mucin, HER2/neu, and epithelial membrane antigen. The similarities between Toker and Paget cells have suggested that the former may represent the cell that undergoes malignant transformation in the initial phases of PD. Toker cells can be present in normal patients as well.

The most accepted explanation for the development of PD is that Paget cells result from the migration of cells from the underlying adenocarcinoma through the epidermis, the so-called epidermotropic theory. This theory is supported by the existence of an underlying carcinoma in about 90% of cases of PD, which usually shares phenotypic similarities with Paget cells.

 

Differential Diagnosis:

  • Eczema – tends to be bilateral and responds to topical steroids
  • Nipple adenoma

Diagnosis: 

  • Wedge biopsy
  • Punch biopsy

Management: Management of PD depends on the underlying breast lump. Traditionally, the surgical procedure of choice has been a mastectomy but there are numerous studies which show that breast conservation surgery can be carried out in patients with PD. Prognosis in PD is largely determined by the underlying breast tumor.

 

Source: 1. Bland & Copeland – The Breast. 4th Edition 2. Michael Sabel – Essentials of Breast Surgery

Palbociclib – A novel drug for metastatic breast cancer

The issue which has been lingering on in the Breast cancer community in the last few days has been the significant clinical benefit shown by Palbociclib in patients with advanced breast cancer in a phase 2 clinical trial. The results of the PALOMA-1 trial were discussed in a recently concluded meeting of the American Association for Cancer Research.

Palbociclib is an inhibitor of cyclin-dependent kinases (CDK) 4 and 6 and it inhibits cell proliferation and cellular DNA synthesis by preventing cell-cycle progression from G1 to S phase. In simple terms, it prevents cell division.

In the trial, patients were randomly assigned to the combination of daily palbociclib 125 mg for 3 weeks followed by 1 week off plus continuous daily letrozole 2.5 mg, or to daily letrozole. Treatment continued until disease progression, unacceptable toxicity, or withdrawal from the study, and tumors were assessed every 2 months.

Patients with hormone receptor positive metastatic breast cancer, demonstrated a significantly better progression-free survival as compared to patients receiving only hormonal treatment. The progression-free survival was significantly better with palbociclib plus letrozole than with letrozole alone (20.2 vs 10.2 months; hazard ratio [HR], 0.488; BP = .0004).

Although there was a positive trend seen in the overall survival analysis as well but the survival data was not mature enough to be shared currently.

The drug was well tolerated and the most common adverse effects were neutropenia, leukopenia, fatigue, and anemia.

Although some people are claiming that this drug will turn out to be the next standard of care in metastatic breast cancer, others share a more guarded opinion. There have been quite a few drugs which have shown promise in phase 2 trials but have not performed well in subsequent phase three trials.

The phase 3 trial (PALOMA-2) is currently underway and only time will tell whether Palbociclib is really beneficial or not.

The other issues which Indian patients & doctors need to consider are:

1. Cost & availability of the drug in India; cost/ benefit ratio

2. Overall survival benefit