Changing global policy to deliver safe, equitable, and affordable care for women's cancers.

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women's health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and women's cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Bilateral adenomyoepithelioma of breast.

Adenomyoepithelioma is a rare tumor characterized by proliferation of two different cell populations. These tumors have a variable biological behavior. Majority of them are benign but have a tendency to recur locally. Malignant transformation is rare in this disease and distant metastasis is rarer still. We report here an unusual case of bilateral adenomyoepithelioma at an unusual age and showing a remarkable response to an unconventional drug, tyrosine kinase inhibitor "imatinib".

Nausea and vomiting after breast cancer surgery, and relationship with tumor receptor status.

BACKGROUND: Breast surgery is associated with frequent post-operative nausea and vomiting (PONV). Studies have suggested that hormonal status affects PONV. Estrogen has been implicated in many emetic syndromes. Estrogen receptor (ER) and progesterone receptor (PR) status in breast tissue are hormonally affected. Kakugawa et al., in 2007, found a clear trend toward higher serum level of estrone, estradiol, and dehydroepiandrosterone sulfate in post menopausal women with PR-positive cancer. PURPOSE: To investigate the possibility of an association between ER and/or PR status of breast tumor and incidence of PONV after breast cancer surgery. METHODS: This observational study included 315 female patients undergoing major breast surgery. Relevant patient data, and intra-operative and postoperative details were noted. Incidence of PONV was noted using the PONV score. Patients were divided into two age groups: less than or equal to 50 years and more than 50 years of age. The ER and/or PR status of the patient was unknown to the investigator until the final analysis. RESULTS: Use of the chi-squared test revealed no association between ER and/or PR and total PONV. Patients below 50 years had higher incidence of total PONV (p = 0.023). In patients above 50 years, the incidence of PONV was higher in the ER-positive group (p = 0.018). CONCLUSION: The incidence of PONV is higher for patients below 50 years of age. The positive association between ER positivity and PONV in patients above 50 years of age could be attributed to the altered hormonal milieu in these patients and should be investigated further.

Estimation of survival rates of breast cancer patients--a hospital-based study from Mumbai.

PURPOSE: To estimate the survival rates of breast cancer patients with reference to various factors like age, literacy status, residential status, T-stage and treatment. This is because there are very few studies reported from Indian subcontinent. METHODS: Survival rates were obtained by using the actuarial method and loss-adjusted survival rate method (LAR) for the above factors and the rates were compared. The present study carried out at the Tata Memorial Hospital (TMH), includes newly diagnosed (who were not treated elsewhere before attending TMH) primary breast cancer patients and having completed the initial treatment. RESULTS: The survival rates, actuarial survival and rates corrected for losses to follow-up (LAR) are presented. It showed that younger patients ( 50 years), with statistical significance ( p=0.024). There was no variation in survival with regard to the residential status but literate patients had a better ( non-significant) survival (77%) than their illiterate counterparts. T3-stage patients had the worst prognosis showing a 5-year survival of 60% (p=0.0002). Survival for those treated with surgery as the only modality and also in combination with other modalities did not show any remarkable differences except for the group that were treated with 'surgery in combination with chemotherapy'. The 5-year survival for those treated with surgery as the only modality was 83%. This study yielded useful information on breast cancer survival, especially in a situation with incomplete follow-up. The method applied (LAR) also clearly demonstrates the bias in estimates obtained by direct application of the standard actuarial method.

Spectrum of HIV/AIDS related cancers in India.

OBJECTIVE: To study the cancer pattern among HIV positive cancer cases. METHOD: The study group included patients registered in the HIV Cancer clinic at the Tata Memorial Hospital (TMH), Mumbai, which is the largest tertiary referral cancer center in India. We used the gender and age-specific proportions of each cancer site of the year 2002 that was recorded in the Hospital Cancer Registry to estimate an expected number of various cancer sites among HIV positive cancer patients during the period 2001-2005. The observed number of site-specific cancer cases was divided by the expected number to obtain proportional incidence ratio (PIR). RESULTS: No case of Kaposi's sarcoma was observed. Increased proportion of non-Hodgkin's lymphoma (NHL) was observed (PIR in males = 17.1, 95%CI 13.33-21.84, females = 10.3, 95%CI 6.10-17.41). In males, PIR was increased for anal cancer (PIR = 10.3, 95%CI 4.30-24.83), Hodgkin's disease, testicular cancer, colon cancer, and few head and neck cancer sites. Among females, the PIRs for cervical cancer (PIR = 4.1, 95%CI 2.90-5.75), vaginal cancer (PIR = 7.7, 95%CI 2.48-23.85), and anal cancer (PIR = 6.5, 95%CI 0.91-45.88) were increased. CONCLUSIONS: The absence of Kaposi's sarcoma and increased PIRs for certain non-AIDS defining cancers among HIV infected cancer cases indicates a different spectrum of HIV associated malignancies in this region. The raised PIR for cervical cancer emphasizes the urgent need for screening programs for cervical cancer among HIV infected individuals in India.

Changes in the tumor grade and biological markers in locally advanced breast cancer after chemotherapy--implications for a pathologist.

There is insurgence of literature evaluating prognostic and predictive factors in breast carcinomas treated with chemotherapy, with a parallel need to develop guidelines for the pathologist interpreting such excisions. Prechemotherapy gun biopsy and postchemotherapy excision specimens from 78 women with locally advanced breast cancer were analyzed for histological changes in the tumor, changes in the tumor grade, hormone receptors, cerb2, and bcl2 and their impact on disease-free survival (DFS). An unusually prominent granulomatous response to tumor was seen in three cases. The tumor grade changed in five patients, estrogen receptor (ER) expression was altered in 10 cases, progesterone receptor detection changed in 16 cases, cerb2 in one case and bcl2 in 16 cases. Fixation of the gun biopsy in Bouin's fluid and severe damage of nuclei after chemotherapy were the reasons for shift in the expression of hormone receptors. A low-grade tumor was associated with better response to chemotherapy. In the Kaplan-Meier analysis the ER expression and a low-grade tumor (grade I and II) significantly affected DFS. None of the factors evaluated impacted the overall survival of patients. To conclude there is a change in the tumor grade, bcl2, cerb2 and hormone receptors after chemotherapy. A pathologist interpreting specimens of breast cancer after chemotherapy must always record the postchemotherapy grade as it is an indicator of better response to chemotherapy and survival.

Fibromatosis-like carcinoma-an unusual phenotype of a metaplastic breast tumor associated with a micropapilloma.

BACKGROUND: Fibromatosis-like metaplastic carcinoma is a newly described metaplastic breast tumor, literature on which is still evolving. CASE PRESENTATION: A 77-year-old lady presented with a 2 x 2 cm mass with irregular margins in the upper and outer quadrant of left breast. Fine needle aspiration cytology (FNAC) from the lump was inconclusive. A lumpectomy was performed and sent for frozen section, which revealed presence of spindle cells showing mild atypia in a sclerotic stroma. The tumor cells revealed prominent infiltration into the adjacent fat. A differential diagnosis of a low-grade sarcoma vs. a metaplastic carcinoma, favoring the former, was offered. Final histology sections revealed an infiltrating tumor with predominant spindle cells in a collagenous background, simulating a fibromatosis. Adjacent to the tumor were foci of benign ductal hyperplasia and a micropapilloma. Immunohistochemistry (IHC) showed diffuse co-expression of epithelial markers i.e. cytokeratins (CK, HMWCK, CK7) and EMA along with a mesenchymal marker i.e. vimentin in the tumor cells. Myoepithelial markers (SMA and p63) showed focal positivity. A diagnosis of a low-grade fibromatosis-like carcinoma breast associated with a micropapilloma was formed. CONCLUSION: Fibromatosis-like carcinoma is a rare form of a metaplastic breast tumor. This diagnosis requires an index of suspicion while dealing with spindle cell breast tumors. The importance of making this diagnosis to facilitate an intra operative surgical planning is marred by diagnostic difficulties. In such cases, IHC is imperative in forming an objective diagnosis.

Primary angiosarcoma of the breast: observations in Asian Indian women.

BACKGROUND: Primary angiosarcomas of breast are rare tumors, with a fatal outcome. MATERIAL AND METHODS: We studied histological prognostic factors and c-kit expression by immunohistochemistry (IHC) in 12 angiosarcomas accessioned at a cancer referral center in India. RESULTS: All patients had primary angiosarcoma; no case of secondary angiosarcoma was accessioned during the study period. Median age of patients was 24.5 years. Nine patients had intermediate grade tumors, one a well differentiated tumor and three patients had high-grade tumors. Interesting cases encountered included an epithelioid angiosarcoma and an angiosarcoma arising on the background of a biphasic tumor. Eight patients had lumpectomy, four mastectomy and two patients were given radiotherapy. Of the nine patients (seven type I/II and two high grade) with follow up, eight patients developed disseminated metastases within a year of presentation. The patient with well-differentiated angiosarcoma also died of metastasis albeit after a longer time. On IHC c-kit staining was weakly seen in two cases. CONCLUSION: Primary angiosarcoma was fatal in young Indian women even in lower grade tumors. The low expression of c-kit on IHC suggests that targeting this protein for therapy may not be successful in treating these tumors.

Immunocytochemistry on scrape cytology in breast cancer: will it unearth the weaker positives?

OBJECTIVE: To standardize the technique of immunocytochemical (ICC) assessment of estrogen (ER) and progesterone receptor (PR) status in breast cancer by scrape cytology and to compare the results with immunohistochemistry on paraffin blocks. STUDY DESIGN: ICC assessment for ER and PR was done on scrape smears from tissue samples in 200 cases of primary breast cancer. The results were compared to those obtained from immunohistochemical (IHC) evaluation of formalin-fixed paraffin same tissue samples. RESULTS: ER/PR positivity rates as well as staining scores were compared between the scrape smears and tissue sections. The concordance between cytology and histology was 84% for ER and 90% for PR. Both the positivity rates and the staining intensity scores were higher for cytochemistry than for histochemistry. CONCLUSION: The ICC method on scrape smears is a simple test with rapid turnaround time. The sample required is small, and antigen loss due to fixation and processing is minimal. This new method gives a higher yield of hormone receptor positivity and, when used in conjunction with the IHC method, may improve the pickup rate of ER-positive cases, thereby playing an important role in risk stratification and therapeutic decision making in patients with breast cancer.