Programa Integrado de Controle do Câncer Mamário: experiência do Sistema Único de Saúde na região leste da cidade de São Paulo / Integrated Program Control of Breast Cancer: Public Health System experience in the east side of the city of São Paulo

Os autores discorrem sobre as dificuldades existentes no rastreamento mamográfico organizado e apresentam um modelo de gestão para atendimento integral do câncer de mama que vem sendo realizado na cidade de São Paulo, fruto da parceria do Hospital Alemão Oswaldo Cruz (HAOC) e da Escola de Ginecologia e Mastologia Prof. J. A. Pinotti (EGIMAJAP) com a Prefeitura da Cidade de São Paulo (Secretaria Municipal de Saúde) e com o Ministério da Saúde. A intersetorialidade do poder público e privado junto à comunidade contribuem para sustentabilidade de intervenções sanitárias com ampla aceitação social.

The authors discuss the difficulties in the organization of the mammographic screening and present a management model to comprehensive care of breast cancer which is being held in the city of São Paulo, the result of partnership of Oswaldo Cruz German Hospital, Prof J. A. Pinotti?s Gynecology and Mastology School (EGIMAJAP) with the Municipality of São Paulo and Ministry of Health. The intersectoral public and private power with the community contribute to the sustainability of health interventions with broad social acceptance

Is electron beam intraoperative radiotherapy (ELIOT) safe in pregnant women with early breast cancer? In vivo dosimetry to assess fetal dose.

Electron beam intraoperative radiotherapy (ELIOT) is a new technique permitting breast radiotherapy to be completed in a single session. Since ELIOT is associated with much reduced irradiation to nontarget tissues, we carried out a study on nonpregnant breast cancer patients to estimate doses to the uterus during ELIOT to better evaluate the possible use of ELIOT in pregnant breast cancer patients. We performed in vivo dosimetry with thermoluminescence radiation detectors (TLDs) in 15 premenopausal patients receiving ELIOT to the breast (prescribed dose 21 Gy) using two mobile linear accelerators. The TLDs were positioned subdiaphragmatically on the irradiated side, at the medial pubic position, and within the uterus. A shielding apron (2 mm lead equivalent) was placed over the viscera from the subcostal to the subpubic region. TLDs showed mean doses of 3.7 mGy (range 1-8.5 mGy) at subdiaphragm, 0.9 mGy (range 0.3-2 mGy) pubic, and 1.7 mGy (range 0.6-3.2 mGy) in utero, for beam energies in the range 5-9 MeV. These findings indicate that ELIOT with a mobile linear accelerator and shielding apron would be safe for the fetus, as doses of a few mGy are not associated with measurable increased risk of fetal damage, and the threshold dose for deterministic effects is estimated at 100-200 mGy. We conclude that studies on the use of ELIOT in pregnant women treated with conservative breast surgery are justified.

Can axillary and supraclavicular radiotherapy be avoided after breast-conserving surgery and axillary dissection in women with multiple involved axillary nodes? Experience at the European Institute of Oncology.

AIMS AND BACKGROUND: Although some guidelines recommend adjuvant radiotherapy (RT) to the axilla and supraclavicular nodes if 4 or more axillary nodes are involved, the current practice at our Institute is not to irradiate the axilla but to perform complete axillary dissection in which all 3 Berg levels are removed. We performed a retrospective analysis of patients with 4 or more axillary nodes involved and sufficient follow-up to provide indications as to whether our current treatment is adequate. METHODS: We retrospectively analyzed 287 T1-T3 patients with a median follow-up of 5 years and 4 or more involved nodes treated by quadrantectomy and breast RT but no axillary RT; supraclavicular RT was given only when prognostic factors were unfavorable. RESULTS: A total of 170 (59.2%) patients did not receive supraclavicular RT, while 117 (40.8%) patients received supraclavicular irradiation. No patient received axillary RT. After a median follow-up of 5 years (range, 4-105 months), 4.7% had died and 13.5% had developed distant metastases in the no supraclavicular RT group, compared to 12.0% dead (P = 0.028 log rank) and 24.8% (P = 0.201 log rank) in the supraclavicular RT group. No patients with supraclavicular RT developed supraclavicular metastases compared to 4 in the no supraclavicular RT group. There were no axillary recurrences. CONCLUSIONS: Complete axillary dissection appears adequate treatment in patients with 4 or more involved nodes. The low breast recurrence rate also suggests that breast conservation is adequate treatment in such patients. Supraclavicular RT appears to reduce the number of supraclavicular metastases but confers no survival advantage. Although a small number of cases were examined in this retrospective single-center series, all received highly uniform treatment.