1. CASE 1: Management of metastatic disease in a resource-limited setting
Dr Sitna Mwanzi
Medical Oncologist
Aga Khan University Hospital
22nd April 2016

2. Objectives Case presentation Diagnostic challenges
Treatment challenges

3. Case Presentation 35 year old female
3 month history of cough, progressive difficulty in breathing and chest pain
Associated 5kg weight loss
On and off fever
Non smoker, does not take alcohol
Married with two children, home maker
No chronic illnesses

4. Reviewed at local hospital:
CXR as shown
Pleural removal done – suggestive of TB
Started on anti TB medication
No improvement after 1 month
Referred to tertiary hospital

5. Review at referral hospital
Found to have large nodes in the armpit(axilla)
CXR – persistent of pleural fluid
Testing of fluid – positive for cancer cells
Mammography – 3cm lump
Ultrasound of abdomen – multiple liver metastases
Biopsy of lymph nodes – invasive ductal carcinoma, ER and PR positive, Her 2 negative

7. Goals of treatment
Break ‘bad news’ – ‘I am afraid the news is not good……you have breast cancer……and it has spread to your lungs and liver…….’
Manage symptoms – physical and psychological
Reduce disease burden to prolong survival and improve quality of life

8. For this patient Further tests Treatments CA 15 -3 (tumor marker)
Blood count, liver and kidney function tests
? Bone scan ? Role of PET/CT
Treatments
Palliative treatment (see overleaf)
Ongoing psychological support

9. Palliative treatment Tamoxifen Anastrazole Exemestane and everolimus
June
2012
Pleural fluid drained;
1st line chemo (ACx6)
Jan
2013
Tamoxifen
April 2014
Anastrazole
October 2014
Exemestane and everolimus
March
2015
2nd line chemo (Xeloda)
Jan 2016
3rd line chemo (Docetaxel)

10. Diagnostic Challenges
Similar symptoms to other diseases can delay diagnosis
Multiple tests required (x rays, CT scans, mammogram, bone scan, biopsy, blood tests)
Need for repeated testing during follow up

11. Treatment Challenges
Multiple lines of treatment needed (good news and bad news)
Other modalities of managing symptoms
Fluid tapping
Radiotherapy
Bone modeling drugs
Pain killers
Psychological support
Cost of treatment
Side effects

12. Treatment Challenges Drug holidays When to stop
Treatment closer to patient’s home
International referrals for metastatic disease

14. Advocate for… Patient and health care worker awareness
It could be cancer
Metastatic disease ≠ Death
Improved public and private health care facilities
Improve public private partnerships
Cancer drugs in the essential drug list
Increased cover by NHIF and other insurance companies