This week (15 January 2013) the National Institute of Health and Clinical Excellence (NICE) launched a consultation process to report on updated guidelines for the management of familial breast cancer. These new guidelines provide advice on genetic testing, breast screening and drug therapy for patient with a moderate or high risk for developing breast and/or ovarian cancer according to their family history.
One of the key developments contained in these guidelines is the potential for patients with a high-risk family history to be treated by chemoprevention with the drugs tamoxifen or raloxifene. High risk is defined as (1) a lifetime risk > 30%, (2) a > 10% probability of having a BRCA1 or 2 mutation or (3) a 10-year risk of >8% at age 40. It is estimated that only around 1% of all women >30 years of age fall into the high risk category but both pre- and post-menopausal high risk women would be eligible for five years of drug therapy under the new guidelines. In addition, drug therapy will also be considered for pre- and post-menopausal women at moderate risk of developing breast cancer within the next ten years. Estimates have been provided that suggest that for every 1000 women given Tamoxifen 20 fewer breast cancers will be diagnosed.
At present women with a high family history risk of breast cancer, or those who carry a mutation of either BRCA 1 or BRCA2 genes, are offered risk-reducing mastectomy by their breast cancer surgeon and this can be combined with immediate breast reconstruction. While this type of prophylactic mastectomy can reduce the breast cancer risk by as high as 95-98%, the use of drug therapy may provide an alternative treatment strategy for those patients who do not want such extensive surgery unless they have a past history of thromboembolic disease (deep venous thrombosis/pulmonary embolus) or endometrial cancer.
Deciding who will benefit from chemotherapy following surgery for early breast cancer is one of the most difficult decisions for breast surgeons and breast oncologists. Although this process has traditionally been more about art rather than science, a number of models are now available to help doctors estimate the survival and benefits of different treatments for individual patients after Breast Cancer Surgery including the Nottingham Prognostic Index (NPI), Adjuvant and PREDICT. Until now, these have all been based on certain pathological prognostic factors including the tumour size, tumour grade and number of positive lymph nodes.
The NPI was first described in1982 and has been regularly validated and updated to provide accurate survival estimates following breast cancer surgery. The introduction of Adjuvant, a web-based (www.adjuvantonline.com) computer tool, in 2001 went a step further by also providing actual treatment benefits for hormone therapy and chemotherapy. Prognostication is becoming more sophisticated however, and additional factors should now be considered in any current prognostic and treatment benefit model. There is a growing body of evidence to show that a patient with an impalpable cancer detected by mammographic breast screening has a better survival compared to a patient who presents with a lump at the same stage. In addition new pathology tests are now performed on breast cancers including measurement of HER2, a receptor found in approximately 10% of early breast cancers that is a sign of a more aggressive breast cancer and a predictor of response from Herceptin, one of the newer targeted breast cancer drugs.
PREDICT is an online prognostication and treatment benefit tool developed in the UK during the last three years by a team of clinicians and scientists led by Consultant Breast Surgeon, Professor Gordon Wishart. The original PREDICT model included the method of cancer detection (lump or detected by mammogram) and provides 5-and 10-year survival estimates as well as treatment benefit predictions for hormone therapy and chemotherapy at both time points. PREDICT has now been updated to include HER2 result (positive or negative) and the benefit of Herceptin and was the first prognostic model used by breast surgeons to include HER2. Recently, PREDICT has recently been updated once more to include KI-67, a breast cancer marker that tells how fast a breast cancer is growing. PREDICT has been directly compared with Adjuvant in published studies and provides more accurate estimates of breast cancer survival than the older model. The inclusion of KI-67 is likely to make PREDICT the most popular prognostic tool used by breast surgeons in the UK. PREDICT is now available online at www.predict.nhs.uk.
Indocyanine Green (ICG) Fluorescence Avoids use of Radioisotope for Sentinel Node Biopsy for Breast Cancer
During the last two decades, there have been several major advances in Breast Cancer Surgery including use of oncoplastic techniques and breast reconstruction to improve cosmesis following wide excision and mastectomy respectively. Furthermore, skin-sparing mastectomy, where all of the skin is preserved during mastectomy and Breast Reconstruction, can now be offered by most breast cancer surgeons.
One of the most significant advances in breast surgery has been the introduction of sentinel node biopsy to stage the axilla in early breast cancer and thus avoid axillary clearance for patients with negative lymph nodes. This has resulted in close to 70% of patients now avoiding an axillary clearance with the known side effects of shoulder stiffness, numbness in the upper arm and lymphoedema of the arm.
Since introduction almost ten years ago, sentinel node biopsy has been performed by breast surgeons using a combination of blue dye +/- radioisotope injections to highlight the sentinel node(s) which is the first nodes or nodes in the axilla (underarm area) that drain the lymphatic fluid from the breast. If tumour cells have spread from the primary tumour in the breast, then they are likely to be present in the sentinel nodes. Patients who have tumour cells in the sentinel lymph nodes will normally require an axillary clearance and are more likely to require additional treatments including chemotherapy.
Use of radioisotope for sentinel node biopsy in breast and other cancers has a number of drawbacks including worldwide shortages of radioisotope, expense and cumulative radiation exposure to healthcare workers. Indocyanine green (ICG) is a safe fluorescent dye that has been used in other areas of medicine and recently has been used to visualise the lymphatics and sentinel lymph nodes in breast cancer. A recent study published in the European Journal of Surgical Oncology by Wishart et al has shown that use of ICG is safe and very effective at displaying the sentinel lymph nodes in early breast cancer (1). In this study the combination of blue dye and ICG had the highest sensitivity for sentinel node detection thus allowing a combined approach that avoids the use of radioisotope.
The Cambridge study, is the first UK study to compare the use of ICG for sentinel node biopsy with blue dye +/- radioisotope and further studies using this approach are planned in the near future. All patients without clinical or radiological evidence of positive lymph nodes should now be offered sentinel node biopsy by their Breast Surgeon. The use of ICG may improve this technique even more by avoiding exposure of patients, Breast Surgeons and other healthcare workers to radioisotope.
(1) Wishart GC, Loh S-W, Britton PD, Jones L, Benson JR. A feasibility study (ICG-10) of indocyanine green (ICG) fluorescence mapping for sentinel lymph node biopsy in early breast cancer. Eur J Surg Oncol 2012; 38(8): 651-6.
The independent review of breast screening in the UK, instigated by the national cancer director Professor Mike Richards, has concluded that breast screening continues to save up to 1300 lives each year in the UK and will remain a cornerstone of the NHS screening programmes in the UK.
The panel was assembled to review previous criticisms of breast screening including a lack of clear and balanced literature for women attending for breast screening as well as the risks of over-diagnosis and overtreatment of harmless breast cancers identified by screening.
The NHS patient literature will now be updated in light of the review and patients will be reassured that screening continues to save lives but that some women may have a breast cancer diagnosed and treated that would never have come to light in their lifetime.
Cambridge-based scientists are contributing to the search for tests that will identify these harmless screen-detected breast cancers, with the publication of a landmark research paper in Nature earlier this year which defined 10 different subtypes of breast cancer according to their genetic architecture, so that unnecessary treatment can be avoided. In addition Predict, an online survival and treatment benefit tool that was developed in Cambridge, is the first prognostic model that demonstrates the improved survival and lower treatment benefits for women with screen-detected breast cancer. Gordon Wishart, consultant breast surgeon and Professor of cancer Surgery at Anglia Ruskin University, was an author on the Nature landmark genetics paper and has led the team of Cambridge scientists that have built the Predict survival model.
Prof GC Wishart
30 October 2012
Leading Clinicians Support Launch of Innovative Early Detection Programmes for Prostate and Lung Cancer at Work
24 September 2012
EMBARGOED until 4th October 2012
LEADING CLINICIANS SUPPORT LAUNCH OF INNOVATIVE EARLY DETECTION PROGRAMMES FOR PROSTATE AND LUNG CANCER AT WORK
Media invited to attend launch
Free health check offered to journalists
HealthScreen UK, a leading provider of private cancer early detection programmes for corporates, is launching two new health checks for prostate and lung cancer using the latest advanced diagnostic tools to improve early diagnosis for two of the most common cancers.
ProstateCheck, available for the first time globally, will reduce the number of unnecessary biopsies by up to 50%. LungCheck is four times more likely to correctly identify lung cancer than low-dose CT.
HealthScreen UK is an exclusive provider of awareness and early detection services from LungHealth UK and ProstateHealth UK as well as for breast and skin cancer and has educated thousands of employees about cancer awareness.
The new services are endorsed by three internationally renowned cancer consultants – urological surgeon, Prof David Neal, Professor of Surgical Oncology at the University of Cambridge and Clinical Director for ProstateHealth UK; Mr Francis Wells, Consultant Cardiothoracic Surgeon at Papworth Hospital and Clinical Director for LungHealth UK; and Prof Gordon Wishart, a consultant breast and endocrine surgeon and Medical Director for HealthScreen UK.
The new services will be launched on Thursday, 4 October at Home House, Portman Square, London, 9.30 – 11.30 am when the three consultants will make presentations about the benefits of HealthScreen UK’s new early detection services, as well as speaking about cancer at work and what companies can do to be prepared.
Prostate cancer is the most common cancer for men in the UK. ProstateHealth UK has secured rights to a new cancer specific biomarker, human glandular kallikrein 2 (hK2) which, when used with a combination of total, free and intact Prostate Specific Antigen (iPSA), has been shown in studies to considerably reduce the number of unnecessary biopsies in patients with an abnormal PSA test result by up to 50%. The use of this panel of 4 biomarkers is a more accurate method for the detection of clinically relevant prostate cancer.
Prof Neal, who last December was named by The Times as one of the top surgeons in his field in the UK, said: “ProstateCheck combines the biomarker panel with risk assessment and symptom score and is a major development for the early detection of prostate cancer. Prostate cancer in its early stages produces no symptoms and men with faster growing cancers benefit from early detection.
“Providing ProstateCheck in the workplace and for private self-paying individuals ensures that men, particularly those over 40 who are most at risk, can benefit from this new exciting development. As a result, a significant number of men with mildly raised PSA levels will not need to go through unnecessary biopsy procedures, and an appropriate referral can be made for cases where further investigation is recommended.”
Lung cancer is the second most common cancer for men in the UK and the third most common cancer among women. LungCheck offers significantly improved cancer detection by providing a unique blood test which is four times more likely to correctly identify lung cancer compared to a low-dose CT scan which is most commonly used to detect lung cancer. The blood test, which is based on a panel of seven biomarkers produced as part of the immune response to lung cancer, can detect early stage lung cancer and multiple pathological types.
Mr Wells, also recognised in The Times article as being one of the top surgeons in his field in the UK, said: “People with lung cancer often have no obvious symptoms and it is often detected later in the development of the disease when it is difficult to cure. I am thrilled that we can offer LungCheck in the workplace and to private self-paying individuals to improve early diagnosis, particularly to smokers who are most at risk, which could save lives. The service is available to non-smokers too.”
Prof Wishart, an expert on cancer in the workplace:
“Eight per cent of all cancer deaths, and more than 20% of lung cancer deaths, are caused by occupational exposure. There is also clear evidence that female night shift workers have an increased risk of breast cancer. Based on this type of evidence, a number of employers have recognised the benefits of providing cancer health checks for their staff.”
“We need to raise awareness about cancer risks in the workplace by educating staff and providing early detection using the very latest and most effective technology.”
“The government is actively encouraging corporate screening and companies should be congratulated for providing these checks and caring for the health and wellbeing of their staff, which ultimately leads to more productive employees who feel valued, as well as leading healthier lives.”
John Picken, Managing Director of HealthScreen UK, added;
“The Health and Safety Executive estimates 13,500 new diagnoses of work related cancer each year and the TUC estimates over 15,000 deaths. By comparison, there are just 250 deaths a year as a result of an immediate injury at work. Couple this with the increasing incidence of the most common cancers and employers have every incentive to give their employees much greater access to cancer awareness and early detection.”
“In the absence of any national screening programme, our two new unique services for prostate and lung cancer will have a dramatic, positive impact on the significant emotional and financial costs involved.”
Hewlett Packard recently took part in a prostate cancer awareness campaign with ProstateHealth UK which resulted in 12 cancers being detected. Sharon Ellerker, HR Director for UK and Ireland, said it proved most beneficial.
“We wanted to raise awareness across the whole HP community. A significant number of our male employees are over 40 and by investing in this campaign, we hope to have given them an understanding of their risk and the tools for early detection.
“The identification of 12 cancers which would have gone undetected otherwise fully justifies our investment and the feedback we have overall has been extremely positive.”
Notes to Editors
1. HealthScreen UK works with employers, their advisers and their insurers to provide the most accurate cancer screening detection tests using the latest advanced diagnostic tools.
2. Providing education and awareness helps employees become the best first line of defence against the rising incidence of the most common cancers.
3. The growing number of employers using HealthScreen UK’s services includes some of the world’s largest organisations.
4. HealthScreen UK has delivered the largest corporate awareness and early detection campaigns for skin and prostate cancer,
5. Services can be delivered on-site at clients’ premises or in more than 50 clinics throughout the UK.
6. The services are readily affordable starting at £5.00 per month under salary sacrifice arrangements
7. All services are clinically governed by leading specialists in their field.
8. Digital images of the key speakers are available on request.
9. Journalists prostate, lung, breast or skin cancer. Please call Marketing Manager Debbie Fuller on 07801 054640 for further details.
10. For media enquiries or interview requests, please contact Press Consultant Ellee Seymour on 01353 648564 or Marketing Manager Debbie Fuller on 07801 054640
A recent initiative by the UK Health & Safety Executive has been investigating occupational cancer risk in the UK and Europe. The findings, recently published in a special edition of the British Journal of Cancer, show that 8% of all cancer deaths are due to occupational exposure to one or more carcinogens. The most striking evidence for an occupational link to breast cancer however, is that shift work is now recognised as a carcinogen for breast cancer. During the last 20 years there has been a significant rise in female shift work, and 30% of women now have a shift pattern that involves night work. It has been shown that exposure to light at night alters circadian (biological) rhythms that lead to genetic changes in key cancer pathways. Based on a number of studies that have looked at night shift workers, it as been shown that the increased risk can be as high as 56% above normal risk. The highest risks occur in those women with the longest exposure to night shift and are probably only significant after 10-15 years.
With an average UK lifetime breast cancer risk of 12.5% (1 in 8 women), this increases to 19.5% (1.56 x 12.5%) with prolonged night work. Further studies in flight personnel have shown an increased risk of 44%, increasing the breast cancer risk to 18% (1.44 x 12.5%). It is now thought that up to 5% of all breast cancer cases are caused by night shift work. In the UK, with nearly 50,000 newly diagnosed cases per annum now, this means that up to 2500 new cases each year are being caused by an avoidable risk factor.
Breast cancer is now a major health issue in Europe and other developed countries. At present 1 in 8 (or 12%) women will develop breast cancer in their lifetime and by the year 2024 that figure will rise to 1 in 7 or 14%. It should be no surprise therefore that most people will now know someone, a friend or relative, who has had breast cancer.
Despite this rising incidence of breast cancer, the number of deaths from breast cancer has been decreasing since the late 1980’s and there are several reasons for this:
1. Women are more breast aware and present with tumours at an earlier stage.
2. The introduction of national breast screening programmes
3. More effective treatments and targeted therapies
3. The creation of multidisciplinary teams – teams of breast cancer specialists who work together to optimise individual breast cancer treatment.
In Cambridge we have had a strong multidisciplinary team for the last 12 years – surgeons, radiologists, pathologists, oncologists working in a purpose-built facility to deliver the very best in breast cancer treatment. This delivery of clinical excellence is built on evidence-based guidelines and a strong tradition of clinical research.
We are very proud that the survival of women treated for breast cancer in Cambridge is now equivalent to the best countries in Europe: Norway, Sweden and Finland and we have an international reputation for clinical and research excellence.
A large part of the success in beating breast cancer in Cambridge is due to:
1. One-stop clinics for diagnostic imaging and biopsy
2. Strong multidisciplinary care where all patients having a biopsy or surgery are discussed by the specialist team
3. Evidence-based guidelines updated every year in light of new research evidence
4. State of the art surgery including immediate breast reconstruction, oncoplastic surgery to improve cosmesis following breast conserving surgery and sentinel node biopsy
4. New technology for the diagnosis and treatment of breast cancer when it is validated and ready for clinical use.
It is extremely important that women realise that 2/3 of women now survive 20 years after optimal breast cancer treatment and that women treated by specialists live longer. With ongoing research into the diagnosis and treatment of breast cancer it is hoped that this figure will become even higher in the years to come.
Incidence of breast cancer (www.cancerresearchuk.org)
More than 1 million cases of breast cancer are now diagnosed worldwide each year.
The lifetime risk is now 1 in 8 women which will rise to 1 in 7 women by the year 2024.
This represents 10% of all new cancers and 23% of female cancer cases.
Lowest rates are in rural Africa and Asia where women still have many children, early first pregnancies and breast feed for a long period of time (all three factors lower breast cancer risk)
Highest rates of breast cancer are in USA
Breast cancer rates are increasing year after year in Western populations
Breast cancer rates are higher in more affluent (richer) social classes
Breast cancer rates increase when breast screening programmes are introduced.
Traditionally lower breast cancer rates in Central/Eastern Europe and the Far East are rising rapidly. In China the increase has been caused by a drop in the birth rate and exposure of Chinese women to lifestyle risk factors including weight gain, alcohol and hormone replacement therapy.
Factors that increase breast cancer risk
Age: breast cancer risk is strongly related to age with more than 80% of cases occurring in women over 50 years of age.
Having a family history of breast cancer
Hormonal: Early onset of periods, late stopping of periods, having no children, not breastfeeding
Obesity in post-menopausal women
Hormone replacement therapy
Most cancers (>90%) can now be diagnosed without surgery using a process called triple assessment:
1. clinical breast examination
2. breast imaging (mammography & breast ultrasound)
3. needle biopsy under local anaesthesia in the clinic
This can be provided in a “one-stop” diagnostic clinic with all the tests being performed during a single visit.
This means that most women will leave the clinic with a diagnosis.
Triple assessment has a diagnostic accuracy of 99.6%1
1Britton PD, Duffy S, Sinnatamby R, Wallis M, Barter S, O’Neill A, Carlos C, Brenton JD, Forouhi P, Wishart GC. One-stop diagnostic breast clinics: how often are breast cancers missed? Br J Cancer 2009; 100: 1873-1878.
Breast Cancer Survival
Breast cancer survival is increasing in UK since the 1980’s due to development of specialist teams (like Cambridge), earlier detection due to greater awareness and breast screening, and better access to treatment following surgery (chemotherapy, radiotherapy, hormone therapy).
Women treated by breast cancer specialists live longer2,3
2Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the West of Scotland. BMJ 1996; 312: 145-148.
3Kingsmore D, Hole D, Gillis C. Why does specislist treatment of breast cancer improve survival? The role of surgical management. Br J Cancer 2004; 90: 1920-1925.
2 out of 3 women (66%) now live for 20 years following breast cancer treatment
Women with breast cancers detected by screening mammograms live longer as they tend to present with smaller tumours that are less likely to have spread4,5
4Wishart GC, Greenberg DC, Britton PD, Chou P, Brown CH, Purushotham AD, Duffy SW. Screen-detected versus symptomatic breast cancer-is improved survival due to stage migration alone? Br J Cancer 2008; 98: 1741-1744.
5Dawson SJ, Duffy SW, Blows FM, Driver KE, Provenzano E, LeQuesne J, Greenberg DC, Pharoah P, Caldas C,Wishart GC. Molecular characteristics of screen-detected vs symptomatic breast cancers and their impact on survival. Br J Cancer 2009; 101(8): 1338-44.
Breast cancer survival in Cambridge UK and surrounding region similar to best countries in Europe (Norway, Finland)6
6Wishart GC, Caldas C, Brown CH, Greenberg DC. East of England breast cancer survival close to best in Europe. Cancer res. 2009; 69(suppl.): 615s.
Professor Gordon Wishart, a leading Cambridge-based breast cancer surgeon and former director of the Cambridge Breast Unit at Addenbrooke’s Hospital, opened a centre of excellence for the diagnosis and treatment of breast cancer in Athens in July 2010. In collaboration with a Greek breast surgeon, Dr Vassilis Pitsinis, Professor Wishart has ensured a smooth transfer of knowledge and clinical experience built up over 12 years in Cambridge, where the breast cancer survival is now among the highest in Europe.
Professor Wishart is now a consultant breast and endocrine surgeon in Cambridge, with clinics and surgery at the Spire Cambridge Lea Hospital and the Cambridge Nuffield Hospital, and has been Professor of Cancer Surgery at Anglia Ruskin University, Cambridge from 2008 to date. Professor Wishart also has a busy medico-legal practice where he specialises in cases of clinical negligence related to breast cancer. As the pioneer of the recently launched breast cancer survival model PREDICT (www.predict.nhs.uk), Professor Wishart is ideally placed to advise both defence solicitors and claimants on both breach of duty and causation related to cases where there has been a delay in diagnosis of breast cancer.
In this article Professor Wishart discussed some of techniques and diagnostic facilities that are now available in Athens as well as his early experience of looking after Greek women.
1. Why should a woman with breast cancer rather go to a specialised Breast Cancer clinic?
There is a very simple answer to this question. Women with breast cancer who are treated by breast cancer specialists live longer. Specialised clinics are run by multidisciplinary teams of breast cancer surgeons, radiologists, pathologists, oncologists, radiotherapists and specialist breast care nurses. This means that you can have full access to all diagnostic tests and treatments by the same team who know you and your personal history extremely well.
2. Are there advanced (new) therapies/methods available? (I have been told about a new method that you use. What is this all about?)
We have recently introduced a new method of sentinel node biopsy. Sentinel node biopsy is a surgical technique where the first group of lymph nodes is removed through a small incision under the arm to look for evidence of metastatic spread from the primary tumour. Traditionally in Europe this is performed by injecting the breast with a combination of blue dye and radio-isotope to make the “sentinel nodes” radioactive or blue but there are many potential problems with using radio-isotope including radiation exposure for patients and surgeons and a worldwide shortage of radio-isotope. Following recent research studies in Japan, Germany and Cambridge we can now use a fluorescent dye called IndoCyanine Green (ICG), instead of the radio-isotope, making the sentinel node procedure safer and more straightforward to perform. I am delighted to say that this method of sentinel node biopsy using ICG is available exclusively in Greece at the Cambridge Breast Clinic at Mitera Hospital.
3. Are your diagnostic tools more advanced?
I believe that the diagnostic process that we have introduced, called a “one-stop clinic” is more advanced rather than the tools themselves. The process involves coming to the breast clinic and having all your tests at the first clinic appointment. This process is called “triple assessment” and involves three components: 1. clinical breast examination by a specialist breast surgeon, 2. breast imaging (digital mammography, breast ultrasound) and 3. a tissue biopsy if necessary.
I am aware that many women in Greece still have their breast lump removed under a general anaesthetic to make the initial diagnosis. This is completely unnecessary as the diagnosis can be made by carrying out a small tissue biopsy through the skin under local anaesthetic in the clinic. This type of biopsy has been common in UK and Europe for the last ten years and allows the diagnosis to be made without actual surgery. A recent research study of over 7000 patients in Cambridge showed that triple assessment has a diagnostic accuracy of 99.6%.
4. Your techniques are innovative and have been characterized controversial in the past. What’s new in this field?
Pioneers in any field are often accused of being controversial. In Cambridge during the last 12 years we have pioneered many different techniques and clinical developments including immediate breast reconstruction at the time of mastectomy, the development of specialist breast care nurses, early discharge of patients with their drain still in place, sentinel node biopsy and use of computer models to predict survival and treatment benefits after breast cancer surgery. All of these developments have now been adopted nationally in the UK.
5. Why an interdisciplinary approach necessary in the fight against breast cancer? What kind of specialists does it have to embrace?
The multidisciplinary team had become a central part of the diagnosis and treatment in UK and Europe. The main difference is that all team members meet weekly to discuss ALL patients who have had a breast biopsy or who have had breast surgery. A team approach, rather than individual approach, is much more likely to produce the best treatment advice for individual patients. A central part of the team is the breast care nurse specialist who can provide emotional and psychological support to each patient as they pass through their treatment pathway.
6. Do you use infrared BreastScan in your clinic? How does it work? What benefits does it have? What population is it aimed to?
A recent research study in Cambridge showed that Digital Infrared BreastScan is effective at detecting breast cancer, especially in younger women where mammography is less effective due to the increased density of breast tissue. The sensitivity for breast cancer detection in women under 50 in this study was 78%. This is one of the technologies that I hope to introduce to Athens once we have fully established the Cambridge Breast Clinic as a centre of excellence for the diagnosis and treatment of breast cancer.
7. What comes after the biopsy? What is different in your clinic?
After the diagnostic biopsy, we send the tissue to one of the foremost breast cancer pathology teams in the UK in London. We receive the result within 5 working days and we then discuss this result at our multidisciplinary meeting together with the clinical and radiological findings. This allows us to plan the optimal initial treatment which is usually surgery. Some tumours however are best treated initially by chemotherapy, to shrink the tumour down before surgery, and therefore we are very fortunate to work with an excellent oncology team who provide valuable input to our team meetings. By planning treatment in this way we can pull on the vast range of expertise from each team member to ensure that our patients receive the very best and most up to date treatment.
8. What can you tell about Greek women and breast cancer so far?
I am aware that Greek women like to obtain many different opinions before making a decision about their breast cancer treatment. I would like to reassure them that by coming to our clinic you are receiving the collective “opinion” of many different experts in breast cancer treatment and not the thoughts of a single clinician. I am also aware that many unnecessary scans are done for these women even before a biopsy and diagnosis is made. Although our approach is commonplace in UK and Europe I am conscious that it may seem alien to women in Greece but all the women who have been seen in our clinic to date have provided excellent feedback about the high standard of care that they have received.
9. Are you also conducting research on treatment prediction? What are your findings?
I have been interested in survival and treatment benefit predictions for many years and until recently we used a computer model developed in Texas, USA. I have always been concerned that this model, which is based on the survival and treatment of women in the US, may not be relevant or valid for women in the UK or Europe. During the last 2 years I have led a research team that has built a new survival and treatment benefit model (PREDICT) based on over 5000 women treated in the East of England. The model has now been validated and is available for use in Greece at our clinic. It can predict the 5-year and 10-year survival, as well as the benefits of chemotherapy and hormone therapy, with a high degree of accuracy and contributes to ensuring that women with breast cancer receive the very best treatment by our clinical team.
10. There is specialised nursing staff in the clinic. What special about them/ where have they been trained?
As I said previously the breast care nurse specialist is a core member of the multidisciplinary team. As a result we felt that it was essential that we introduced the concept of the specialist breast nurse to Greece and took five nurses to Cambridge for a foundation course in breast cancer nursing. The nurses followed a programme of seminars, lectures and practical training at Anglia Ruskin University in Cambridge, where all nurse training is coordinated for Cambridge and the surrounding areas. The selection process and training has resulted in our team benefiting from five experienced nurses who are now passionate about pioneering this role in Greece and supporting patients with breast cancer in our clinic.
11. What is the cost of the triple assessment?
When a patient with breast symptoms or a breast lump comes to a “one-stop” clinic we never know exactly what tests are required. At the very least they will have a relevant history taken as well as a clinical breast examination. Depending on the results of the examination patients may require a mammogram, breast ultrasound and sometimes a breast biopsy. Clearly there is a charge for each of these tests so it is not possible to predict exactly what the price will be. What I can say is that we will only carry out essential tests and patients will not have to pay for a second and third opinion if they come to our clinic.
12. There are different kinds of breast cancer. Which one is the most dangerous?
The term breast cancer comprises many different diseases that co-exist under the one title. Without alarming any patients with breast cancer who are reading this article, the prognosis (life expectancy) is related to many different prognostic factors including tumour size, the grade of the tumour (a measure of how fast it is growing), whether the lymph nodes contain tumour, Estrogen Receptor (ER) status and whether the tumour presented as a lump or was picked upon a screening mammogram. All of these components can be fed in to our computer model PREDICT to give an accurate prediction of the prognosis for an individual patient.
13. Risk factors for breast cancer. Myths & Truths.
The main risk factors for breast cancer are increasing age (breast cancer increases with older age) and a family history of breast and/ovarian cancer. Relevant factors that increase breast cancer risk include first pregnancy at an older age, not having children and not breastfeeding. Recently it has become apparent that the increasing incidence of breast cancer in Western countries is partly due to alcohol consumption and obesity.
14. Assisted reproduction, birth controls pills and hormone replacement therapy have all been “accused” as responsible for causing breast cancer. What is your opinion?
We know that hormone replacement therapy does increase the breast cancer risk slightly while patients are taking it but the risk returns to normal soon after stopping it. Modern oral contraceptive pills do not increase breast cancer risk. Finally I am convinced that assisted reproduction does contribute to an increased breast cancer risk. I have seen many women with breast cancer in the UK who have had in vitro fertilisation (IVF) following massive does of female hormones. As every other factor which exposes women to increased estrogen increases their breast cancer risk, I have no doubt that IVF does the same. I would encourage all women to have some form of breast screening before and after IVF.
15. How often should a woman have a mammogram?
Women who are at increased risk of developing breast cancer may benefit from starting screening mammography at age 40. This usually involves women with a strong family history of breast cancer and between 40 and 49 they should have a yearly mammogram. After age 50 most women should have a mammogram every two years.
16. What symptoms should take a woman to the breast clinic?
Symptoms that are suspicious of breast cancer and should be investigated at a “one-stop” clinic include:
- A new solitary breast lump
- Change to the shape of the breast
- Skin or nipple retraction
- Eczema of the nipple
- Recent nipple inversion
- Blood-stained nipple discharge
Symptoms that are less suspicious of breast cancer but which should also be investigated at a “one-stop” clinic include:
- Breast pain
- Non blood-stained nipple discharge
- Persistent lumpiness of the breast
NEW UK MODEL PREDICTS SURVIVAL AFTER SURGERY FOR BREAST CANCER
A major breakthrough in survival prediction using a new UK model (PREDICT) has just been published on line1 in the journal Breast Cancer Research (6 January 2010). The PREDICT model has been designed by a clinical research group in Cambridge, UK led by Professor Gordon Wishart, Consultant Breast & Endocrine Surgeon and Director of Breast Services at the Cambridge University Hospital-based Cambridge Breast Unit. The model allows breast cancer specialists to enter patient and tumour characteristics into a computer model following breast cancer surgery to calculate the predicted survival in ten years time and to determine the potential benefit of additional (adjuvant) treatment including hormone therapy, chemotherapy or both.
The model was created using data stored in the Cambridge cancer registry from 5694 women treated in ten hospitals in the East of England from 1999-2003. Cancer registries in the UK store accurate information on all patients with breast cancer including details about type of treatment, tumour pathology and date and cause of death. After initial development, the model was validated in a completely separate cohort of 5468 women in central England who were also diagnosed between 1999 and 2003. The breast cancer mortality predicted by the model was within 1% of the actual survival of this second group of patients and suggests that PREDICT will be an excellent tool to estimate the projected 10-year survival, as well as the benefits of individual therapies such as chemotherapy, in the UK and Europe.
Professor Wishart said “There are a number of survival prediction models available but many are based on women treated many years ago, often in a single breast unit, where accurate treatment data was not available. I was very keen to design a model using large number of UK women diagnosed in recent times where we had up to date accurate patient records as well as survival data”.
PREDICT is the first model that allows clinicians to enter whether the tumour was detected by mammographic screening (screen-detected) or if the patient presented with a lump or other symptom in the breast (symptomatic). This is extremely important as Professor Wishart’s research group recently showed that even when they present at the same stage, women with screen-detected breast cancers live longer than those who present with symptomatic cancers. Survival prediction and estimates of treatment benefit are both therefore likely to be more accurate with this model than other currently available tools.
Professor Wishart explained “the choice of optimal adjuvant therapy, following breast cancer surgery, depends on accurate prediction of prognosis and the measurement of certain molecular markers in the tumour itself. As new markers are identified we will be able to include them in updated versions of the PREDICT model.”
The model will be hosted on a NHS web-site with free access to breast cancer specialists and the launch is planned for mid 2010. It is likely to be useful in the UK as well as mainland Europe. A recent research study, presented by Professor Wishart at the San Antonio Breast Cancer Symposium in December 2009, has shown that breast cancer survival in the East of England is close to the best countries in Europe including Sweden, Norway and Finland. Professor Wishart stated “I hope that breast cancer specialists in the UK and Europe find this useful to help them decide on the best treatment for their patients with breast cancer”.
The research paper (http://breast-cancer-research.com/content/pdf/bcr2464.pdf) is an open access article that is free to download. It is currently the most commonly downloaded research paper for articles published during the last month in Breast Cancer Research.
Professor Gordon C Wishart is Director of the Cambridge Breast Unit at Cambridge University Hospitals NHS Foundation Trust, UK and Medical Director of BreastHealth UK.
1 PREDICT: a new UK prognostic model that predicts survival following surgery for invasive breast cancer. Wishart GC, Azzato EM, Greenberg DC, Rashbass J, Kearins O, Lawrence G, Caldas C, Pharoah PDP. Breast Cancer Research 2010, 12: R1
2. Screen-detected versus symptomatic breast cancer-is improved survival due to stage migration alone? Wishart GC, Greenberg DC, Britton PD, Chou P, Brown CH, Purushotham AD, Duffy SW. Br J Cancer 2008; 98: 1741-1744.