Ductal carcinoma in situ (DCIS), a non-spreading type of breast cancer, constitutes a major public health problem, and now represents up to half of the cases detected by breast screening. A proportion of these cases detected by routine breast screening would not have progressed to a life-threatening form of breast cancer during the patient’s lifetime, and overdiagnosis of breast cancer is a problem that was recently highlighted during a review of the NHS breast screening programme in the UK. At present, once DCIS has been detected, treatment is obligatory and present technologies do not allow accurate risk stratification such that intensity of treatment can be tailored to risk of recurrence and progression to invasive disease.
A recent article(1) entitled “Predictors of recurrence for ductal carcinoma in situ after breast conserving surgery” by Prof John R Benson and Professor Gordon C Wishart, both Cambridge-based breast surgeons, has been published in The Lancet Oncology in August 2013 and explains how a combination of traditional and molecular risk factors for DCIS may help to avoid unnecessary treatment in low risk cases and focus maximal therapy on those cases likely to develop into invasive breast cancer.
(1). Benson JR & Wishart GC. Predictors of recurrence for ductal carcinoma in situ following breast conserving surgery. Lancet Oncology August 2013; 14(9): e348-e357.
Professor Gordon C Wishart recently talked to News Medical about a new and innovative method for sentinel lymph node biopsy in breast and other cancers. The new approach has already been adopted in Europe and Japan and further studies are already underway in sentinel node biopsy in melanoma skin cancer and anal cancer.
You can read the full article here.
The National Institute of Health and Clinical Excellence (NICE) has today recommended taking Tamoxifen and Raloxifene, which can halve the risk of developing breast cancer.
These new guidelines are specifically aimed at women with a family history of breast cancer, as one in every five cases of the disease has a family link. Tamoxifen will be offered to pre and post-menopausal women for a period of five years, which will act as an alternative option for women who were thinking of undergoing a bilateral mastectomy. Raloxifene will have the same effects, however this drug is only available to women who are post-menopausal, as it has not yet been tested in pre-menopausal women.
Unfortunately the drugs aren’t suitable for women with an increased risk of DVT or pulmonary embolus and NICE pointed out that the drugs are not currently licensed for use as a preventative treatment in the UK.
Although the drugs have been approved there are still some key details that need to be addressed, such as the prime age for women to begin the 5-year treatment plan. It is also unclear whether the period of time taking the drug would be increased or de-creased in specific circumstances.
Despite breast nurse specialist Susan Heard stating that giving the treatment to women is much cheaper than later treating a woman for breast cancer the NICE approval doesn’t come with any funding, which leads to more concerns regarding how NHS hospitals will manage to implement these guidelines, whilst also dealing with an increase of women wanting to be tested for the BRCA gene, the gene that can cause breast cancer.
Although some details about the drugs are still unclear, with around 50,000 women diagnosed with breast cancer in the UK each year these new guidelines offer women all over the country an alternative option.
A recent British study shows that breast cancer is less likely to recur if women that have already been treated for the disease take Tamoxifen for ten years, rather than five. Part of a larger international trial, the study is now set to change the recommended time period for taking the cancer-treating drug. Until now, the recommended time-scale for taking Tamoxifen has been five years, with medical professionals doubting the benefits of taking the drug for any longer than this. However, this recent study demonstrates new evidence, which indicates significant benefits for those that take the drug for double the original five years.
It has been estimated by researchers that compared with taking no Tamoxifen, ten years of taking it reduces breast cancer death rates by one third in the first ten years and by one half after that.
These results have been determined by research that was carried about between 1991 and 2005. Over this fourteen year period, 6,953 women in Britain who had been taking Tamoxifen for five years were randomly asked either to continue the treatment or to stop immediately. The results showed that breast cancer recurred in 16.7% of the 10-year group, and with 19.3% in the five-year group. The difference in those who experience recurring breast cancer was not the only effect highlighted. It was also demonstrated that longer treatment reduced the risk of dying from breast cancer. The women that continued to take Tamoxifen had a 25% lower recurrence rate and a 23% lower breast cancer mortality rate than women who stopped after the originally recommended five years.
Tamoxifen is a low-cost generic treatment for breast cancer that has been used for many years. Most women start taking Tamoxifen, which is an oestrogen-blocking drug, immediately after their surgery or chemotherapy.
“These findings are extremely exciting for women who are diagnosed with the most common type of breast cancer,” says director of research at Breakthrough Breast Cancer, Dr Julia Wilson. “The study proved that 10 years of taking Tamoxifen has a much higher survival rate than the current five years, which is vital in helping us to stop breast cancer coming back and more importantly to help us stop women dying of breast cancer.”
It should be noted that side effects related to the taking of Tamoxifen do increase when taking it for longer periods of time. These side effects include:
- Increased risk of endometrial cancer
- Blood clots
As a result, the pros and cons of continuing Tamoxifen beyond 5 years should be considered on an individual patient basis when women get to the end of the first five years of treatment.
ICG with PDE camera and blue dye wins B. Braun Award at 48th European Society for Surgical Research (ESSR) in Istanbul on 31 May 2013
At the 48th Annual Conference of the European Society for Surgical Research (ESSR), held in Istanbul from 29 May to 1 June 2013, the research study entitled “ICG with PDE camera and blue dye for sentinel node biopsy in early breast cancer” was awarded the B. Braun Scientific Award. This prestigious award is presented annually for the best presentation that describes the best surgical technique or surgical device. The research study was led by Professors Gordon Wishart and John Benson from Cambridge (UK) and was presented by Mr Vassilis Pitsinis from Mediterraneo Hospital, Athens, Greece. The study demonstrated how the use of fluorescent ICG, detected by a PhotoDynamic Eye (PDE) camera, can replace the use of radioisotope for sentinel lymph node biopsy in breast cancer with a method that is cheaper, avoids the radiation risk of radioisotope and is easier to use for training of junior surgeons. Current research studies with ICG and PDE camera are now under way in sentinel lymph node biopsy for melanoma and anal cancer. For more information a full interview with Gordon Wishart can be seen on the News Medical website.
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