Controversies in breast cancer

Just back from two days in Edinburgh at a conference titled “Controversies in breast cancer”. An unusual conference organized by scientists and clinicians and by invitation only. Papers are not reviewed and there is no press coverage: just a forum for experts in the field to discuss and debate a wide range of topics in breast cancer research. The proceedings will be published online before the end of the year.

The conference is now in its fifth year and draws from a diverse group both geographically (international) and in terms of discipline and it is a refreshing experience. I don’t claim to understand the more esoteric science but one is left in no doubt that scientists are continually challenging each other, and themselves, to decide which paths to follow to do the best for breast cancer patients.

One topic which was rather less controversial than it sounded was titled the “Emerging breast cancer epidemic”. We have seen breast cancer incidence rise steadily in the UK and in fact in the developed world and this is predicted to continue through the next decades. More and more are surviving so mortality (death) rates are going down but just because we can sometimes cure a disease does not make it less of an epidemic.

That breast cancer is the most common cancer in women knows no geographic boundaries – it is a global burden that has doubled in the last 30 years. We are used to hearing stories about the disease burden in developing countries of, say, HIV/AIDS, malaria and TB but cancer is not a rare disease in Africa.

What was also interesting is if you take a country such as France the at risk population for breast cancer changed from 19.1 million in 1970 to 21 million in 2010. In Nigeria it went from 24.6 million to 42 million. As infectious diseases are being more successfully treated, the impact of AIDS is reducing and therefore women are living longer. This trend is going to continue and of course it is a good thing. However the single most significant risk factor for breast cancer is age and as these populations live longer the incidence of breast cancer will increase rapidly.

At present the number of young women developing breast cancer in Africa appears high – this is not due in the main to some genetic difference but more to do with the fact that the women who are diagnosed are educated, economically active and more likely to seek help. There are women in rural areas who die from advanced breast cancer without diagnosis or treatment.

The problems they are facing are so different from ours - adulterated drugs, very few trained oncologists. Screening programmes are not an option – lack of access to mammography let alone the resources to deal with any false positives and of course a lack of a consistent supply of electricity!

So as the control of infectious diseases improves and the scourge of AIDS is reduced; as life expectancy increases and with economic growth changing lifestyles – the breast cancer epidemic is a reality.

All Party Parliamentary Group on Cancer

On Tuesday I was at the House of Commons for a reception held by the All Party Parliamentary Group on Cancer. The All Party Groups I have been associated with are very effective. They bring together MPs and members of the Lords and the charities and others with an interest in the subject. In this case and the case of the group on breast cancer – this is very much the patients as well.

Paul Burstow MP, who is the Health Minister with responsibility for cancer, announced that the Government will update the Cancer Reform Strategy (CRS). The original strategy was a huge piece of work to which we all contributed and it is really encouraging that the new government is planning to build on that rather than start from scratch.

A White Paper on Health will be published shortly and we understand that the update to the Cancer Reform Strategy will focus on aligning cancer services with the reforms that will be announced in this White Paper. It is really good news for the sector and for patients that the update process will be led by Professor Sir Mike Richards, the National Cancer Director, as he has been a tremendous influence for good in forming policy.

There was talk of making cancer outcomes the best in Europe and dealing with inequalities in care – something which we have been campaigning about for some time. Access to treatments was also mentioned and there was a very moving presentation from an individual who had kidney cancer and had to fight twice for the drugs which have kept him alive – and having a good quality of life.

I won’t say “watch this space” but rather watch out for the White Paper and then for the revision to the Cancer Reform Strategy which will be out sometime in the winter.

Too old to treat?

I remember my late mother-in-law had a routine check-up when she was in her late eighties and they found a shadow on the lung. No one was very sure what it was and the doctor said that they would watch it as they did not want to operate on her because of her age. Before any discussion could be had my mother-in-law said that she wouldn’t contemplate any treatment anyway as she had lived long enough! There was no question of her being manoeuvred into this position – no one manoeuvred her into doing anything! As she then survived until just a few months short of her century this was probably a wise decision.

But when is old? I am sure that you are as shocked as we are to learn about the discrimination faced by older women with breast cancer. NHS doctors believe women are being denied treatments due to age rather than ability to benefit and this was widely reported in the press last week. A national consultation which was published last week revealed that women over the age of 65 are at risk from exclusion from chemotherapy for example. Only 16 per cent of women over 65 received chemotherapy compared with 77 per cent under 50. We also know that older postmenopausal women are less likely to receive surgery than younger ones. The only acceptable criteria for older people not receiving treatment are personal choice and poor health.

There is a deep irony here as the greatest risk factor for breast cancer is age – the risk increases the older you get. As older postmenopausal women (aged 70 or over), make up roughly a third of the 45,700 women diagnosed with breast cancer each year, it is imperative find out the reasons why they may not be receiving potentially beneficial treatments.

This is why Breast Cancer Campaign is currently supporting research in Manchester which aims to find out whether some older women with operable breast cancer are not being given surgical treatment because of their age rather than choice, health or ability to benefit.

The researcher will interview 550 patients aged 70 and over with operable breast cancer about their general health and choice of treatment. She will use the information collected to establish whether decisions about providing surgical treatment are being based on age even when the patient choice and health would make appropriate to operate.

Knowing the extent to which older women are not given surgery as a result of age, patient choice and poor health will help researchers establish whether these women are being discriminated against. This will provide researchers with evidence to encourage a change in practice and ensure all women receive the best treatment possible regardless of their age.