Do British women with breast cancer still get a raw deal?

Written by Karol Sikora

Karol Sikora is Professor of Cancer Medicine at Hammersmith Hospital and Medical Director of Cancer Partners UK. He is the senior editor of Britain’s most widely used textbook for specialists, Treatment of Cancer, which is now going to its sixth edition. He has campaigned for the last 30 years for improvements in many aspects of cancer care. He passionately believes we could save more lives simply by applying the knowledge we already have in a more efficient and equitable way across our NHS.
The problem
The figures are startling. A woman diagnosed with breast cancer in Britain today has a significantly lower chance of being alive 5 years later than in 10 other European countries1. And even for early stage disease, which because of greater awareness and screening is becoming the predominant form of this cancer, we are still far behind the USA. An American woman has a 97% chance of being alive 5 years after the diagnosis compared to only 84% here. The numbers involved are large – this year there will be nearly 50,000 women affected and 12,000 will die of their cancer. So even a small improvement in treatment can make a lot of difference for many British families.

Nobody disputes the data anymore. A recent report from a UK Government Public Accounts Committee 2 concludes “Whilst survival rates have improved and mortality rates have fallen, the gap in survival rates with Europe has not been closed. There remains wide, unexplained variation in the performance of cancer services and in the types of treatment available across the country”

We’ve at least managed to move on to try and fix the problem. But it’s not so simple to disentangle the very complex way in which healthcare systems can influence outcomes even for a single cancer. And of course it’s not just breast cancer where Britain has poorer outcomes – patients with any of the four commonest cancers – breast, lung, colon and prostate have worse outcomes here than most of Europe.

Since 1997 cancer registry data from across Europe has been pooled to examine mortality in the EUROCARE studies 3. There are several ways of looking at outcome data. The stage of presentation is determined by public education, access to good primary and secondary care and the availability of speedy diagnostic pathways that are easy for women to use. The overall mortality expressed as the number of deaths per year per 100,000 women gives an overall figure reflecting incidence, stage at diagnosis and the quality and speed of treatment. This statistic is also affected by the age distribution and other variable social factors. The all-stage five year survival figure is perhaps the best way of looking at the comparative effectiveness of care in different countries. As can be seen in Table 1, this is not good news for Britain. But what are we doing wrong and how can you ensure getting the best care for yourself? Table 2 lists some possible reasons.

Table 1:  5 year survival % for breast cancer in women

Table 2: Why is Britain only number 11 out of 16 in the European survival table?

• Lack of public awareness
• Poor access to GP
• Poor access to breast clinics
• Diagnostic delays in getting scans and biopsies
• Delays in getting started on surgery, radiotherapy and chemotherapy
• Lack of good precision radiotherapy
• Poor access to new drugs
• Huge variability in practice – access and quality – across the country
• Major survival difference across socioeconomic spectrum
• Delay in getting innovation into the NHS

The diagnostic pathway

One of the most obvious differences between health services of Europe is the ease of access to care. Getting to see a GP, getting a hospital referral and getting scans and biopsies are all part of the diagnostic process. In Britain it can all still be painfully slow unless the cancer is obvious to the GP. Despite all the controversy of the effectiveness of the breast screening programme it has created a fantastic process for dealing with women found to have an abnormal mammogram. This same downstream pathway can be used by women who have actually found a lump themselves so speeding up the process for all. We need to make the NHS far more accessible especially to women that find it difficult to use. Some receptionists are just not that great at customer care. And several studies have shown that it’s the poor and the uneducated that have the greatest difficulty in working the system.

The initial assessment of a patient suspected of having breast cancer includes a careful
examination to assess the size, location of character of the primary tumour, together with evidence of spread of lymph nodes in the axilla and other areas around the breast.
Some patients actually present with disease that has already spread, often to the bone.
Sometimes they may ignore the ominous symptoms of a growing lump in the breast and it can actually break through the skin creating very unpleasant infection around the breast.

Investigations required to fully assess a patient with early breast cancer include a blood count, liver function tests, a CT scan of chest and abdomen and a bone scan. Other types of scanning are not routinely performed but may be requested if there have been abnormalities found on clinical examination or there are particular symptoms that give rise to the suspicion that the disease may have already spread. Getting an accurate diagnosis and to the point of treatment should never take more than 2 weeks but unfortunately it often does.

The treatment of breast cancer

There is a lot of controversy about the best way to treat breast cancer and this is where we need to look for the causes of national variation. There are really two problems. The first is how to treat cancer in the breast itself and the second, how to reduce the risks of recurrence in other sites. Both involve a trade off between damage to normal cells and the risk of the disease returning.

The biggest problem with breast cancer is not dealing with the primary cancer but avoiding the consequences of metastasis. Metastasis just means “next place” and is the process by which cancer cells break off and spread through the lymphatic channels or blood vessels and settle in other parts of the body. Tumours of the breast particularly like to form what are often called secondaries in the bone, liver, lung and less frequently the brain. The first line of metastasis is usually the lymph nodes in the axilla (armpit). Around 80% of patients developing early breast cancer will be cured of their disease. Those that are not cured develop recurrence and spread in other sites of the body. Most of the variation in treatment patterns is in dealing with the primary tumour.

Breast cancers tend to grow extremely slowly, most take up to five years to reach the size of one centimetre. The commonest way in which a woman notices a breast cancer is a painless lump often found while bathing or in the shower. Screening has increased the detection of early cancer although there is considerable controversy as to how worthwhile it really is. The problem is not that it doesn’t pick up breast cancer, it also picks up a lot of minor abnormalities that really do not need to be detected and have no consequences for the life of the woman. This creates a huge amount of anxiety amongst the patient and their families and sometimes outweighs the benefit of
a few months earlier diagnosis.

Surgery

Until 1890 a crude wide excision of the cancer was the only procedure possible. In 1895 William Halstead, a pioneering American surgeon, developed an operation that was called the radical mastectomy. This became the archetype of many cancer operations. The primary tumour in the breast was removed with surrounding tissue and in contiguity with the regional lymph nodes and underlying muscle. This operation was subsequently modified to reduce its cosmetic impact. Over the last two decades the thrust has been towards more conservative surgery. Instead of performing a mastectomy, the tumour alone is removed often with a 1-2 cm scar and the patient is given postoperative radiotherapy. This approach gives a better cosmetic result with no evidence of an increased rate of local recurrence or poorer survival when compared with the more aggressive surgical procedures. It is not always possible to use this conservative approach, for example, if there is a large tumour in a small breast where its removal would result in a very poor cosmetic appearance and similarly if there are several tumours in the breast which does occur in about ten percent of women making mastectomy necessary. Alternatives are always discussed and they form part of the decision making process.

Radiotherapy

Radiotherapy is used in conjunction with surgery to prevent the disease coming back within the breast. It is important it is planned carefully and delivered using advanced equipment preferably with IMRT and IGRT (intensity modulated and image guided radiotherapy).  We know that the long term results of surgery and radiotherapy can be excellent; however, if radiotherapy is given using old fashioned techniques fibrosis and other late side effects occur caused by damage to normal tissue surrounding the tumour’s bed. Because of the breast’s unusual shape in three dimensions and the inability to use a template because of variation between women, determining the correct technique for irradiating an individual breast is a very skilled process.

Chemotherapy

Chemotherapy is used in two ways; as an adjuvant after surgery and for treating known metastatic disease. Adjuvant therapy is defined as the use of additional treatment given after apparently successful removal of all known disease detectable by clinical X-ray and other investigations. Breast cancer has provided an incredible test ground for many trials of adjuvant treatment in both chemotherapy and hormones that have been used in other cancers. The concepts behind adjuvant chemotherapy are logical. At the time of the removal of the primary tumour access to any small areas of spreading cells will be good, the patient will tolerate even aggressive regimens as she is not in poor health because of the effects of large metastases. Remaining tumour cells should theoretically be sensitive to chemotherapy as they are dividing at their most rapid rate and finally there is good evidence from tumour model systems to support the role of adjuvant chemotherapy in preventing recurrence.

Adjuvant therapy began in 1965. Injections of chemotherapy were given immediately after surgery to reduce the ability of circulating tumour cells to get hold in distant organs. Although some benefit was seen the results were not startling initially. In the 1970’s two large studies were published which showed that chemotherapy given for a year following surgery had a dramatic effect on long term survival. Over the years the drugs have changed and become much more tolerable. They are also given with supportive drugs to prevent sickness and other side effects, which have really revolutionised adjuvant treatment of breast cancer. 

The benefits of adjuvant chemotherapy are easy to determine by using the very educational website www.adjuvantonline.com. It represents the distillation of data from over 10,000 US women. You have to go through the tedium of registering on the site but it’s free and very good. Better still get your consultant to go through your options with you. You can really see how much or how little you will gain with adjuvant treatment. In the end it’s all up to you.

Over 80% of patients will be just fine following primary treatment of cancer. However, for those where the disease recurs chemotherapy is also offered. A full assessment is made and if the recurrence has recurred outside the previously treated volume and is localized, then radiotherapy may be used instead. The same agents that are used for adjuvant treatment are given and the patient closely monitored after two or three cycles. The most important part of a management plan of the patient is to check that the tumour is actually disappearing when chemotherapy is given. This often takes two to three months and therefore a critical re-assessment is needed. A difficult clinical problem arises when chemotherapy is only partially effective. It is then up to both the physician and patient to balance the benefits in terms of tumour response with the drawbacks arising from the side effects of therapy.

Hormone treatment is used in both adjuvant and metastatic situations. A variety of drugs are available including; Tamoxifen, Anastrozole, Letrozole and Exemestane. Sometimes these drugs have different trade names but they all act by suppressing the oestrogen drive for cancer cells by affecting the hormonal composition of the body. Most patients will have little side effects.
Tamoxifen is much less used now but was the first anti-oestrogen drug to be discovered in the UK in the 60’s. It led to a plethora of other drugs that are in some cases more effective especially in women that have had their menopause.

Conclusion

There have been huge advances in the treatment of breast cancer over the last fifty years and this is reflected in the much better survival. There has also been an increasing trend for women to go to their doctors when they have early disease. This is good as it makes treatment much easier for both doctor and patient and the most important message is not to ignore a breast lump however innocuous it seems.

What can I do to help?
Table 3 is a ten point action plan for you. If we all do our bit we will definitely save lives in this and the coming generation. We can’t eradicate breast cancer but we can make it have less impact on our lives.
Table 3: A ten point action plan for breast cancer
• Be breast aware – report any change in the shape or feel of your breast to your doctor
• Do not ignore a breast or axillary lump especially if it is painless
• Do not be fobbed off if you are worried – insist on referral to a breast clinic
• Take part in the NHS mammography programme
• Stay slim 
• Do lots of exercise and keep fit
• Reduce your alcohol intake to less than 2 glasses of wine or equivalent a day
• Eat healthily – lots of fruit, vegetables and fibre
• If you have more than 2 close relatives with breast cancer seek genetic counselling
• Lobby your MP, Councillors and local hospital for better breast care services

REFERENCES:

1. Health at a Glance: Europe, OECD, 2012 http://www.oecd.org/health/healthataglanceeurope.htm
2. http://www2.breastcancercare.org.uk/news/blog/statement-public-accounts-committee-report-one-year-cancer-survival-rates
3. http://www.eurocare.it/