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To mark World Health Day and the 70th anniversary year of the NHS, a Professor at the Institute of Cancer Research in London and Honorary Consultant at The Royal Marsden NHS Foundation Trust, looks at key medical advancements that have significantly changed NHS care for breast cancer patients and helped double survival rates:
Unlike leukaemia, real advancements in breast cancer are relatively modern, beginning in the 1970s.
Since then we have seen more patients surviving breast cancer, and patients with incurable cancer living longer. There’s been a shift from purely thinking about cure, to also thinking about recovery of life quality.
The first big change came from clinical trials proving that intravenous chemotherapy reduced breast cancer deaths in young women with early breast cancer. Since that time, new drug regimens have built on this major advance to further improve cure rates across a much broader range of patients.
Prior to the 1970s surgery and radiation therapy were the main treatment options for women with breast cancer, and most patients lost the whole of their breast by an operation called mastectomy. However, clinical trials showed that this was not always necessary, and the development of specialist breast cancer surgeons meant that local tumour resection – where only a narrow rim of healthy breast tissue around the cancer is removed – became a valid treatment option when followed by whole breast radiation therapy. This was a huge change as it meant that people didn’t lose their whole breast, and less invasive surgery was also associated with faster recovery times and fewer long-term side effects.
In the 1980s, the impact of anti-oestrogen drugs on the progress of breast cancer was shown in the first clinical trials. A huge breakthrough was the testing of tamoxifen, an anti-oestrogen therapy taken in the form of a tablet that reduced the risk of breast cancer deaths by almost one-third. Tamoxifen remains a successful and hugely affordable drug for the NHS that is still used globally today. Stronger anti-oestrogens, effective in women who have gone through the menopause have since been developed and tested, adding further improvements in life expectancy.
A new screening approach was also introduced following a study led by Professor Martin Leach; using magnetic resonance imaging (MRI) to identify the risk of breast cancer in women who were probable BRCA mutation carriers. Early detection is crucial in these women, as cancer can occur at a younger age and often progresses more rapidly.
The last 25 years were also marked by the development of sub-specialisms within oncology, enabling teams of professionals to gain expertise and learning in specific areas and types of cancer. This has led to patients benefitting from the combined expertise of a range of different health professionals working together in a multi-disciplinary team, including surgical, clinical and medical oncologists, radiologists, pathologists, specialist cancer nurses and radiographers.
Over this period, another breakthrough at The Royal Marsden and the Institute of Cancer Research (ICR) was the application of intensity-modulated radiotherapy (IMRT) to breast cancer patients. IMRT enabled the X-ray beam used in radiotherapy to be adjusted to adjust for wide variations in size and shape of women’s breasts, allowing higher intensities to be concentrated on the tumour while sparing the surrounding tissue.
Along with Professor Judith Bliss at the ICR, I led eight randomised clinical trials testing improvements in radiation therapy for women with early-stage breast cancer. Historically, breast cancer was treated with a high overall dose of radiation therapy delivered in many small doses over five to six weeks. The safety and effectiveness of giving a lower total dose of radiotherapy in fewer larger daily doses over a shorter period of time has been confirmed in these trials.
Importantly, patients experienced a reduction in chronic side-effects after a three-week schedule compared to the standard five weeks. Today, researchers are investigating whether a five-day radiotherapy programme is safe and effective as a future replacement for the current three-week course.
The 1990s were also marked by an awareness of the hereditary risks of cancer. While the BRCA1 gene had been discovered, work at the ICR identified the breast cancer gene BRCA2. This meant that patients who didn’t have breast cancer, but had a family history of breast cancer, could now be assessed for future risk and offered treatment or follow up. It also laid the groundwork for developing novel forms of therapy for BRCA-associated cancers.
As we move beyond the millennium, as doctors, we are grateful to see more of our patients being cured of breast cancer. In fact more than four in five of our patients live ten years or more after diagnosis, so now our research needs to look at reducing the long-term impact of cancer and cancer treatment.
We also want to see cancer detected earlier and as just over one in five breast cancers are preventable, we have a lot of work to do to seriously address lifestyle and public health in terms of cancer risks.