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Beating breast cancer

To mark Breast Cancer Awareness Month, Professor Gordon Wishart – Gordon Wishart, Professor of Cancer Surgery and Medical Director of Check4Cancer – talks about the importance of breast screening, why it is a success story and how women can help to reduce their own risk.

 

You have referred in the past to breast cancer and its treatment as “a success story” – why is that?

Like other types of cancer, the incidence of breast cancer is increasing, with around 50,000 new cases in the UK per annum. However, the mortality rate for breast cancer has actually been falling since the 1980s. In fact, 2012 figures showed a fall of 45% for women aged 50-64 since 1989, the year after the breast screening programme began.

To put this into perspective, it’s helpful to compare breast cancer with lung cancer. This is the second most common cancer in the UK after breast cancer, but has a much higher mortality. There is no screening programme at all for lung cancer, and 90% of cases come to light as a result of symptoms such as weight loss, or coughing up blood. By the time this happens, however, it is already too late for effective treatment. 43,463 new cases of lung cancer were diagnosed in UK in 2011 – a slightly lower incidence than breast cancer – but by comparison the number of deaths is huge. There were 11,716 deaths from breast cancer in the UK in 2012, but 35,400 from lung cancer. If lung cancer could be detected at an earlier stage like breast cancer is, we could expect to see the number of deaths reduced by as much as two thirds.

As with all forms of cancer, early detection is key to effective treatment – and high levels of awareness and a national screening programme have made a huge impact. So, breast cancer really is a success story – but we can still do better, and part of that involves encouraging all women to be breast aware and have regular screening.

 

What about recent claims that screening is not effective, or is even counter-productive?

The 2012 NHS Breast Screening Review consulted a wide majority of opinion from scientists and doctors who specialise in breast cancer, and they concluded that the breast screening programme confers significant benefit and should continue. I agree that we need to get better at identifying those breast cancers that would never have caused harm in the patient’s lifetime, and we need to provide adequate information about the pros and cons of screening before the mammograms are performed. There is no doubt in my mind that women in the UK continue to benefit every day from breast screening with minimal risk to radiation exposure,

The proportion of women attending breast screening has dipped in the last few years – perhaps as a direct result of these questions being raised – so we need to get the message across that screening is still vitally important, and is saving lives every day. The NHS calculates that, overall, the national screening programme saves one life from breast cancer for every 200 women who are screened – that’s about 1,300 lives saved from breast cancer each year in the UK.

 

How can we improve on what we have?

One way is through more targeted or risk-stratified screening, taking into account medical history and family history in a more sophisticated way, so that we can concentrate screening to those who are at higher risk for developing breast cancer. At Check4Cancer – which offers testing to women in a younger age range than the NHS standard range of 50+, often as a benefit through their employers – we start the process with a questionnaire about lifestyle and family history, then a thorough examination with an experienced nurse. Only then are women who are considered at higher risk referred for mammography. This keeps overdiagnosis and overuse of mammography to a minimum. I believe this is the way forward. The better we in the UK target our screening services, the higher the success rate will be – and the more confidence women will have in it.

 

Genetic testing has figured prominently in the press over the past couple of years – how can this help?

There have been several high profile celebrity cases recently – Angelina Jolie being one – which have highlighted the role that genetic testing can play in identification of women who have an extremely high risk of getting breast cancer in their lifetime. We now know that carrying certain genes, such as the BRCA1 & BRCA 2 genes, significantly increase a woman’s chances of developing breast cancer. Armed with this information, Angelina Jolie was in a position to take preventative steps, and in 2013 she opted for a double mastectomy. While this is clearly a radical move, it has reduced her risk of breast cancer from 87% to a minimal level. Women who have inherited a BRCA mutation can also choose to have more frequent breast screening from an earlier age or, they can choose to take drugs like Tamoxifen to lower their risk. Genetic testing should always be linked with counselling before and after testing to help women make the right choices for them as an individual.

 

What about other lifestyle factors?

Obesity, especially in post-menopausal women, increases cancer risk. There is also plenty of evidence to show that the risk of breast cancer, in particular, is directly proportional to alcohol intake. Recent US research published in the British Medical Journal this month, showed that even light to moderate intake of alcohol increases risk. Women themselves are the first line of defence when it comes to breast health, not only by detecting unusual changes in their own bodies, but also moderating lifestyle factors that affect their risk. When it comes to early detection of cancer, this new information will also help all clinicians to fine-tune their risk assessment criteria, and that, ultimately, will save lives.

Some risk factors that we might consider “lifestyle choices” are also connected to the world of work. Factors now known to increase risk of breast cancer include having no children or having them late in life (that is, after the age of 25) and not breast feeding. We know that many women put off having children, or decide not to have them at all, because of a desire or need to work. The downside of this, however, is increased breast cancer risk. This is nothing to do with their specific working environment, of course, but is nonetheless a result of the pressure on women to have both career and family.

Also, those involved in shift work have increased risk of breast cancer. A third of women in the UK work shift patterns that include an element of night shift work, and we now know that over a prolonged period of time this increases breast cancer risk by as much as 50% (in men, shift work carries a similar increased risk of prostate cancer). In fact shift work was declared a carcinogen by the International Agency for Research on Cancer (IARC) in 2007, and this increased risk has been confirmed by the Health & Safety Executive in the UK.

 

How do you see the fight against breast cancer being carried into the future?

Often people talk in terms of a “cure” for cancer, but in reality I think it is more about tackling it on a whole variety of fronts. We are finding new ways to detect and treat it all the time and, although they predicted breast surgeons would soon be extinct when I was still at medical school, breast surgery remains the single most important element of curative treatment. In my opinion, much of the success in reducing mortality from breast cancer during the last 15-20 years can be linked to early detection, the development of breast cancer specialist teams and breast screening. I believe that future improvements will rely on better identification of high-risk groups with refined genetic testing for women without a family history (SNP testing), increased use of risk-stratified screening and the development of new targeted therapies that are directed against specific products of the tumour cells.

I also believe, partly for reasons already described, that employers will have an increasing part to play. In our experience, many employers are already finding that by offering employees cancer checks as a benefit they can not only save lives, but cut down on health insurance costs and increase employee engagement. It’s a win-win for both employer and employee, so I hope this will add an extra dimension and increased impetus to the fight.

 

Professor Gordon Wishart – former clinical director of the Cambridge Breast Unit – is visiting Professor of Cancer Surgery at Anglia Ruskin University and has an international reputation in the field of clinical breast cancer research. He is also Medical Director of Check4Cancer – a company dedicated to tackling cancer in the workplace.

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