Breast Cancer Care & Research

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1 Breast Cancer Care & Research Professor John FR Robertson University of Nottingham Nottingham City Hospital

2 Breast Cancer (BC) 15,000 BC deaths in the UK each year 20% female cancer deaths 5% all female deaths 89% BC deaths occur in women >50yrs

3 Structure of Cancer Care in UK SHA C A N C E R N E T W O R K PCT PCT PCT T FT T FT FT VOLUNTARY SECTOR AND HOSPICE SHA = Strategic Health Authority PCT = Primary Care Trust T = Trust Hospital FT = Foundation Trust Hospital (more independent)

4 Trusts & Foundation Trusts - Breast Units Integrated Breast Service Specialist Teams Breast Surgeons Radiologists Pathologists Plastic Surgeons Oncologists Orthopaedic Surgeons BCN Nurse Practitioners Paramedical Specialities (eg physiotherapist) Specialist Facilities Education & Training Control of Budget

5 Breast Units - Integrated Service Core Medical Members Diagnosis Primary Surgery Surgeon Radiologist Pathologist Breast Surgeon Oncologist Plastic Surgeon Pathologist Adjuvant Therapy Advanced Breast Cancer Breast Surgeon Pathologist Breast Surgeon Radiologist Oncologist Oncologist

6 Current Screening Programme 3 yearly screening for women aged Two views at all screens Single Reading

7 Has screening quality improved in the UK? SDR s all screens NHSBSP 0 93/94 95/96 97/98 99/ / /4

8 Has screening quality improved in the UK? Preoperative diagnosis in NHSBSP 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 96/97 98/99 00/ /03 preop diagnosis % by core biopsy alone

9 Has screening quality improved in the UK? Nodal staging of invasive cancer in NHSBSP 95% 90% 85% 80% nodal staging 75% 70% 96/97 98/99 00/ /03

10 Diagnosis Screening highlighted relative lack of resources for women presenting with a symptom (eg nipple discharge, lump) Screening has improved overall diagnostic facilities both screening & symptomatic

11 Structure of Cancer Care in UK SHA C A N C E R N E T W O R K PCT PCT PCT T FT T FT FT VOLUNTARY SECTOR AND HOSPICE SHA = Strategic Health Authority PCT = Primary Care Trust T = Trust Hospital FT = Foundation Trust Hospital (more independent)

12 ISSUES PCTs have multiple & competing priorities Commissioners/PCTs have a finite resource and many NSFs to fund Trusts have multiple & competing performance targets Networks have other priorities within Cancer

13 Structural Issues with The System Idea of fixed health care budget economically prudent or economically flawed? Cost control mechanism all within the box Health Care funding is now a political agenda UK is a wealthy country Implies that the cost of health care can be known before it happens Sets clinicans against each other for resources Cardiovascular Vs Cancer Lung Cancer Vs Breast Cancer

14 Structural Issues with The System More negative control mechanisms within the health care box Bureaucracy to get anything changed endless committees Focus on process rather than outcomes eg governance, audit Spending on non-front-line staff (eg governance, audit) rather than treatment (eg new drugs) New drugs have often to be found from cost savings Funding one drug for breast cancer may mean cannot fund another drug for another cancer NICE approval

15 Adjuvant Herceptin- Disease-Free Survival 100 B-31 N9831 AC TH 100 AC TH 90 AC T 87% 85% 90 AC T 87% 86% % % 66% % 68% N Events N Events AC T AC T AC TH AC TH HR=0.45, 2P=1x HR=0.55, 2P= Years From Randomization

16 B-31/N9831 Survival AC T % AC TH % 91 % 87 % N Deaths AC T AC TH HR=0.67, 2P=0.015 Years From Randomization B31/N983 1

17 Process for funding New Drugs Development of a business case/proposal Business case to Network Drugs and Therapeutics committee Recommendation to commissioners PCT process for agreeing priorities and identification of funding Authorisation/Endorsement/Implementation Audit of Compliance

18 Structure of Cancer Care in UK SHA C A N C E R N E T W O R K PCT PCT PCT T FT T FT FT VOLUNTARY SECTOR AND HOSPICE SHA = Strategic Health Authority PCT = Primary Care Trust T = Trust Hospital FT = Foundation Trust Hospital (more independent)

19 Structure of Cancer Care in UK C A N C E R N E T W O R K SHA PCT PCT PCT T FT T FT FT NICE VOLUNTARY SECTOR AND HOSPICE SHA = Strategic Health Authority PCT = Primary Care Trust T = Trust Hospital FT = Foundation Trust Hospital (more independent)

20 Breast Cancer Care in UK 2005 Performance driven Process rather than outcomes Target driven Time (eg 2 week wait ) & cost Health expenditure on breast cancer has to be justified against other diseases Processes to control spending on new drugs of developments

21 Main Research Themes Screening & Early Diagnosis Prognostic and Predictive Factors Blood Tumour Markers Autoimmunity Screening & Early Detection Antigens Diagnosis & Monitoring of MBC Therapeutics Endocrine & Growth Factor Therapies Chemotherapy Pharmacogenomics

22 Main Research Themes Screening & Early Diagnosis Prognostic and Predictive Factors Blood Tumour Markers Autoimmunity Screening & Early Detection Antigens Diagnosis & Monitoring of MBC Therapeutics Endocrine & Growth Factor Therapies Chemotherapy Pharmacogenomics

23 The average breast cancer time line Months Years MRI Mgm Symp. Detection Detection Metastasis Detected Death Primary Tumour Initiation Earliest Autoantibodies Detected 23% decrease in BC mortality. ( Mgm screening) 82% 5% Blood Antigen 70% Metastatic Cells Disseminated

24 Intensive Vs Routine Follow-up N = 1320 < 70 yrs BS & US - annual CXR - 6/12ly Compliance - 80% MFI - NS Survival - NS GIVIO Trial, 1994 N = 1243 < 70 yrs BS & CXR - 6/12ly US - None Compliance 75%-80% DFI - p<0.05 Survival - NS Del Turco et al, 1994

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26 Absolute Reduction in Recurrence During the First 10 Years After Treatment with Tamoxifen for 5 Years EBCTCG, Lancet 1998; 351:

27 Proportion with first event (%) ATAC study Anastrozole (AN) Tamoxifen (TAM) Tam + AN P = LN(-) 61% Time to event (months) IES 031 study P = Disease free Survival Exemestane Tamoxifen 86.8%* 91.5%* LN(-) 51% ITA study P = Event-free survival Anastrozole Tamoxifen LN(-) 0% Years ABCSG 8 / ARNO 95 Anastrozole(A) Tamoxifen (T) Event-free survival (%) p-value

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29 Antigen Research Studies Biological/molecular studies to characterise the antigens Early Diagnosis of Recurrence 5 yrs sequential collection of sera Early Intervention study pilot study UK study of standard FU Vs Early Intervention with TMs