Breast Cancer Care & Research Professor John FR Robertson University of Nottingham Nottingham City Hospital
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
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)
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
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
Current Screening Programme 3 yearly screening for women aged 50-69 Two views at all screens Single Reading
Has screening quality improved in the UK? 1.4 1.2 1 0.8 0.6 0.4 0.2 SDR s all screens NHSBSP 0 93/94 95/96 97/98 99/00 2001/02 2003/4
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 00/01 2002/03 preop diagnosis % by core biopsy alone
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 00/01 2002/03
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
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)
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
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
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
Adjuvant Herceptin- Disease-Free Survival 100 B-31 N9831 AC TH 100 AC TH 90 AC T 87% 85% 90 AC T 87% 86% % 80 70 74% 66% 80 70 78% 68% N Events N Events 60 60 AC T 872 171 AC T 807 90 AC TH 864 83 AC TH 808 51 50 HR=0.45, 2P=1x10-9 50 HR=0.55, 2P=0.0005 0 1 2 3 4 5 0 1 2 3 4 5 Years From Randomization
B-31/N9831 Survival AC T 94 92 % AC TH % 91 % 87 % N Deaths AC T 1679 92 AC TH 1672 62 HR=0.67, 2P=0.015 Years From Randomization B31/N983 1
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
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)
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)
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
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
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
The average breast cancer time line Months 0 10 20 30 40 50 60 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
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
Absolute Reduction in Recurrence During the First 10 Years After Treatment with Tamoxifen for 5 Years EBCTCG, Lancet 1998; 351:1451-1467.
Proportion with first event (%) 20 15 10 5 ATAC study Anastrozole (AN) Tamoxifen (TAM) Tam + AN P = 0.013 LN(-) 61% 0 0 6 12 18 24 30 36 42 Time to event (months) 100 75 50 25 0 IES 031 study P = 0.00005. Disease free Survival Exemestane Tamoxifen 86.8%* 91.5%* LN(-) 51% 0 1 2 3 4 1.0 0.8 0.6 0.4 0.2 0.0 ITA study P = 0.0002 Event-free survival Anastrozole Tamoxifen LN(-) 0% 0 1 2 3 4 5 6 Years 100 95 90 85 80 75 ABCSG 8 / ARNO 95 Anastrozole(A) Tamoxifen (T) Event-free survival (%) p-value 0.0009 0 0 1 2 3 4 5
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