Breast Cancer Care & Research

(1)

Breast Cancer Care & Research

Professor John FR Robertson

University of Nottingham

(2)

Breast Cancer (BC)

l 15,000 BC deaths in the UK each year l 20% female cancer deaths

l 5% all female deaths

(3)

Structure of Cancer Care in UK

N E T W O R K VOLUNTARY SECTOR AND HOSPICE SHA PCT PCT PCT T FT T FT FT

SHA = Strategic Health Authority

PCT = Primary Care Trust T = Trust Hospital_{FT = Foundation Trust Hospital (more independent)}

C A N C E R

(4)

Trusts & Foundation Trusts

-

-Breast Units

Breast Units

l Integrated Breast Service

– Specialist Teams lBreast Surgeons lRadiologists lPathologists lPlastic Surgeons lOncologists lOrthopaedic Surgeons lBCN lNurse Practitioners

lParamedical Specialities (eg

physiotherapist)

– Specialist Facilities

– Education & Training

(5)

Breast Units

-

Integrated Service

Core Medical Members

Breast Breast Surgeon Surgeon Plastic Plastic Surgeon Surgeon Pathologist Pathologist Primary Surgery Primary Surgery Oncologist Oncologist Surgeon Surgeon Radiologist Radiologist Pathologist Pathologist Diagnosis Diagnosis Adjuvant Therapy Adjuvant Therapy Breast Breast Surgeon Surgeon Pathologist Pathologist Oncologist Oncologist

Advanced Breast Cancer

Breast Breast Surgeon Surgeon Radiologist Radiologist Oncologist Oncologist

(6)

Current Screening Programme

l 3 yearly screening for women aged 50-69 l Two views at all screens

(7)

Has screening quality improved in the UK? Has screening quality improved in the UK?

0 0.2 0.4 0.6 0.8 1 1.2 1.4 93/94 95/96 97/98 99/00 2001/02 2003/4 SDR

(8)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 96/97 98/99 00/01 2002/03 preop diagnosis % by core biopsy alone Preoperative diagnosis in NHSBSP Preoperative diagnosis in NHSBSP

(9)

70% 75% 80% 85% 90% 95% 96/97 98/99 00/01 2002/03 nodal staging

Nodal staging of invasive cancer in NHSBSP

(10)

Diagnosis

l Screening highlighted relative lack of resources for women presenting with a symptom (eg nipple discharge, lump)

l Screening has improved overall

diagnostic facilities – both screening & symptomatic

(11)

Structure of Cancer Care in UK

C A N C E R

(12)

ISSUES

l PCTs have multiple & competing priorities l Commissioners/PCTs have a finite resource

and many NSFs to fund

l Trusts have multiple & competing performance targets

(13)

Structural Issues with

‘

The System

’

l Idea of fixed health care budget – economically

prudent or economically flawed ?

Ø Cost control mechanism – all within ‘the box’ Ø Health Care funding is now a political agenda Ø UK is a wealthy country

l Implies that the cost of health care can be

known before it happens

l Sets clinicans against each other for resources Ø Cardiovascular Vs Cancer

(14)

Structural Issues with

‘

_‘

The System

_{The System}

’

_’

l More negative control mechanisms within ‘the health

care box’

Ø Bureaucracy to get anything changed – endless committees Ø Focus on process rather than outcomes – eg governance,

audit

l Spending on non-front-line staff (eg governance,

audit) rather than treatment (eg new drugs)

l New drugs have often to be found from cost savings l Funding one drug for breast cancer may mean cannot

fund another drug for another cancer

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0 1 2 3 4 5 50 60 70 80 90 100 0 1 2 3 4 5 50 60 70 80 90 100

Adjuvant Herceptin- Disease-Free Survival

B-31 N9831 ACàTH 864 83 ACàT 872 171 ACàT 807 90 ACàTH 808 51 N Events N Events HR=0.45, 2P=1x10-9 _{HR=0.55, 2P=0.0005} AC ACààTHTH ACACààTHTH ACàT ACàT 74% 87% 85% 66% 78% 87% _86% 68%

Years From Randomization

(16)

B

-

_-

31/N9831 Survival

_{31/N9831 Survival}

AC ACààTHTH 94 94 % % 9191_%_% 87 % 92 % ACàT N Deaths ACàT 1679 92 ACàTH 1672 62 _{HR=0.67, 2P=0.015}

Years From Randomization _B31/N983

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Process for funding New Drugs

l Development of a business case/proposal l Business case to Network Drugs and

Therapeutics committee

l Recommendation to commissioners

l PCT process for agreeing priorities and identification of funding

l Authorisation/Endorsement/Implementation l Audit of Compliance

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Structure of Cancer Care in UK

C A N C E R

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Structure of Cancer Care in UK

C A N C E R NICE

(20)

Breast Cancer Care in UK 2005

lPerformance driven

– Process rather than outcomes

lTarget driven

– Time (eg “2 week wait”) & cost

lHealth expenditure on breast cancer

has to be justified against other diseases

lProcesses to control spending on new

(21)

• 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)

• 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

Death Mgm Symp. Detection Detection 0 10 20 30 40 50 60 Months 23% decrease in BC mortality. ( Mgm screening) Years Metastasis Detected Metastatic Cells Disseminated Primary Tumour Initiation 5% _AntigenBlood 70% 82% Earliest Autoantibodies Detected MRI

(24)

“

Intensive

_Intensive

”

_”

Vs Routine Follow

_{Vs Routine Follow}

-

_-

up

_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

(25)

(26)

Absolute Reduction in Recurrence During the First 10 Years After Treatment with Tamoxifen

for 5 Years

Absolute Reduction in Recurrence During the Absolute Reduction in Recurrence During the First 10 Years After Treatment with

First 10 Years After Treatment with TamoxifenTamoxifen for 5 Years

for 5 Years

(27)

ATAC study

IES 031 study

_{IES 031 study}

1.0 0.0 0.2 0.4 0.6 0.8 0 1 2 3 4 5 6 Years P = 0.0002 Event

Event--free survivalfree survival

Anastrozole Tamoxifen 0 1 2 3 4 0 25 50 75 100 86.8%* 91.5%* Disease free Disease free Survival Survival P = 0.00005. Exemestane Tamoxifen

Time to event (months)

Proportion with first event (%)

20 15 10 5 0₀ ₆ ₁₂ ₁₈ ₂₄ ₃₀ ₃₆ ₄₂ Anastrozole (AN) Tamoxifen (TAM) Tam + AN

ITA study

P = 0.013 LN(-) 61% LN(-) 0% LN(-) 51% 0 75 80 85 90 95 100 0 1 2 3 4 5 Anastrozole(A) Tamoxifen (T) p-value 0.0009 ABCSG 8 / ARNO 95 ABCSG 8 / ARNO 95 Event-free survival (%)

(28)

(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