Read Part One of our blog on the UK Interdisciplinary Breast Cancer Symposium
How to avoid overtreatment of DCIS
Dr Judy Boughey, breast surgeon and Professor of Surgery at the Mayo Clinic, spoke about the problem with ‘turning people into patients’ in the treatment of Ductal Carcinoma in Situ (DCIS). DCIS is the most common type of non-invasive breast cancer, where the cancer cells are found only in the milk lobes (LCIS) or ducts (DCIS) of the breast and not in other tissues. Non-invasive breast cancers sometimes later develop the ability to spread to surrounding tissues, and become invasive. For this reason, women with non-invasive breast cancers are advised to have treatment such as surgery and radiotherapy.
But without treatment, around half of people diagnosed with DCIS would never see their breast cancer become invasive, which means many are being treated for a cancer that will never become a danger to them. Dr Boughey explored the issues of overtreatment –where people with DCIS go through tests, treatments, and surgeries such as mastectomies that they may not need. She then suggested an alternative approach, using different risk models that can help predict how likely it is that someone’s DCIS will become invasive or recur, and then using these to make treatment decisions. She raised the question “has the time come for surgeons to stop operating on DCIS?” - whether surgery is an example of a treatment that could be avoided, and if utilising anti-hormone therapy could be a way to reduce the amount of surgery and radiotherapy performed on people with DCIS.
Dr Boughey concluded by discussing her COMET trial which aims to assess whether observing people with low risk DCIS (who have the offer of anti-hormone therapy) to look for any changes to their disease would be a successful alternative to performing surgery when DCIS is diagnosed.
Thinking beyond the tumour
Dr Marc Lipman explored the importance of looking at the other biological factors in play around the body as well as the cancer itself.
He raised the issue that depression could be affecting outcomes in patients with metastatic breast cancer. This finding came initially from a study by Dr David Spiegel, who enrolled his patients in a psychiatry trial in the hopes that it would help them to feel better. What he found unexpectedly was that those who had the psychiatric intervention also had better cancer outcomes afterwards. Research in the field of psychiatry has suggested links between depression and inflammation – something that also plays a role in breast cancer, providing a possible explanation for Dr Spiegel’s surprising finding. This also gives us a clue as to how we might be able to reverse these biological effects of depression in patients, in addition to offering them psychological support.
The importance of looking beyond the tumour was echoed by different experts throughout the conference. Obesity is a known risk factor for many types of cancer, and Professor Clare Isacke shared the work of Dr Johanna Joyce, who has found that obesity can increase the likelihood of breast cancer spreading to the lungs in mice. Dr Joyce investigated mice who had been fed a diet high in fatty foods, and found that these mice had higher levels of immune cells called ‘neutrophils’ in the lungs, creating an environment that encouraged breast cancer to spread there. She discovered that a protein called IL-5 was involved in this response, and when the mice were switched to a low fat diet and treated with anti-IL5 therapy the effects were reversed, suggesting a potential drug target to slow the progression of secondary breast cancer.
In a session sharing some of 2017’s research highlights, Professor Peter Schmid told us about the importance of the gut in influencing how breast cancer responds to treatment. The cells and environment of the digestive system have direct links to the body’s immune system, and evidence is building to suggest that bacteria in the gut could influence how cancers respond to immunotherapy. Studies in animals show that taking antibiotics (which kill off both harmful and useful bacteria) before immunotherapy reduces its effectiveness, but this can be reversed if the helpful bacteria are given back. This could be an important consideration when treating patients with immunotherapy, and further emphasises the importance of looking at the body as a whole, rather than tumours in isolation.
Making decisions together
The overarching theme of the conference was the importance of collaboration between people in different fields, and many sessions emphasised how vital it is for people with breast cancer to also be a part of the this conversation.
Professor Deborah Fenlon & Mrs Lesley Turner introduced the ‘Shared Decision Making’ session by reminding the audience that sharing decision making between clinicians and patients not only helps patients to feel empowered and in control, but helps clinicians to better understand the everyday issues that affect patients – all of which leads to mutual respect.
Professor Diana Harcourt explained that patients have to start making decisions at a time when they are still trying to process their diagnosis, which can be overwhelming. Clinicians need to ensure they are not overloading patients with information, or being rigid and prescriptive, but allowing decisions to be made as a team. Professor Harcourt reminded us that both clinicians and patients are experts in their field: with clinicians bringing the research and medical understanding, whilst patients are contributing their values and context to how each decision will affect them.
The more the decision making is shared between patients and clinicians, the more likely patients are to feel satisfied with the decision or results, for example with breast reconstruction surgery, and are more likely to want to continue with treatment – improving their chances of survival.
Dr Alex Clarke emphasised how decisions need to be based on a patient’s core beliefs and values to avoid regret. She spoke about how people use their own subjective measures of outcomes, and gave the example that many people undergoing hip replacements simply want to know “can I go and play with my grandchildren again?”. It is important to differentiate physical goals – such as shape, symmetry or scarring in the example of breast reconstruction, with psychological goals – such as confidence and feeling feminine. Clinicians should be wary of promising patients they will feel more confident or feminine, and instead be asking “If you were more confident what would be different?”, or “What could you do that you can’t do now?” as a way to clarify their goals.
The session ended with a quote from Canadian physician Sir William Osler, echoing the points made by the speakers, that “the good physician treats the disease. The great physician treats the patient who has the disease”.
Closing thoughts
The conference concluded with Professor David Cameron reflecting on the UK’s contribution to breast cancer research. The conference came the week after the US FDA announced the approval of the PARP inhibitor drug olaparib as a treatment for BRCA mutated secondary breast cancer, and Professor Cameron began by exploring the story of PARP inhibitors and its strong links to the UK, from the initial concept’s discovery by Breast Cancer Now scientists at the ICR, to the creation of the drugs and early clinical trials.
Professor Cameron shared further examples of the discoveries and advances made in basic science, treatments including surgery and radiotherapy, ways to improve quality of life and initiatives to improve doctor-patient communications, to which the UK’s scientific community has contributed enormously.
While this session brought to life the UK’s major contributions to improving the lives of people with breast cancer, the conference itself emphasised everyone’s continued commitment to working together to continue pushing forward progress, bringing us ever closer to a time when everyone who develops breast cancer will live, and live well.
Read Part One of our blog on the UK Interdisciplinary Breast Cancer Symposium