So, it slows the whole field down and I just think if we had a fraction of the amount of funding that they have for new drugs I think we can make massive progress, we really could find out who these therapies work in and who they don’t work in. They’re initiated by a specialist in hospital and then continued by GPs – is that what’s supposed to happen? And there are now nearly 200 that have been linked to breast cancer risk, each one individually only very slightly alters your risk – it may alter it upwards or it may alter it downwards.
So, it really does limit what we can do and it means we are completely reliant really on charity funding and government funding to do the trials. So, it really is just random chance as to what cards you get from your parents.
And Mark Porter speaks to Professor Gareth Evans working with his team at the Wythenshawe Hospital in Manchester to reliably identify women at higher risk of breast cancer. And the reason we chose that name was because there’s a conscious effort to get away from chemo-prevention because the people that work in the breast cancer field they realised, several years ago, that having the chemo has the negative connotations for women, they’ve seen their relatives, they know friends, they know that tamoxifen is used for the treatment of cancer. And the trials are expensive and long. What we currently call breast cancer should be thought of as 10 completely separate diseases, according to an international study which has been described as a "landmark". And some people might consider that a bit of semantics.
And a high lifetime risk, that’s 30% plus. Series that demystifies health issues, bringing clarity to conflicting advice. THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.
The balance of risks and benefits is not so clear in your situation. You could say the same about statins, couldn’t you? And there are links to Sam’s study, the latest NICE guidance on breast cancer prevention, and more information on breast density and SNPs on the Inside Health page of the Radio 4 website. "Being able to tailor treatments to the needs of individual patients is considered the Holy Grail for clinicians and this extensive study brings us another step further to that goal.". Dr Sam Smith, from the University of Leeds, led the team behind the research into tamoxifen in women at high risk of breast cancer, the research that found just one in seven choose to take it. One thing, Sam, I haven’t seen covered much in the media is how women get to be in the situation where they’re discussing whether or not they might benefit from tamoxifen with any doctor. More on breast cancer prevention later. In heart disease, there are well-known risk factors such as blood pressure and cholesterol, which can inform treatment. But when you multiply them together they can actually have a substantial effect on your risk. I’m 52 years old and I’m one of five sisters. And actually, that’s a very substantial reduction. The Health Secretary, Andrew Lansley, has already described the promise of the field as "immense". I couldn’t agree with you more but as in all things in the Health Service these things take time to get commissioned and we know that half of women in our family history clinic would change risk category based on the SNP test alone. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY. But there are deviations around this and one of the difficulties is that the hospital clinicians they may not actually be eligible to prescribe these medications. However a woman’s risk is calculated, and SNP testing is currently generally only available on the NHS through research centres like Prof Evan’s, most of those at high risk – six out of seven of them – still don’t opt for tamoxifen or similar drugs.
One is, tamoxifen, but the difficulty we have is that there is nothing to measure to see whether it’s actually working, until you wait for cancer as an outcome. And those are the density of the breast tissue on the mammogram. Its chief executive, Dr Harpal Kumar, said: "This is the largest ever study looking in detail at the genetics of breast tumours. Acid Attacks and Corneal Grafts, Bowel Cancer Screening, Sports Prosthesis for Children, Only 1 in 7 high risk women taking preventative therapy, Breast cancer risk calculator (classic factors - Tyrer.Cuzick model), Breast density and breast cancer, BBC Inside Health, 9 Aug 2017, Single nucleotide polymorphisms (SNPs) and risk assessment.
So, the more of that there is the more dense the breast tissue is the more the risk is potentially. A large proportion of the cases occur in women who have risk factors. And it feels like a blunt tool to me, especially since I’m one of five because I have two sisters and a mother who don’t have breast cancer, so it felt a bit random. And I think very often in general practice and probably in life as well, we do what we can with the information that we have and we try and make the best decision that’s available. I feel better. So, in your hand of cards, your deck of cards, you had more kings and aces – now you have one where you got two of the bad copies, but that was more than made up for by the fact that most of your SNPs were good and some of them were well below a relatively risk of one. Of course, another big barrier to an otherwise healthy person taking any form of medication is concern about side effects, with tamoxifen things like blood clots, maybe increased risk of cancer of the uterus, hot flushes, sweats – those sorts of things. Yeah, so obviously tamoxifen does cause side effects and I think what we have to do to improve that information and help make that decision a bit easier I think is to better understand the risk. They say patients with more than 75% "dense breast tissue" had at least four times the risk of developing breast cancer than patients with mainly non-dense tissue. But what about the women out there who aren’t even coming along to see their doctor, we’re not even getting to them at the moment are we? That decision is probably going to be a bit different for very many people. However, they are not available as a preventative measure in the UK. I was very moved when I was reading about a woman who decided not to take them because she felt as though having a bottle of tamoxifen on her dressing table and taking a tablet every morning was a constant reminder of her own mortality. And then the final factor that we look at is common genetic variance. And in both those populations the SNPs very accurately predicted the level of risk. The other issue here, for me working in primary care anyway, is the language used – chemo-prevention. In the UK, 46,000 women are diagnosed with breast cancer each year. "This will change the way we look at breast cancer, it will have an enormous impact in the years to come in diagnosing and treating breast cancer. So yes, there’s a breakdown in communication perhaps, where people in the prevention field haven’t disseminated the information to GPs, so they’re not as used to using drugs for cancer prevention. "If this is confirmed in long-term studies, breast density could become a powerful way to identify high-risk women who could benefit from preventive treatments.". Read about our approach to external linking. That is Herceptin, which is already used in a targeted group of patients. The moderate lifetime risks, so that’s higher than normal but not as high as high, is between 17 and 30%, again lifetime risk, up to the age of 90. And you can see whether they’re working, you can go back to your GP, get your blood pressure tested, measure your cholesterol and see that they’re actually doing what you expect them to do.
Prof Caldas said this was a "completely new way of looking at breast cancer". The panel suggests breast density. In the end I went to my GP and I asked for a referral because one of the things is that because I’m high risk I would be offered tamoxifen and I’ve been trying to think my way through that. She has a strong family history of breast cancer and is just the sort of person at whom the latest NICE guidance is aimed. Yeah, absolutely. Inside Health may have been off air for a couple of months, but that hasn’t stopped us keeping a wary eye on the headlines and there’s been a lot in the news about breast cancer.
But really those that have used these tests and they have been validated in a number of other populations, they know that these are really accurate. So, we can talk about the evidence of benefit and that’s the reduced risk of getting breast cancer but there’s a price to pay for that, in terms of side effects presumably? But actually, NICE think quite carefully about that and I’ll quote from their own guide. And I asked him, and GP Dr Margaret McCartney, what they think the hurdles might be. This is the essence of personalised medicine - tailoring treatments to the genetics of a disease. And so, patients don’t get a feel for whether the drug is working for them. If you’re a healthy person, just with an increased risk, no certainty that you’re going to get breast cancer but an increased risk of it, that is a very hard thing to grapple with. And it seems like a minor thing but actually it’s a major thing because there’s no point us doing all this research, doing clinical trials, if ultimately someone isn’t going to take the therapies that we develop because of the wording. And one of the concerns that I have at that stage is that we may be creating inequalities. However, as preventative therapy may have negative side effects it would not be appropriate for everyone. Sam, can you clarify exactly how these drugs are prescribed? Well it’s a different thing, you know, I think tamoxifen is known as a drug that’s used specifically for cancer treatment, as opposed to statins which are I think are used so widely and broadly for people without cardiac disease, as well as people with cardiac disease. But also, in our family history risk study where we got DNA from 2,000 women, again nearly 500 of those have developed breast cancer. And yes, if they don’t have that biomarker, that thing that they can measure to say yes it’s working, they’re perhaps going to be less convinced by it. Just time to tell you about next week’s programme when I head to a sleep clinic for an update on the latest in managing insomnia and discover how copying the latest generation of biological drugs is saving the NHS a fortune.
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