Now and then

While the number of people being diagnosed with breast cancer in Australia is increasing every year, the number of deaths from breast cancer is decreasing.

When BCNA began 20 years ago, five-year survival was 87 per cent. It is now 90 per cent.

This improvement in survival is due to earlier diagnosis of breast cancers through the BreastScreen screening program and improvements in treatments.

As BCNA celebrates its 20th anniversary, The Beacon speaks to five breast cancer specialists about how treatment and care has improved over the past two decades.

Medical oncology
Associate Professor Jacquie Chirgwin
Associate Professor Jacquie Chirgwin
Medical Oncologist, Box Hill and Maroondah Hospitals, Melbourne

Since the birth of BCNA in 1998, there have been many changes in breast cancer treatment. The undoubted star of the show is trastuzumab (Herceptin), which is used to prevent recurrence of early breast cancer and to control breast cancer when it has spread.

Herceptin was the first of a new kind of drugs called ‘targeted’ treatments, which target specific proteins or enzymes that play a role in the growth of cancer cells. This is very different from usual cancer treatments such as chemotherapy, which affects all cells – cancerous and normal.

Herceptin is effective for the 20 per cent of breast cancers that are HER2-positive. Its benefits are more impressive and it has fewer side effects than other treatments.

In 2000, Herceptin was approved for sale in Australia but was too expensive for most people to buy. In 2001 and again in 2006, BCNA ran successful campaigns to make Herceptin available through government subsidies. This drug has been a major breakthrough and has saved many lives.

The new hope for the immediate future is the inclusion of the CDK inhibitors ribociclib (Kisqali) and palbociclib (Ibrance) into standard care. This new class of targeted treatment drugs is for hormone positive, HER2-negative metastatic breast cancer.

As technology progresses, detailed profiles of the molecular make-up of the cancer and of the patient should be possible, which could produce a computer-generated fully personalised treatment plan.

However, each patient’s values and preferences must always be considered to ensure treatments best suit their needs.

Pathology
Associate Professor Wendy Raymond
Associate Professor Wendy Raymond
Consultant Pathologist, Flinders Medical Centre and Clinpath Laboratories

Pathologists are the people who make the definitive diagnosis of breast cancer. They test the tumour sample to determine what drives the cancer to grow and to predict the most likely behaviour of the cancer if it is left untreated. This helps the treating team to determine the best treatment for that patient.

Breast cancer research over the past two decades has shown that breast cancer is not one disease, but that there are many different types. Pathologists can now more effectively diagnose a much greater range of individual breast cancer types, allowing patients to receive treatments better targeted to their particular type of cancer. This has ultimately saved lives.

Today we can also use smaller samples of a tumour, called core biopsies, to not only perform the diagnosis but also to get a lot more information about the tumour before surgery.

This information can be particularly helpful for people considering having chemotherapy before breast cancer surgery (neoadjuvant treatment), because the results of the core biopsy can help to guide which type of chemotherapy may be most beneficial.

The past 20 years have also seen the emergence of the multidisciplinary team meeting, where the radiologist, pathologist, medical oncologist, surgeon, radiation oncologist and other team members meet to discuss each patient’s case and make treatment recommendations.

By improving communication among the treatment team, clinicians are more aware of the implications of what we do, and we better understand the individual person and their cancer.

Surgery
Dr Chris Pyke
Dr Chris Pyke
Breast and Endocrine Surgeon, Mater Medical Centre, Brisbane

In the past, breast cancer surgery always included radical axillary surgery, where a number of lymph nodes – sometimes many – were removed from under the armpit. This could create complications, including the lifelong risk of lymphoedema.

Axillary surgery has been revolutionised with sentinel node biopsy, which started in Australia in the late ’90s. This involves identifying and removing only the first one or two lymph nodes to which the breast cancer may have spread for testing by a pathologist. Lymph nodes are also now treated in ways other than surgery, which means fewer people need to have additional nodes removed.

Twenty years ago, the rates of breast conserving surgery (lumpectomy) were only 40 per cent and immediate breast reconstruction was in its infancy. Now, breast conservation rates have increased to 60 to 70 per cent in most areas, and some women having mastectomies are offered immediate reconstructions.

Neoadjuvant chemotherapy (chemotherapy given before surgery) has allowed 20 per cent more women with cancers larger than 3 cm, especially those with HER2-positive disease, to have breast conserving surgery instead of mastectomy.

In the past 10 years, cosmetic outcomes of breast cancer surgery have also improved, thanks to the introduction of oncoplastic surgery. Combining traditional breast cancer surgery with plastic surgery techniques has helped to increase breast conservation rates to 90 per cent in some hospitals.

Radiotherapy
Associate Professor Michael Penniment
Associate Professor Michael Penniment
Director Radiation Oncology, Royal Adelaide Hospital

In the past, radiotherapy for breast cancer could cause terrible side effects. Treating other areas, such as the head and neck region, could leave major functional problems.

Over the past 20 years, radiation oncology has fundamentally changed its tactics to be more strategic, rather than the treatments of the past.

We are now more accurate in our ability to diagnose the extent of the disease that we need to treat. This has allowed us to really tailor our radiation therapies, including how we apply them and exactly where we apply them. As a result, we can save a lot more of the person’s tissue.

I can recall years ago using tracing paper to help us mark out and map where the therapy should be applied. Exciting advances have since been made with amazing computer technology, which provides us pinpoint accuracy for the treatments we deliver.

Today, there are also more sophisticated radiotherapy centres around Australia. People from remote Indigenous communities used to have to travel vast distances for radiotherapy and experienced family upheaval through treatments that may have taken months.

Since starting the radiotherapy service in Darwin, the uptake of radiotherapy services among Indigenous people diagnosed with cancer has increased from 20 per cent to close to 50 per cent.

Survivorship
Professor Bogda Koczwara AM
Professor Bogda Koczwara AM
Medical Oncologist, Flinders Centre for Innovation in Cancer in Adelaide

It’s taken us 20 years, but significant successes in research into treatment and supportive care means more Australians are surviving to live long, happy lives with families and loved ones.

With increasing numbers of people surviving breast cancer, survivorship is being reprioritised on the breast cancer treatment agenda.

Survivorship is about what happens when you are not having cancer treatments. That can be between chemo treatments, a year or years afterwards, or any time in between. It’s about living with the history of cancer diagnosis and its consequences that can affect patients, as well as their carers or families.

Survivorship relates to post-cancer physical, emotional, and practical needs including health needs, employment, financial or other issues. The last 20 years have witnessed increased refinement of structures and strategies to help people address and resolve many of these challenges.

The future of survivorship care and research should focus on getting better at understanding the mechanism of many of the late effects that people experience.

Doing this more effectively will pave the way for even better recovery and restoration of the health of people who have had breast cancer.

Issue 82
Autumn 2018