Breast Cancer Now – Delivering real choice: the future of breast reconstruction in England

Breast Cancer Now – October 2022

For those who choose it, breast reconstruction is a vital part of recovery from breast cancer or risk-reducing surgery. However, this report reveals that too often, access and choice is being denied – making it harder for people to rebuild their lives. Breast Cancer Now is calling on NHS England to work in partnership with them, the Association of Breast Surgery (ABS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) to develop a practical plan for breast reconstruction services that addresses the backlog, removes barriers and ensures timely and fair access to reconstruction for all women who want it. The report makes recommendations to help achieve this.

Recommendations

Women must be given information about the different types of reconstruction and supported to make the decision
that is right for them

Services must be structured in a way that enables patients to access the type of reconstruction that is right for them.

Capacity to perform free flap breast reconstruction must be increased.

The payment for breast reconstruction must reflect the true cost over time.

All local restrictions on breast reconstruction must be removed

The backlog and long delays facing those awaiting breast reconstruction or risk-reducing surgery must be addressed.

Consistent data must be collected on the number of patients waiting for breast reconstruction and risk-reducing surgery, and how long they have been waiting, both locally and nationally.

Full Report – Breast Cancer Now

Older women with breast cancer chose less aggressive treatment when they used a decision aid

NIHR | March 2022 | Older women with breast cancer chose less aggressive treatment when they used a decision aid

New research funded by the National Institute for Health Research (NIHR) explored the impact of decision aids among women over 70 who were diagnosed with breast cancer. The women either had a consultation using the decision aid or without it (standard care). Researchers found women in the centres using the decision aids were less likely to have surgery or chemotherapy.

The women were followed for an average of 3 years. Using the decision aid had little impact on their chances of being alive at 3 years. This suggests that the decision aids were well-targeted and used with women for whom the treatment choice would make least difference to their length of life.

The study found women who used decision aids were better informed about their treatment options. There was little difference in quality of life between women who used the decision aids and those who did not. (Source: NIHR)

Full Alert is available from NIHR Older women with breast cancer chose less aggressive treatment when they used a decision aid

The Alert highlights research and the findings of a recent paper: Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices 

New cancer risk test based on routine cervical screening sample can identify breast and ovarian cancer and may help in future cancer risk prediction

Eve Appeal| n.d | New cancer risk test based on routine cervical screening sample can identify breast and ovarian cancer and may help in future cancer risk prediction

Research funded by the charity Eve Appeal, published today in Nature Communications, provides new tools, the Women’s cancer risk identification for breast cancer and ovarian cancer (WID-BC and WID-OC) tests, which can detect these two cancers using only routine cervical screening samples. Importantly, the tests do not detect actual cancer but rather indicate genetic, lifestyle and environment risk factors associated with them and may be able to predict future risk. In this blog, researcher Dr Chiara Herzog goes into detail of how the test works and who it could benefit.

Further details are available in the blog post from the Eve Appeal

Papers are published in Nature Communications

The DNA methylome of cervical cells can predict the presence of ovarian cancer

The WID-BC-index identifies women with primary poor prognostic breast cancer based on DNA methylation in cervical samples

Earlier decisions on breast and ovarian surgery reduce cancer in women at high risk

Marcinkute, R. et al | 2021| Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers | Journal of Medical Genetics | Published Online First: 10 February 2021. doi: 10.1136/jmedgenet-2020-107356

This NIHR Alert summarises the recent findings of a longitudinal study that followed more than 800 women who carry the BRCA1 or BRCA2 genes who have an increased risk of developing ovarian and breast cancers (as well as other cancers). After testing positive for these genes, the individuals were followed up twenty years later, where more than half (57.9 per cent) had a risk reducing mastectomy, and 77 per cent had elected for a bilateral salpingo-oophorectomy (RRSO).

Abstract

Background Women testing positive for BRCA1/2 pathogenic variants have high lifetime risks of breast cancer (BC) and ovarian cancer. The effectiveness of risk reducing surgery (RRS) has been demonstrated in numerous previous studies. We evaluated long-term uptake, timing and effectiveness of risk reducing mastectomy (RRM) and bilateral salpingo-oophorectomy (RRSO) in healthy BRCA1/2 carriers.

Methods Women were prospectively followed up from positive genetic test (GT) result to censor date. χ² testing compared categorical variables; Cox regression model estimated HRs and 95% CI for BC/ovarian cancer cases associated with RRS, and impact on all-cause mortality; Kaplan-Meier curves estimated cumulative RRS uptake. The annual cancer incidence was estimated by women-years at risk.

Results In total, 887 women were included in this analysis. Mean follow-up was 6.26 years (range equal to 0.01–24.3; total equal to4685.4 women-years). RRS was performed in 512 women, 73 before GT. Overall RRM uptake was 57.9 per cent and RRSO uptake was 78.6 per cent. The median time from GT to RRM was 18.4 months, and from GT to RRSO–10.0 months. Annual BC incidence in the study population was 1.28 per cent. Relative BC risk reduction (RRM versus non-RRM) was 94 per cent. Risk reduction of ovarian cancer (RRSO versus non-RRSO) was 100 per cent.

Conclusion Over a 24-year period, we observed an increasing number of women opting for RRS. We showed that the timing of RRS remains suboptimal, especially in women undergoing RRSO. Both RRM and RRSO showed a significant effect on relevant cancer risk reduction. However, there was no statistically significant RRSO protective effect on BC.

Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers [abstract only]

NIHR Alert Earlier decisions on breast and ovarian surgery reduce cancer in women at high risk

Rotherham NHS staff can request this article from their Library

Women under 35 face higher risk of breast cancer spreading – study

via The Guardian | 3 November 2021 | Women under 35 face higher risk of breast cancer spreading – study

Women diagnosed with breast cancer under the age of 35 face a higher risk of it spreading, according to the first global study of its kind.

Breast cancer is the most common form of cancer, with 2.3 million people diagnosed every year. Survival rates are generally good, which is largely because of screening, early diagnosis and improved treatment.

However, until now, little has been known about the risk of secondary breast cancer, where the disease spreads to other parts of the body and becomes incurable.

A meta analysis of more than 400 studies has found the risk of breast cancer spreading to another part of the body ranges from 6 per cent to 22 per cent. The results of the study are being presented at the sixth International Consensus Conference for Advanced Breast Cancer.

Full story from The Guardian

Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy

Freeman, K. et al | 2021| Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy| BMJ | 374 | n1872 | doi:10.1136/bmj.n1872

This review was commissioned by the UK National Screening Committee to determine whether there is sufficient evidence to use artificial intelligence (AI) for mammographic image analysis in breast screening practice. The research team’s aim was to assess the accuracy of AI to detect breast cancer when integrated into breast screening programmes, with a focus on the cancer type detected. They identified 12 studies which evaluated commercially available or in-house convolutional neural network AI systems, of which nine included a comparison with radiologists. The reviewers’ findings disagree with the publicity some studies have received and opinions published in various journals, which claim that AI systems outperform humans and might soon be used instead of experienced radiologists (Source: Freeman et al, 2021).

Abstract

Objective 

To examine the accuracy of artificial intelligence (AI) for the detection of breast cancer in mammography screening practice.

Design 

Systematic review of test accuracy studies.

Data sources 

Medline, Embase, Web of Science, and Cochrane Database of Systematic Reviews from 1 January 2010 to 17 May 2021.

Eligibility criteria 

Studies reporting test accuracy of AI algorithms, alone or in combination with radiologists, to detect cancer in women’s digital mammograms in screening practice, or in test sets. Reference standard was biopsy with histology or follow-up (for screen negative women). Outcomes included test accuracy and cancer type detected.

Study selection and synthesis 

Two reviewers independently assessed articles for inclusion and assessed the methodological quality of included studies using the QUality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A single reviewer extracted data, which were checked by a second reviewer. Narrative data synthesis was performed.

Results 

Twelve studies totalling 131 822 screened women were included. No prospective studies measuring test accuracy of AI in screening practice were found. Studies were of poor methodological quality. Three retrospective studies compared AI systems with the clinical decisions of the original radiologist, including 79 910 women, of whom 1 878 had screen detected cancer or interval cancer within 12 months of screening. Thirty four (94 per cent ) of 36 AI systems evaluated in these studies were less accurate than a single radiologist, and all were less accurate than consensus of two or more radiologists. Five smaller studies (1 086 women, 520 cancers) at high risk of bias and low generalisability to the clinical context reported that all five evaluated AI systems (as standalone to replace radiologist or as a reader aid) were more accurate than a single radiologist reading a test set in the laboratory. In three studies, AI used for triage screened out 53 per cent, 45 per cent, and 50 per cent of women at low risk but also 10 per cent, 4 per cent, and 0 per cent of cancers detected by radiologists.

Conclusions

 Current evidence for AI does not yet allow judgement of its accuracy in breast cancer screening programmes, and it is unclear where on the clinical pathway AI might be of most benefit. AI systems are not sufficiently specific to replace radiologist double reading in screening programmes. Promising results in smaller studies are not replicated in larger studies. Prospective studies are required to measure the effect of AI in clinical practice. Such studies will require clear stopping rules to ensure that AI does not reduce programme specificity.

The BMJ Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy [primary paper]

NICE draft guidance recommends abemaciclib for advanced breast cancer

NICE |  August 2021 | NICE draft guidance recommends abemaciclib for advanced breast cancer

NICE has recently published draft guidance which recommends twice-daily pill abemaciclib (also called Verzenios and made by Eli Lilly) as an option for adults with a type of breast cancer called hormone receptor-positive, HER2-negative breast cancer which has spread to other parts of the body.

Draft guidance Abemaciclib with fulvestrant for treating hormone receptor-positive, HER2-negative advanced breast cancer after endocrine therapy [ID2727]

Full details from NICE [press release]

National Audit of Breast Cancer in Older Patients: Annual Report 2021

Healthcare Quality Improvement Partnership

The National Audit of Breast Cancer in Older Patients, which aims to evaluate the process of care and outcomes for older women diagnosed with breast cancer in NHS hospitals within England and Wales, has published its annual report for 2021. Based on data from women aged 50+ years diagnosed with breast cancer between 1 January 2019 and 31 July 2020, this report reviews diagnoses and treatment patterns across England and Wales, taking the early months of the pandemic into consideration.

Read the full report here

Breast cancer screening: women with poor mental health are less likely to attend appointments

NIHR | 21 June 2021| Breast cancer screening: women with poor mental health are less likely to attend appointments

This Alert from National Institute for Health Research (NIHR) highlights the findings of recent research that looked at resaons why women chose not to attend breast screening appointments. This research was conducted in Northern Ireland and included nearly 60 000 women between the ages of 50 and 70. They were all eligible for routine NHS screening for breast cancer. One in ten of the sample reported poor mental health. This group was almost a quarter (23 per cent) less likely to attend breast screening than women without mental health problems.

In the last decade evidence suggests that women who live in less affluent or urban areas, and those who are not married, are less likely to attend screening.

The researchers used data from the Northern Ireland Longitudinal Study includes data on one in four (28 per cent) of the Northern Ireland population. It includes women’s responses to questions on mental health in the 2011 Northern Ireland Census. The authors linked this information to women’s records on breast cancer screening. 

Their investigation into the factors that impacted on a woman’s likelihood not to attend a screening appointment were:

• women with mental illness were less likely to attend screening than women who did not report mental health conditions
• not being married or living in an urban area were each linked to a similar reduction (23 per cent less) in attendance
• the effect of social deprivation was greater, and women in this group were 34 per cent less likely to attend breast screening
• mental health had an impact across all groups of women, regardless of social deprivation, urban living or marital status.

The authors of the study call for health services to explore targeted interventions, such as more frequent appointment reminders. This could encourage women with mental illness to attend screening appointments. 

[Abstract] Does poor mental health explain socio-demographic gradients in breast cancer screening uptake? A population-based study.

If you’d like access to this paper, please request it from the Library

Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer

Franzoi, M. A. et al | 2021| Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer | The Lancet Oncology | DOI:https://doi.org/10.1016/S1470-2045(20)30666-5

The growing availability of more effective therapies has contributed to an increased survival of patients with breast cancer. In hormone receptor-positive early disease, increased survival is strongly correlated with the use of adjuvant endocrine therapy, but this therapy can cause side-effects that have major consequences in terms of treatment adherence and patients’ quality of life. In premenopausal breast cancer survivors, these side-effects might be even more prominent due to the abrupt suppression of oestrogen associated with the most intense endocrine therapies. An important ambition of cancer care in the 21st century is to recover pre-cancer quality of life and emotional and social functions, which is only possible through the mitigation of the side-effects of anticancer treatments. This Review presents a comprehensive summary of the efficacy and safety data of the available interventions (hormonal and non-hormonal pharmacological strategies, non-pharmacological approaches, and complementary and alternative medicine) to control selected side-effects associated with adjuvant endocrine therapy (hot flashes, sexual dysfunction, weight gain, musculoskeletal symptoms, and fatigue), providing updated, evidence-based approaches for their management.

Rotherham NHS staff can request a copy of this review from the Library