NCRI Cancer Conference 2010, 7 November 2010, Liverpool

Professor Alastair Thompson – University of Dundee, UK

Multidisciplinary approach to breast cancer treatment

You are chairing a session on breast cancer, and a sort of multidisciplinary session which is the way it should be. We don’t maybe always do multidisciplinary research, however, although we do patient care that way. What are you expecting to pull out of this meeting today at NCRI?

So what I feel is really critical is that we integrate what pathologists do with what basic scientists do with what we can deliver at the clinical coal face, if you like. And so the NCRI breast session is going to be really revolving around having an NHS pathologist telling us about some of the things that he does, then a scientist from Sheffield telling us about some of the basic science she has taken through from the bench to the clinical bed side and then finally hearing about some clinical trials which are delivering novel therapies into patients, so brilliant at letting us, I guess, try out new treatments they really don’t know what’s going to happen. And that delivery of clinical trials into the clinic is really what we’re all about.

You are missing the surgeon there, if I may be allowed an obvious point, and I work, as you know, in the European Institute of Oncology in Milan where we operate on 4,000 breast cancer patients each year, and my view is the surgeon is of prime importance. He feeds the best material to the pathologist who then picks up the tricks from the molecular pathology lab and so on. Is that the way you are going to present it today? I’m not boasting!

That’s a very kind way of looking at it. I think we need to acknowledge that whatever tumour type you are dealing with surgery is absolutely critical and getting the right operation on the right patient by a surgeon who’s got the technical and the management, patient management, abilities, is crucial to everything else we do. But I think a surgeon in this day and age needs to do more than that; he or she needs to understand that the materials that are removed from a patient, in a patient’s view, are often wasted unless they go to a pathologist who can service a tissue bank, for example, who can also service the bench work that’s done so well by our British scientists who are amongst the foremost in the world, and can lead through to new therapies which may not be surgical, may be radiotherapy, may be chemotherapy, endocrine therapy or even novel biological agents that are coming along. So I think the surgical role is critical and underpins everything we have talked about, but I think it is the part of team work now rather than being a surgeon alone who can help manage patients.

Dundee, of course, has got a unique blend. I remember being at the opening of your labs by James Black and this was a surgical oncology team together with the David Lane molecular medicine team I suppose, and you’ve now built on that in Dundee?

Yes, so people like Sir Alfred Cuschieri and David Lane are fundamental to us developing team work and now we have many people that work following in their footsteps, if you like, and we link across the world to Singapore, to North America, to make sure that we not just deliver what we can do well in Dundee but also spread across the UK, Europe and across the world linking up with those who do complementary things to the work we do and integrating what they do with what we do, and hopefully making a difference to our patients at the end of the day.

And what do you do?

So personally, apart from my day job as operating on those patients with breast cancer that come under my management I guess, we do a lot of laboratory based research. We’ve this year been able to demonstrate that if you have disease recurrence it’s really important to take a sample from that breast cancer and look at it for oestrogen receptor, DRSA receptor, HER2 receptor, because in about one in about six patients the changes in those receptors in the metastatic or recurrent disease will change the subsequent therapy. So that’s basic pathology, basic biology, feeding through to change a patient management. And there are many more complex angles on the P53 gene, for example, and so many other minutiae that are there in the cancer genome that we are keen to dissect out. But at the end of the day it’s those fundamental changes that impact patient care that I am particularly proud we are involved in at Dundee.

You take part in, and probably lead, breast cancer trials?

Yes, so as Chair of the Breast Clinical Studies Group, I obviously have a good idea of the many, over 50, clinical trials that are going on and the breast cancer trials in the UK have always been at the forefront of what goes on internationally. So personally I am an advocate of neo adjuvant pre-operative trials. I am a great fan of doing adjuvant trials as well to try and extend out the lifespan and the quality of life of women who have had breast cancer. And personally if I had the opportunity to invite a patient to go into a clinical trial I will certainly take that opportunity and if she is willing we’ll go for it.

Chemoprevention trials are not on your list?

They are on my list. The list is long, and in Dundee we are proud that we’ve been involved in both IBIS1 and now the IBIS2 trial which is trying to prevent either DCIS, ductal carcinoma in situ, progressing or recurring, or preventing women getting any sort of breast cancer at all. And I think the IBIS2 trial is probably the pivotal trial for the future in terms of us managing particularly post-menopausal women at risk of breast cancer.

Tell us about it.

Well, the trials really revolve around the fact that many women are at risk because of their family history or have had some pre-invasive early changes in their breast biopsy. And what these trials are trying to do is find in these women whether giving them a drug such as an aromatase inhibitor or such as tamoxifen, whether that can prevent them subsequently developing disease relapse or developing breast cancer at all.

The tamoxifen story is... you know, we got there, and the Scottish study actually was part of the eventual meta-analysis which was very interesting. I have always been intrigued to know what the longer term follow-up was on the consequent heart disease rate in that Scottish trial; have you any up to date figures? So has tamoxifen cut down the heart disease death rate or not?

So personally I don’t have the up to date figures on that 30 year old trial now.

I’m old too so I must remember it!

I remember it as a medical student; I guess that dates us both! But I think it’s important that we do follow patients in the longer term and look for the long term consequences of treatment, and that changes with time so in the first five years there is a clear benefit to taking tamoxifen. Between five and ten years there’s a sort of benefit, hangover is probably the wrong term to use, but continued benefit, and then what happens thereafter becomes more and more complex as you have to integrate,  meta-analyse multiple trials. And so the heart protective story, the problems with deep venous thrombosis prophylaxis that would be needed if you wanted to continue to use tamoxifen indefinitely, the issues with endometrial cancer and lesser effects, perhaps to us as doctors, but what’s still major for the patient: hair thinning, eye changes, weight changes. These are all things that I think the quality of the patient’s life is important and we need to keep an eye on it all.

So the IBIS2 is an aromatase inhibitor versus tamoxifen?

That’s right.

How far are you through that?

Well we are hoping that recruitment will stop in a couple of years’ time. It’s been driven very much in the UK but it’s an international trial and, as always, the Australians have been very supportive of it.

Good. Alistair, thank you very much indeed, I appreciate that you’ve got to go off and chair your session now and then back to Dundee after that.

It’s been my pleasure. Thank you very much.