Focus on breast cancer: 'C' is for cure

A cure for cancer. It is what medical scientists dream about. And this week's announcement about breast cancer - the most common form in women - brings it closer to reality. The discovery that a drug which already treats cancer could also prevent it will give hope to all women with a family history of the disease. But while the scientists are hailing an historic breakthrough, the reality for patients in hospitals and doctors' waiting rooms is altogether more desperate

By the end of today, 35 women will have died from breast cancer in England and Wales. Tomorrow, 116 more will be told they have the disease. But a breakthrough in our current understanding of the most common form of cancer in women means that, within the next two decades, that toll could be halved.

Last week Cancer Research UK announced a £10m trial that will test how anastrozole, a drug currently used to treat breast cancer, can also prevent it. Anastrozole has been hailed as the biggest breakthrough in breast cancer treatment for two decades, and scientists believe it could halve the chances of high-risk women developing the disease.

It works in a similar way to an older drug, tamoxifen, but is almost twice as effective and has none of the adverse effects such as hot flushes and vaginal bleeding as well as an increase in the risk of cancer of the womb, blood clots and strokes. Instead of simply blocking oestrogen, as happens with tamoxifen, anastrozole shuts down the hormone's production altogether, because it is known to stimulate the cancer cells.

Scientists are so excited about anastrozole because it is also much more effective than tamoxifen - reducing the recurrence rate of cancer by 70 per cent compared to 45 per cent with the older drug.

It holds the hope of a future free from fear for those women with a family history of breast cancer or other known risk factors. They will simply take a daily pill to prevent it. Professor Trevor Powles, head of the breast cancer unit at the Royal Marsden hospital in London, said: "This is not pie-in-the-sky wishful thinking - we are already there in terms of being able to prevent most high-risk women from getting breast cancer. I think we are probably only halfway there in terms of cutting the mortality rate.

"The most exciting developments are in molecular therapy, where we can look at a patient, at their specific cells, and target the right treatment at them."

This is cutting-edge science where, through genetic testing, people become patients even before they fall ill and "smart drugs" play cancer at its own game by targeting the malignant cells.

Yet although breast cancer treatment is one of the great success stories of the NHS, it is also an example of its worst deficiencies. The NHS screening programme, which was set up in 1986, has saved thousands of lives through earlier diagnosis and detects approximately 9,000 cases of the disease a year. Deaths from breast cancer have fallen by 21 per cent in the past decade alone to 13,000 a year. Twenty years ago, only half of the women diagnosed with breast cancer were still alive five years later; now 82 per cent survive beyond that point.

Early detection means that only 30 per cent of patients with operable breast cancer now have to undergo a mastectomy, compared to 50 per cent before the screening programme was introduced.

Another major factor in the falling mortality rate has been tamoxifen, introduced in the early 1980s. Furthermore, the Government's pledge of a maximum two-week wait from a patient who suspects she may have cancer seeing her GP to an appointment with a specialist has added to the speed with which women are diagnosed.

All of these statistics paint a rosy picture of breast cancer care in the NHS. What they fail to show is the reality of life on the front line for patients. Chronic shortages of radiographers mean that some women are waiting five months for radiotherapy following breast cancer surgery, when the recommended time is five weeks.

The Government's two-week cancer pledge has speeded up initial diagnosis but has led to a backlog in other areas, such as the processing of test results. Patients should wait a maximum of five working days for results, but a recent survey by the charity Breakthrough Breast Cancer found that one in seven women was waiting double that time.

Furthermore, the postcode lottery of the NHS means that while patients in some parts of the country have access to cutting-edge drugs and treatments, others are denied them.

Delyth Morgan, the chief executive of Breakthrough Breast Cancer, said: "Women are still not getting the care they need. They are facing agonising delays for test results and, more worryingly, for radiotherapy.

"The research means these great drugs and treatments are coming through, but some patients are dying while they wait for them."

Doctors are also failing to give women the information and the emotional support they need when they receive the devastating diagnosis of breast cancer, the Breakthrough researchers found.

Ms Morgan said: "Too often, women tell us that they haven't been given the full facts. They are told they have cancer, told they need treatment and then sent home.

"Doctors can be brutal when giving a diagnosis, then don't give information about the risks of the cancer recurring, or what it means for a woman's daughters and their chances of getting breast cancer."

She added: "It is not just the big things like radiotherapy that can make a difference. It's little things like the fact that women can sit for hours in a bleak waiting room with a broken coffee machine, waiting for an appointment with a specialist."

While the death rates from breast cancer are falling, scientists are beginning to spot a more worrying trend.

Cases of the disease appear to be rising by 2 per cent a year.

In 1999, the last year for which figures are available, 42,500 women in Britain were diagnosed with breast cancer, an all-time high. At the current rate of increase, this means that more than 50,000 women will be told that they have the disease this year.

While increased detection through the screening programme accounts for some of the rise, experts say other factors are also at play. New studies have shown that a variety of environmental factors, including stress, obesity, alcohol and lack of exercise, can all increase the risk of breast cancer.

Some of these risk factors, such as obesity, are down to the production of oestrogen, the hormone that can be shut down by drugs such as anastrozole.

This raises a dilemma: if anastrozole is given to women with a genetic predisposition to breast cancer in order to prevent the disease, should it also be made available to someone who is overweight and at risk?

The worldwide bill for cancer drugs is set to triple by 2010, and the National Institute for Clinical Excellence will have to make tough decisions on who should have access to the latest medicines and treatments on the NHS.

Despite these problems and dilemmas, the experts agree that at long last a world is dawning where a diagnosis of breast cancer no longer means for the patient a certain fear of death.

As Professor Powles said: "In 20 years', even 10 years' time, we could be at a stage where breast cancer is a manageable condition, and given where we were 20 years ago, that is incredible."

The Radiographer: The service is being brought to its knees

Audrey Paterson is the director of professional policy at the Society of Radiographers. She said: "We just do not have the staff we need to reduce the backlogs and get people treated within an acceptable period of time.

"We now have these great new shiny machines in hospitals, but they are useless unless you have the people on the ground to use them."

Vacancy rates for radiographers in the NHS are currently running at 20 per cent, while in some parts of the country, including major cities such as Manchester and London, one in three posts are unfilled.

"This year we saw the lowest number of radiographers qualify in the last five years," Ms Paterson said.

"The service is being brought to its knees, and the depressing thing is that it is going to get worse before it gets better."

While historical problems with a shortage of training places for radiographers are partly to blame for the situation, the biggest problem is recruitment and retention.

Radiographers are responsible for both diagnostic services for breast cancer, through the screening programme, and the therapeutic area of radiotherapy sessions.

Radiologists may diagnose the cancer and consultants plan the treatment programme, but they need radiographers to use the equipment.

Despite being central to the breast cancer service, a qualified radiographer will start on a salary of just £17,000.

"A lot of people qualify, work for the NHS and then go to the private sector or an agency," said Ms Paterson.

"We have heard of hospitals where there are 24 radiographer posts, and they have just one staff person, with all the other positions having to be filled by agency people. Radiographers in the NHS do not feel valued for the work they do."

The Government argues the backlog could be cleared if radiographers worked evenings and weekends, but this cuts little ice with Ms Paterson.

"It is all very well having evening and weekend sessions, but you need the staff to fill those shifts," she said.

"Radiographers are already working flat out now and I don't think they can take much more.

"They are the ones at the coalface who have to meet the patients day after day, telling them that they will have to wait for treatment, and coping with the anguish and the anger."

Her wish: "We need better pay, a better career structure and the Government to listen to our concerns."

The Doctor: Screening and drugs have had a huge effect

Professor Trevor Powles is head of the breast cancer unit at the world-renowned Royal Marsden hospital in London, andemeritus professor at the Institute of Cancer Research.

He said: "Breast cancer services have been transformed over the last 10 years. Diagnosis and treatment have improved immeasurably. The screening programme, tamoxifen, the reorganisation of services, have all had a huge effect."

Twenty years ago, half of breast cancer patients were treated by doctors who saw fewer than 10 cases a year.

Now, says Professor Powles, most women are seen by multi-disciplinary teams including specialist breast cancer nurses, surgeons and consultants.

"Even in the last five years, we have learnt so much more about breast cancer, how the treatments work, what the risk factors are," he says.

"Breast cancer has led the way in the field of cancer [research], and I am optimistic about the future."

But he added: "Radiotherapy is the biggest problem - we should not have people waiting for treatment.

"Radiotherapy should be given within six weeks of surgery - women should not be waiting three months."

However, Professor Powles says breast cancer has remained a political and health priority, partly because women have become such powerful advocates for their own care.

"I am amazed by how much women know about new drugs and new treatments," he said. "Charities such as Breakthrough Breast Cancer have given patients such a powerful voice."

His wish: "More money. I obviously have a vested interest in this area, but we can prove that the money put into breast cancer services has a real, visible result."

The Patient: I had to sit at home and wait, knowing that the cancer was in my body

When Liz Rhoades was diagnosed with breast cancer in 1993, she was impressed with the speed with which she was seen and treated.

Eight years later, when the cancer returned, she was left feeling let down and betrayed by the NHS. She had to wait 20 weeks before receiving radiotherapy, despite her history of the disease. The delay came as a blow, particularly because, as a former health visitor, Mrs Rhoades had devoted much of her working life to the health service.

"I just couldn't believe that in this day and age I was made to wait that long for treatment," she said. "I had to sit at home and wait, knowing that the cancer was in my body. It was the most horrendous time.

"There were days when I lay in bed, thinking if I didn't move around maybe the cancer wouldn't spread either."

Mrs Rhoades, from Mill Hill, north London, was 52 when a routine mammogram in 1993 picked up a malignant tumour in her left breast. She underwent a mastectomy at Edgware hospital and, after five weeks' recovery time from the surgery, began a course of radiotherapy. She was prescribed tamoxifen, and five years later was given the all clear. But in 2001, she found a lump at the very edge of the area where her breast had been removed.

"I was devastated. I had to have more surgery and was told I would need another course of radiotherapy, which I assumed would start as soon as I had recovered from the operation."

But Mrs Rhoades waited six weeks before being called for a consultation for the radiotherapy course.

"I assumed I was coming in to be measured up for radiotherapy and would start the next week," she said. "Instead, I was told I would have to wait 14 weeks because there weren't enough staff.

"It was incredible. I dedicated my life to the NHS, and totally believe in its principles, but I felt completely let down. I was crying and shouting at the radiographer when he told me. I can't believe things have actually got worse in eight years, rather than better."

Mrs Rhoades is now clear of cancer but is having her right breast removed in December in order to prevent a return of the disease.

Her wish: "No one should have to wait for months on end for treatment that could save their life."