When Angelina Jolie made the dramatic revelation that she had undergone a double mastectomy to reduce her risk of breast cancer, her decision was met with shock, but also with a good deal of admiration and respect. With a mother who had died from the disease in her 50s, tests showing that she herself carried one of the risky genes, and with surgery, as she said, reducing the likelihood of her contracting it from more than 80 to 5 per cent, her choice was understandable.
But not everyone with a family history of breast cancer will be prepared to contemplate such drastic action. So it is to the credit of the National Institute for Health and Care Excellence that it is offering a middle way. In a new guideline, Nice says that women in England and Wales who are over 35 and have a moderate or high risk of breast cancer should be considered for preventive drug therapy. They will be offered a five-year course of either tamoxifen or raloxifene – drugs that have been found to cut the risk of breast cancer by as much as 40 per cent. Surgery is already an option, but drugs are likely to be the preferred choice.
The new Nice guideline is welcome for several reasons; first, of course, because it could and should mean that breast cancer claims fewer lives. And if fewer women develop breast cancer in the first place, fewer will have to go through the gruelling and debilitating treatment that is now almost the only option.
A second reason is that it shows Nice doing the job it was set up to do: reviewing treatments and judging how NHS money can most effectively be spent. The two drugs mentioned are affordable and both have a proven record in treating breast cancer, even though they have not been expressly approved for prevention, at least in Britain. But Nice has clearly calculated that the lives, suffering and long-term treatment saved by the prophylactic use of these drugs will make economic, as well as medical, sense.
And a third, related, reason is that it signals a new attention to family history in health matters. As multiple GP practices have proliferated, and patients no longer always see the same GP, the likelihood that a doctor will be familiar with a patient’s family history has declined. A whole body of pertinent knowledge has thus been lost. Advances in genetic research and a realisation of the potential benefits to be reaped from genetic testing, however, are encouraging a new emphasis on family history. If this fosters prevention, as well as – it is to be hoped – leading the way to cures for diseases once regarded as death sentences, that is a huge step forward.
With the news so generally positive, however, we would still urge a note of caution. A time can already be foreseen when drugs are precisely tailored to a patient’s genetic make-up and so rendered more effective and less wasteful. But a five-year course of preventive drug treatment for women judged to have a higher risk of breast cancer is quite a blunt instrument. Some, perhaps many, of those who opt for the treatment may not need it, and there may be long-term side-effects that are as yet undetected. This is not a question of money, but of health.
And a more general question arises over the idea of healthy people taking drugs solely for preventive purposes. Aspirin is one supposed “miracle” drug whose long-term use can produce damaging side-effects, and the notion that cholesterol-reducing statins bring only benefits is already being challenged. Some 50,000 women and 400 men are diagnosed with breast cancer every year and any serious attempt to reduce that is to be welcomed. But the choice for those with a family history of breast cancer may still be harder than it looks.