Illuminating cancer in the operating room, eliminating surgery altogether, and simplifying BRCA testing – here's our first update of highlights from the National Cancer Research Institute (NCRI) Cancer Conference in Liverpool.
We’re excited to bring you the latest developments from this year’s conference, where the cancer research community gathered to share their progress and debate the best ways forward to prevent, detect and treat cancer, and improve the lives of everyone affected.
Establishing best practice for chemotherapy before surgery
This year’s conference had a strong showing from the surgical community, and stepping in last minute to talk about surgical trials was Stuart McIntosh, Consultant Breast Surgeon at Belfast City Hospital.
Giving chemotherapy before surgery (as ‘neoadjuvant’ treatment) has many benefits, including reducing the risk of breast cancer spreading, shrinking inoperably large tumours so they can be operated on, or allowing smaller tumours to be removed with breast conserving surgery rather than a mastectomy. However, Mr McIntosh explained that the way neoadjuvant therapy is used and evaluated is worryingly inconsistent across UK hospitals.
He went on to describe an upcoming audit he’ll be running, called NeST, which hopes to improve this situation. He will be finding out how clinicians currently prescribe neoadjuvant treatment, how they monitor and report on tumour response, and how this goes on to inform decisions about the kind of surgery a patient will have. Through NeST, he hopes to define best practice, and generate much-needed national guidelines to ensure everyone uses this treatment pathway in the best way for breast cancer patients.
Can chemotherapy eliminate surgery for some?
Also talking about neoadjuvant treatment, Dr Henry Kuerer from the US highlighted that for some patients, chemotherapy is so effective at shrinking their tumour before surgery that there isn’t any disease left for a surgeon to remove. This poses the question, could these patients avoid surgery altogether? This is an exciting possibility, which could not only eliminate the worry, recovery time, and side effects of surgery for patients, but could save money and hospital resources too.
While standard scans may suggest someone’s tumour has disappeared, the concern is there may be some tiny areas of cancer left in the breast that would allow their disease to return if they weren’t removed surgically. Dr Kuerer has therefore developed methods, combining biopsies with imaging, to identify ‘exceptional responder’ patients with no detectable disease. He shared results showing that this response is more common in patients with triple negative and HER2 positive breast cancer, where it was seen in over a third of patients.
He is now conducting a pioneering trial at The University of Texas MD Anderson Cancer Center where these patients will be treated with radiotherapy but not surgery. If his trial shows it’s a safe approach, he predicts that surgery’s days as a universal treatment for breast cancer may be limited.
Illuminating cancer in the operating room
For lots of patients, surgery will remain an essential treatment that dramatically reduces the chance of their cancer coming back. We heard from Prof Gooitzen van Dam from the Netherlands about how cutting-edge imaging techniques are being used to help surgeons distinguish between cancerous and healthy tissue during surgery. The aim is to help surgeons avoid removing too much or too little tissue in the operating room, which can result in patients needing to undergo further surgery (called re-excision) if they later find out that some cancer remains after their initial operation.
While surgeons are highly skilled at identifying cancerous tissue, which can be whiter and harder than healthy tissue, sometimes there are no obvious signs of smaller deposits which can also be elusive on pre-surgery scans. Researchers including Prof van Dam have therefore developed fluorescent tags, which can either be injected into the body or sprayed onto tissue during surgery, where they then attach to specific proteins found on cancerous cells. With special cameras, surgeons can then see brightly coloured areas alerting them to cancer that needs to be removed. A lot of hard and expensive work goes into making these tags, which need to work in real-time during surgery and be safe for patients. Trials like the BIRDYE study involving breast cancer patients are currently underway, and we look forward to finding out if they will ultimately make surgery more precise and minimise the risk of patients needing repeat operations.
3D images to transform breast reconstruction
In a session asking ‘What’s hot in breast surgery?’, we heard from Jennifer Rusby of the Royal Marsden Hospital, who showed us computer generated 3D images of the chest, which she hopes will improve outcomes of breast reconstructive surgery. Jennifer reminded us that women are now living longer than ever before after a breast cancer diagnosis, which means these women are living with the consequences of their treatment for longer. The appearance, texture and sensation of a reconstructed breast can have a big impact on a woman’s life, and it’s therefore incredibly important that we do all we can to achieve outcomes that women are happy with.
3D images have the potential to be used in a number of ways. They can help surgeons visualise a patient’s breasts from angles a 2D image wouldn’t allow – such as looking down on the breasts as a woman would herself. Another exciting possibility is that these 3D images can show women a computer-generated model of what their breasts could look like after surgery. Jennifer pointed out that this is much more relatable for patients than looking at images of other women’s reconstructive surgeries, and can better prepare someone for the outcomes of their reconstruction. To assess the accuracy of this method, Jennifer’s team will be following women for 5 years after their surgery to see if their breasts do in fact look like the 3D prediction.
Breast Cancer Now researcher Prof Diana Harcourt is also testing an intervention called PEGASUS to help women discuss their expectations for reconstruction with their surgeon.
A better way to select patients for BRCA testing
In a change of topic, Prof Nazneen Rahman from The Institute of Cancer Research presented a new and improved way to determine which breast cancer patients should be tested for inherited mutations in their BRCA genes.
BRCA testing has been available for over 20 years now, but Prof Rahman believes that the system we use to determine who is eligible hasn’t been as successful as it could be and needs improving. Currently, anyone who has more than a 10% chance of having a BRCA mutation is recommended for genetic testing. This percentage is calculated using complex family history criteria, which Prof Rahman explains is time intensive for patients and clinicians.
Instead she proposes that BRCA testing should be offered if someone fits one of the following criteria: has had breast cancer under 40 years old, bilateral breast cancer under 60 years old, their breast cancer is triple negative, they’ve had breast and ovarian cancer, or a man with breast cancer. To incorporate family history, Prof Rahman says that breast cancer patients can be eligible for testing if they don’t fit any of the criteria, but have a parent, child, or sibling who does. Her study showed that this ‘cancer status’ criteria was a more accurate as well as more cost-effective way of determining whether a person should have BRCA testing.
Look out for our second instalment of highlights from the conference – coming soon! You can also follow the latest from the conference on Twitter using the hashtag #NCRI2017.