Who am I?
Hello, and welcome to my first blog. I am a medical breast cancer specialist, and I’ve worked for many years at the Royal Marsden Hospital, London and more recently in addition at Cancer Centre London, Parkside Hospital, Wimbledon. I’m also a Trustee and Board member of Breast Cancer Haven. This is a UK charity specifically dedicated to providing physical and emotional support for anyone with breast cancer, which you probably already know since you’re on the website. To me it’s a very special charity.

My blogs and breast cancer
My blogs are going to be for patients who have or have had breast cancer. I’m going to cover the big current issues in this disease as they affect people going through treatments and those recovering and trying to get back to a normal life.

Over the last few decades breast cancer has become one of the great success stories in cancer medicine. When I began my career only 30% of patients were cured, but now this number has risen to well over 70%. And I strongly believe this cure rate is going to keep improving as we learn more about the disease and develop better ways of treating it. But as many of you will know only too well, our treatments come at a price. Patients often require prolonged treatment including surgery, drugs and radiotherapy, which can go on for many months. These treatments are not easy, and the path to recovery can be difficult. So we’re going to talk about all this in my blogs. And you will have the chance to feed back to me your particular concerns and questions, so that I can keep my topics as relevant as possible

The Impact of Covid-19: delay in diagnosis
Today I’m going to start with the obvious big issue of the moment, the impact the Covid-19 pandemic is having on cancer diagnosis and treatment, and in particular breast cancer

Let’s deal with diagnosis first. You will all be aware through the media that there has been a very large fall in the number of people coming to hospital with concerns that they might have breast cancer over the last few weeks. This is totally understandable. Hospitals are seen as dangerous places these days, hotbeds for becoming infected with the virus. And also, the public is all too aware of the stress treating Covid-19 has put on NHS resources, and many feel we shouldn’t be bothering doctors and nurses already thought of as being overstretched.

Well, there’s good news here. For the time being at least hospitals have weathered the virus storm and most are not running at capacity. In addition, the NHS has set up a cancer hub structure throughout many parts of the country, so that workload can be divided and shared amongst groups of hospitals. Some hospitals are now specifically designated to look after patients with cancer, and have either no patients with Covid virus, or at least very low numbers. In South West London these include my main hospital, the Royal Marsden, which is again now carrying out a lot of cancer surgery and other cancer treatments. An impressive feature of these hubs has been the coming together of NHS and private hospitals to share in the diagnosis and treatment of all patients.

There should therefore no longer any good reason to hold back from going to see a doctor if you have worries that you might have something wrong with your breast. There is now the capacity in the system for you to be seen promptly and there should be very little increased risk of catching the virus. Remember that breast cancer is usually curable these days providing it is detected early.

The Impact of Covid-19: delays in starting treatment
The next big issue concerns delays in starting treatment. Because of Covid-19 there is already a big backlog for patients diagnosed with breast cancer, and in the short term this is likely to increase; some operating theatre space is still needed to treat those most seriously affected with Covid-19, and anaesthetists are in the front line for looking after patients requiring ventilators. So for a fair number of breast patients surgery will have to be delayed. This is obviously worrying and the question arises – how do we prioritise?

Fortunately we have an answer and it’s based on an important feature of breast cancer, the oestrogen receptor, usually shortened to ER (not OR because Americans call it estrogen and in breast cancer they usually call the shots!) The majority of women with breast cancer (about 75%) have ER in their tumours, and these are called ER+ve. The growth of these cancers is often stimulated by oestrogen, a hormone circulating in all of us to a greater or lesser extent. Many (but not all) ER+ve breast cancers stop growing and shrink when exposed to a group of simple oestrogen- blocking drugs. These include tamoxifen and a group called aromatase inhibitors (including letrozole and anastrozole). They are very widely used AFTER surgery to eradicate residual microscopic cancer cells and increase the chances of cure.

In the last few weeks I have been part of an international study group which has come up with a way of identifying which patients with ER+ve breast cancer can safely be treated with these simple drugs up front, BEFORE surgery, if necessary for several months, until surgery becomes available. It’s a good idea, and it can also be applied to other medical treatments before surgery. I’m going to tell you the story of this approach in my next blog, and hopefully it will give some good reassurance to those of you caught up in the delays and waiting to start surgery.

If you have any queries or comments please email the team at Breast Cancer Haven and I will answer these in my next blog.

Ian E Smith
Professor of Cancer Medicine
Royal Marsden Hospital and Institute of Cancer Research, London

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