sMater | Women's Health: Breast Cancer | Prof Chris Pyke

This week on sMater, we're continuing the conversation around women's health, with a specific focus on breast cancer. 

Tune in to hear Mater Private Hospital Brisbane's Director of Medical Services Professor Chris Pyke talk about early breast cancer, including the developments that have improved detection and how he sees that continuing to advance in the future.   

GP Education activity log:
  Podcast title - sMater: Women's Health: Breast Cancer
  Provider - Mater Misericordiae Ltd
  Date published - March 09, 2024
  Certificate of completion - click here

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Jillian Whiting and I'm Ash Mondolo Breast Cancer Clinical Nurse Consultant at Mater Private Hospital Brisbane and we're coming to you from Meanjin the land on which this podcast is being recorded.

Today we are joined by Dr Chris Pike Director of Medical Services at Mater Private Hospital in Brisbane. Chris is also a general surgeon with a special interest in breast and endocrine surgery. He is currently the Director of Surgery at Mater, Professor of Surgery at University of Queensland and Chair of Professional Standards at the Royal Australian College of Surgeons. He's a former president of BreastSurgANZ.

Today he's going to talk to us about what's new in the world of early breast cancer.

We are Mater. We are Mater. We are Mater. This is sMater.

Chris welcome to sMater. Hi Jillian how are you? Very well thank you and now today we're looking specifically at early stage breast cancer stages one and two. Are you seeing more early stage presentations now than say 10 years ago? Yes with the widespread use of breast screening

there's many more patients being detected at an earlier stage so stage one and stage two is the majority of the presentations for breast cancer now. Science plays its role here. Apart from general breast awareness the amount of gene testing in the community the amount of consciousness of gene testing is increasing and the federal government have done a wonderful thing and made gene testing NDS rebatable for quite a larger proportion of the population that it used to be so it used to be a very high threshold for a very expensive test it's now a test that's quite cheap and was just a number of relatives involved you'd be able to get free gene testing it's been a great thing. Specifically on screening what developments have there been more recently in techniques that that have really improved detection?

Once a woman has got to the point where she knows that she needs to have some screening mammography thankfully science once again has stepped in and there's some great improvements with that as well so the machines are gentler
making the study less painful so it's been a great step forward. Second thing is that with the onset of digital mammography this is instead of an old analog kind of interpretation of mammograms it's opened up the way for automatic 

density measurement of women's breast. The higher the density the is a risk factor for breast cancer so all of a sudden automatically you've got this readout of is this patient that an increased chance of developing breast cancer just because of the breast density and then lastly the last part of the digital mamogram story is yet to evolve and it's where the patients will have their mammog s read by artificial intelligence that's that's on our doorstep has already been done in a few places so all of a sudden at your first screening mamogram you can by by filling out a series of questionnaires just about your height, weight, reproductive history and hormonal history and adding that to breast density you can confidently be stratified at that point into whether you're in high risk of developing breast cancer for the rest of your life or low risk. Iit's been a great step forward.

We know that only half of Australian women who are eligible for screening actually attend. Women living in these very remote areas have even lower participation rates. What's being done to improve these rates and hopefully result in an improved early detection in this cohort of women? Yes we know for a screening program to be successful around about 70% of women in the eligible age group need to attend. Australia has a very healthy private public mix of medicine and some patients often have their own screening through the private system system and other patients go with the public system that there's a third group and I think that's the one you're referring to and that's the people who don't partake of of screening and really this is a common thing in health that some people know what is a healthy measure to do but they they somehow neglect to do it or find a barrier to do it. 
Is there anything that we can do to make it even easier? Mobile units for example or I don't know that personal contact and reminders? Those simple things will they make a difference? Yeah I think technology is going to be our friend there.

People already get written reminders the mobile vans are already there at least every part of Australia no matter how rural or remote will be serviced every two years with screening mammography by virtue of the Commonwealth government but to be honest it can be made better we can always improve on that. Women with a BRCA1 or BRCA2 gene mutation have a higher risk of developing breast cancer than the general population. The cumulative breast cancer risk to age 80 was 72% for women who carry a fault in BRCA1 and 69% for women who carry a fault in BRCA2.

So focusing on genetic testing. My understanding is that the BRCA gene was only discovered in 1990. How has genetic testing for cancer advanced since then? 

What a great breakthrough was the discovery of the BRCA genes the tumor suppressor genes which on average in inherited by half of the offspring of carrier. So along with the BRCA genes are now identified maybe seven or eight or maybe even more less penetrant genes who which would predispose a woman to cancer so 
the discovery of the genes human Genome Project.

I mean that we're we're standing on the shoulders of those great scientists who came before us who discovered all those things and for the 
from the government's viewpoint they made gene testing easier it's now much easier to get a gene test done and whereas on one hand surgical techniques have got so good with breast conservation surgery almost anyone can have their breast conserve if they if they need to. Likewise the early identification of being a gene carrier and identifying a higher life lifetime risk allows many women to have prophylactic mastectomy at a young age so simultaneously have more people preserving their breast with breast cancer and more women having bilateral mastectomies because of they know their genetic status much earlier. One of the other advances that gene testing has given us is it provides a set of guidelines. It allows health practitioners, health providers to give good firm guidance about at what stage do you need to consider having major surgery to remove the breast and it and on the on the flip side of that it allows us to tell women who have a strong family history that know that they're not at any increase just compared to the rest of the population so for example BRCA1 one carrier who comes to see you she's say an 18-year-old woman who comes with her mother who's been your patient or is a known carrier the publish guidelines which are freely available to the public and to doctors would
suggest that a very specific screening regime begin for the younger woman from the time she from age 30 onwards and also that she should consider risk reducing surgery before she turns 40. So the general advice is we provide a safe environment for the younger woman to get through various reproductive milestones in her life should they want to do that and but when they've finished say having a family finished breastfeeding then that we will have been able to safely get them through that period before then embarking on appropriate preventative testing or risk reducing surgery before it becomes a dangerous time.

Who is eligible for gene testing should it be everyone?

Well why not.

If money was no object right?

Yeah and it's like any test there's any screening test has there are benefits and there are harms and and the benefits are that early

identification of people at risk allows them to be safely managed until you can make the risk go away. Likewise allows you to detect their cancers early. So 1 in 300 people would be carriers of the BRCA genes men and women alike and there's benefit to almost everyone to know their genetic status.

If you knew you're a gene carrier you would perhaps take preventative measure measures which you can. There are there are modifiable risk factors for breast cancer exercise in frequently less alcohol intake, reducing body mass index all those things help decrease the chance of getting, breast cancer taking a uh chemoprophylaxis in the form of an anti-estrogen tablet. It allows you to start that at an appropriate age. Likewise if you're proven to have another gene that's not BRCA that then your risk of developing breast cancer can be adequately conveyed to you so that you know for sure that even though there's a slightly increase risk you don't need to consider you can do something less than that during your lifetime. So the gene test have allowed us to give that information to all those women who need that advice. At the moment we would be pushing for what the Americans are trying to push for and that is all women with early breast cancer below the age of 65 should be offered gene testing with ongoing testing or Domino testing for the family members if it came back positive. That isn't what is offered by the government at the moment the government has fairly strict rules around at least three relatives or triple negative breast cancer below the age of 50 or any breast cancer below the age of 40 or a known gene carrier in your family. That's not likely to change as far as Australia versus the American system?

I think you'll find they'll discover more genes. I think science will once again make a leap forward and I think also that the government has proven very responsive to the very powerful lobby that that is that is now increasing a massive and increasing cohort of survivors of breast cancer that the mortality has decreased enormously so it means that women who've had breast cancer now constituted a huge lobby group in our society.

Given women are now able to know and understand their risk for developing breast cancer before their diagnosis,

how has that shaped interventions and preventative measures?

So the broad interventions, well prevention comes really in the forms I just mentioned so prevention primary prevention would be removing the breast tissue or trying to do something about your general body health to prevent breast cancer and these modifiable risk factors body mass index are same as when you're 18 years old, limiting alcohol to two glasses a day and exercising four hours a week have been shown to decrease your chance of getting breast cancer by about 40% so we all know what to do like all of us know these are the right things to do the secondary prevention is the early detection of a cancer so the gene test if someone is a proven gene carrier you know that that it has the potential the gene associated breast cancers by and large grow more rapidly so they need increased screening so instead of having mammographic screening every two years which is based on the average growth of cancer these women would have some form of screening tests every six months until it becomes a safe time to remove their breasts so they're the things that we're doing at the moment.

How does Australia's approach to genetic testing for breast cancer compared to other countries?
Compared to most of the world we're well ahead of average the federal government really has done a great thing by offering an MBS rebate for what they consider appropriate gene testing and the criteria they would use would be three relatives with breast cancer on the same side of the family family of be or a positive family history of breast and ovarian cancer on the same side or relatives on both sides of the family then we get down to triple negative breast cancers below the age of 50 or any breast cancer below the age of 40 or any bilateral breast cancers so we're already well in the game and well above a lot of the rest of the OECD nations with that and that the cost of the testing has come down from $4,000 which it was even 5 years ago down to about $400 . It's become amazingly accessible to almost everyone. The Americans are pushing a bit further so they would argue at least one and 300 of us carry the gene if we're not going to go to population screening which is you know as I'm I mentioned before it may have harms as well as benefits why not test everyone who's got early breast cancer below the age of 65 so that the rate of them being a gene carrier is going to be well above 1 in 300 why not offer it to that group and it's possible with the amount of community support that the breast cancer survivors have that the government will be tipped in that direction. One way to diagnose breast cancer is through a triple test which as its name suggests involves three steps. One medical and personal history and clinical breast exam. Two Imaging, and three a biopsy if the result of any one test differs from the others then the diagnosis is uncertain and further investigation is required however if all three tests are negative cancer can be ruled out with a 99% accuracy.

Chris a number of clinical Peak bodies have endorsed triple testing and have established guidelines for GPs. What difference has it made?

So the guidelines you're talking about are the triple assessment of breast lumps breast.
Lumps are really common you know at least 40% of women in any given year would feel a new breast symptom so the determining of whether a new breast symptom is something to worry about or not is really high in the mind of all women and all Primary Healthcare Providers I'd have to say so a triple assessment allows you to safely rule  rule in benign things and to rule out malignancy so if a patient has a lump then if these three things are concordant if the clinical exam the Imaging and the tissue sampling are all concordant and all three show that it's benign then that truly is a benign lump and the good thing about breast is and breast conditions are that the benign lumps don't turn into cancer so unlike say polyps in the bowel if you leave a pull-up there long enough it will turn into a bowel cancer in the breast if you have a benign lump it will never turn into a breast cancer breast cancer begin as tiny breast cancers which grow. Now as the years are gone by the triple assessment has been kind of weaponized if I could say with the clinical exam and the imaging and the tissue sampling all being concordant but confirming the presence of cancer then with the use of core biopsies as tissue sampling we can now do a phenotype of the breast cancer so we know about its grade and the receptor status from the time of diagnosis and what that has meant is that patients can be stratified into either surgery first which still constitutes about two-thirds of our patients or chemotherapy first which constitutes around about the other third of our patient so that that has changed in the past 5 years so whereas you know 5 years ago almost one got surgery first by exception now the systemic treatment for breast cancer is so good and the amount of information that we get from neoadjuvant treatment is so useful a third of patients are given chemotherapy first and surgery to follow and it's all because that triple assessment has allowed us to look at the grade and the receptors on the cancer.

Chris if the diagnosis is uncertain how quickly do you want to be brought into the picture?

Yeah I think part of the major role of all health providers is to provide psychological safety for all of our patients I'd have to say uncertainty is almost unbearable if you think you've got a cancer of any sort let alone breast cancer if the testing has not defined the issue one way or the other I really think you cannot get the information that you need fast enough in my in my own practice I would endeavor that that those patients should be seen within a week. I know in other parts of the world say in the UK where the work up of breast symptoms is done at a hospital level not at a general practice level they have to open rapid access clinics so that there can be daily assessment of new breast symptoms. I think it's an acute awareness of the fact that the uncertainty about diagnosis is such a psychologically crippling condition so for most patients who don't have a diagnosis the guidelines would say they should be seen within two weeks in my own practice I would endeavor to see them the same week as their new finding just on the grounds that the mind is such a powerful tool and it can be so destructive left to its own devices.

How important is that that relationship that GP and patient led diagnosis and the key to its success? Yes having a good GP will save your life. So the GP is the key to it all that they will have the skill the experience of clinical exam the knowledge of your background and they would also have all the keys to where to get to services as rapidly as possible. A good GP will also have a number of specialists that can call on. They'll have them on their mobile phone it's a common thing for all of us who to treat breast cancer to take phone calls from GPs at all times. 
According to the ANZ breast cancer trials group in the past 20 years the 5-year relative survival rate for early stage breast cancer has increased from 73% to 91% in Australia. The chance of surviving at least 10 years in Australia is now 83% if detected early by a mammogram.

Beyond screening and testing what else has contributed to the survival rates and improvements in breast cancer?

So the two great advances have been screening which we've been talking about and the fact that cancers are diagnosed at a at an earlier stage the other huge input into the survival of breast cancer survival rates for breast cancer now are 90% plus for almost everyone with early breast cancer and that's only happened during the last 20 years with the number of new drugs that have been proven effective in the adjuvant treatment of breast cancer so it's the chemotherapy drugs that new biologic agents so these are antibody testing and small molecules and then there's a number of conjugated drugs now as well where a clever antibody will be linked to a chemotherapy agent where the antibody delivers the chemotherapy agent right into the tumor cell that these have been great advances in in breast cancer and as I say that as much as early diagnosis these new drugs have diminished the chance of breast cancer shortening your life.

All those things are making an incredible difference that all those improvements we've seen recently. What about in the future? Can you look ahead?

Where do we see survival rates going in the near future?

Yes so in an ideal world it would be completely preventable like until we find the actual cause or the causes of breast cancer and trying to rule them out then I think it's possible to get even earlier detection and what we're getting in at least in theory . There's um the possibility of liquid biopsies which is where someone will have a blood test and the circulating DNA from say from cancers would be able to be detected this is already present that in in the world of obstetric a pregnant mother will be able to have a blood test now
the DNA from the baby that she's carrying can be analyzed fully from that just a blood test of the mother's circulating blood so we would see that having a role in breast cancer as well either in the early diagnosis of breast cancer or in the early diagnosis of detection.

And finally Chris bringing out your crystal ball. Where do you think we'll be in 10 years time?

I think the things that would be here in 10 years partly here already as someone said the future is already here it's just not evenly distributed yet so I think that I think that's at the point of diagnosis  where we're doing core biopsies now and people are getting a phenotype of their cancer I think more stratification is going to go on at that point I think I think so we're already picking off a third of people for neoadjuvant chemotherapy and two-thirds are going into surgery first. I think we're going to find that there's a group we find whose mammograms are so easy to interpret and their overall risk is so low that we're going to be able to tell them no you can only you only need screening test done every five years rather like the cervical cancer screening story we're going to find some factor that allows us to separate off people at low risk to decrease their amount of concern. I think when it comes to stratification at the other end of treatments I think we're going to find some patients whose prognosis is so good that they won't need a fully structured five years follow up that this would be largely be able to be done by self- testing, self-reporting and a lot of it electronic kind of follow up. I think the pandemic has been good for that to tell us there are some things which absolutely need to be done face to face but other things just need to be just followed up and made sure that they're done and you can rely on the imaging. I think that will probably be the point we'll be at. I really do think in 10 years time that the first run through of screening mammography will almost certainly be done uh by computer generated AI and I think that the cancer detection rates will increase because of that. I think we will use that as our friend I think we'll also use as our friend to make sure that no one falls through the gap in follow up in gaps in follow up. I think it's going to be a much safer world in 10 years time.
We'll catch up in 10 years time and see where we're at.

Before you go though, special treat for you Chris. We want to introduce you to a little segment that we call The Checkup. So this is about understanding more about Chris as the human the person as well as the medical profession. So Ash has five quick questions for you? Ready? You'll be disappointed. No I won't be this is going to be great.

Chris if you had to invite three guests to dinner who would you invite?

Well that's a great question as I'm assuming my wife Jan my wife of 39 years now is there. So other than Jan two of them would be people who do a podcast called The Rest Is History Tom Holland and Dom Sandbrook. I thought you were going to say us.  
For texture, diversity, moral guidance and framework sister Angela Mary. She's always been great company.

Chris if you weren't doing this what would you be doing?

Turned down the acceptance into a teaching course early on and even in surgery when I started off I did think that cardiac surgery looked pretty good.

We're glad you haven't found anything else to do.

Who is the most underrated member of the hospital team?

You know we've looked at this before there are 80 occasions of service in a breast cancer episode and the people who are there at the

very beginning making sure that someone gets early attention and gets to the right specialist at the right time and I have to say you know that's

it's the Breast Care nurses and the receptionist. They're the ones that they carry the patients through that.

How do you want your patients to see you?

I'd be hoping that they thought they got service equal to the best of the breast surgeons in Brisbane. That's what I'd be hoping.

And lastly who do you admire?
Who do I admire? John Heron I'd have to say he was

a surgeon mentor of mine. He had some great aphorisms so should be no tension in anastomosis and no tension in the surgeon.

Chris thanks so much for joining us on sMater. For our listeners at home or in the car or having a well-deserved break between patients, thanks for tuning in.

Join us for our next episode where we continue exploring  Women's Health. See you next time on sMater.