The gauntlet has been well and truly thrown down. After decades of British women suffering among the worst breast cancer death rates in the world, the government is now committed to matching the best survival levels in Europe by 2010.
Achieving such a huge turnaround within nine years will take a great deal more than wearing pink ribbons, the emblem of breast cancer awareness, on our lapels. The omens so far are reasonably good. Death rates are already falling, firm plans and guidelines are in place to improve screening and treatment, and a major injection of resources is promised. Yet serious anxieties remain over the health service's ability to deliver this ambitious goal. There is all to play for.
Breast cancer is the main cancer killer of British women, causing around 12,000 deaths in England and Wales each year. Latest figures reveal women in the UK still suffer one of the highest death rates in the European Union, although 1996 data shows we have been edged out of bottom place by Denmark, Ireland and the Netherlands.
Our marginally better position reflects a sharp downward trend in UK death rates since the late 1980s, which so far shows no sign of plateauing. From 1987-97, annual UK death rates from breast cancer fell by 22 per cent for women aged 20 to 69, with a projected drop of 30 per cent by 2000, according to analysis by the Imperial Cancer Research Fund.
1 Life would be simple if this dramatic success was due to a single bold innovation. But, as the ICRF researchers stress, there is no one medical breakthrough or miracle cure. Beating breast cancer depends on a complex combination of best practice in detection, diagnosis and appropriate, effective treatment.
As death rates simultaneously drop elsewhere in Europe, Britain still has much catching up to do.
Matching survival rates of the best in Europe - as pledged in the NHS cancer plan in September - will be no mean feat.
2 The plan involves injecting£570m in extra funds each year by 2003-04, recruiting 1,000 more cancer specialists on top of extra cancer surgeons, and providing 250 more MRI and CT scanners. It has been broadly welcomed by cancer lobby groups, yet doubts remain about its feasibility.
'For the first time we do have a very comprehensive blueprint for tackling cancer in a pathway approach, ' says Elisabeth Davies, director of the UK Breast Cancer Coalition. Like many in the field, she is impressed by the apparent determination of public health minister Yvette Cooper and cancer 'czar' Professor Mike Richards to improve breast cancer care by systematically tackling detection, treatment and follow-up. But success will depend on two key elements: finding enough staff to do the job and turning ambitious treatment aims into reality, she argues.
Since we know so little about preventing breast cancer, prompt detection is a vital element. But the beginning of this year saw doubts cast over the very purpose of breast screening, when researchers from the respected Nordic Cochrane Centre in Copenhagen revisited data from early pilots, including one in Edinburgh, to conclude: 'There is no reliable evidence that screening decreases breast cancer mortality.'
3 Although it ruffled feathers at the time, the study, which mainly argued trials had not been adequately controlled, has been largely discounted.
And this autumn brought the first ever concrete evidence that the UK breast screening programme does save lives, although disappointingly few.
Epidemiologists, again from the ICRF, reported that breast cancer deaths fell by 21 per cent from 1990-98 in England and Wales and attributed one-third of this reduction - about 6 per cent - to screening.
4 Among the women studied, who were aged 55-69, this saved an estimated 320 lives.
Treatment improvements, such as wider use of tamoxifen, emerged as far more significant, accounting for about 15 per cent fewer deaths. But screening, which only achieved UK coverage in 1995, will become increasingly important, the researchers argued. They predicted that by 2005-10 screening should account for at least a 25 per cent fall in deaths compared with 1990.
While the relatively small impact so far gives weight to the minority of doctors who believe the£37m annual bill for screening would be better spent on improving treatment, Richard Winder, deputy national coordinator of the NHS cancer screening programme, takes a robust view. 'The problem for anything like this is we can only claim the success that we can absolutely prove, ' he says. 'I think we feel our success is greater than that.' In addition, he argues that screening has had a 'knock-on' effect, raising breast awareness, increasing patients' expectations and bringing together specialist multidisciplinary teams to improve treatment.
Ambitious targets in the cancer plan will take the screening programme further, extending the age limit to women up to 70 years by 2004, and ensuring all mammograms, not just the first, are double views. Both changes are based on pilot study evidence that they will save lives, says Mr Winder. But the age extension, providing women with seven screens during a lifetime instead of five, will create a 40 per cent hike in workload, he warns.
'We are confident we can cope, otherwise we would not have embarked on it, ' he says. Four 'development sites' are piloting skill-mix changes, creating a four-tier career structure for radiographers, in a bid to ease the load on radiologists. But quality will remain paramount, insists Mr Winder, or the expansion will not go ahead.
At Bolton, Bury and Rochdale breast screening unit, one of the skill-mix pilots, staff are optimistic. People have already been recruited or slotted in to the new posts. These include a new non-state registered assistant practitioner, who will perform routine mammograms, and radiographers upgraded to advanced practitioners, who will read films and perform ultrasound procedures.
'We are all very committed to it, ' says radiographer Christine Hopkins, now lead practitioner under the new structure. 'If it is going to work, it is going to work here.' However, no pay scales have yet been agreed or extra staff recruited to cope with the expected workload increase.
Nationally, there are still shortages of both radiologists and radiographers. Although the new assistants may help ease the load, they will still need careful supervision by radiographers, says Julia Shrimpton, who is on the council of the Society and College of Radiographers. Many universities cannot fill radiography places, she warns.
The Royal College of Radiologists is also worried. With a national shortfall of 35-40 consultant radiologists already, screening units are 'sinking fast', says Dr John Fielding, who chairs the college's breast group. While welcoming the skill-mix experiments, it is still unclear they will resolve existing problems, let alone expansion, he says.
His predecessor in the group, Dr Stuart Field, agrees.
Extending the age limit will require more equipment, films and buildings, as well as scarce staff. While the skill-mix proposals may help, radiologists will still need to supervise newly promoted radiographers. 'There is considerable anxiety, ' he says.
Such pressures suggest that demands to extend screening beyond 70 will fall on stony ground at present. Charity Age Concern argues that inviting women over 70 for screening would save 1,500 lives a year, since 40 per cent of breast cancers occur in this age group. Although women over 70 can self-refer, failing to invite them sends the message they are not at risk, it says.
Ian Fentiman, professor of surgical oncology at Guy's Hospital, London, agrees that on a value-for-money basis screening women over 70 makes sense. Huge amounts of time are currently spent screening and assessing younger women who are generally not at risk, he says.
But the best detection system in the world is little help if cancer care itself does not improve.
Professor Fentiman believes the screening programme has brought major benefits to treatment standards, too.
'Instead of just surgeons dabbling in this, suddenly you do have groups of individuals - surgeons, radiologists, pathologists - all working in teams, ' he says.
Decisions on treatment are far more structured and patients are much more likely to receive appropriate care, such as limited breast surgery plus tamoxifen, which is just as effective as a full mastectomy, if not more.
Although the UK still lags behind Europe in numbers of cancer specialists, Professor Fentiman believes treatment standards have improved. 'I think in some places we are as good, if not better, than many places in Europe, ' he says, blaming British stoicism - women delaying seeing their GP when they discover a lump - for our trailing survival rates. Indeed, the initial Edinburgh pilot revealed that women who failed to respond to screening invitations also presented late to GPs with symptoms of breast cancer.
Kate Law, head of clinical programmes at the Cancer Research Campaign, agrees screening should ideally be extended to women over 70. She recalls one 90-year-old who had a successful mastectomy, although she points out that nine out of 10 cancers are still detected by women themselves. She, too, believes treatment regimes have improved. 'We have obviously made huge gains. We have made greater strides than other European countries, ' she says.
Britain still lags five to 10 years behind other countries in introducing new anti-cancer drugs such as herceptin, used to treat some women with advanced cancer, which was fast-tracked for prescription in the US but is still under investigation by the National Institute for Clinical Excellence in the UK. Yet she hopes we may still 'struggle up' to European standards.
The cancer plan and its increased staff quotas could make the difference. 'There seems to be actually something happening, rather than a lot of platitudes and promises, ' she says. 'It seems to be realistic. That is the first time that has happened in the eight years I have been in the job.'
REFERENCES
1 Peto R et al (research letter).The Lancet 2000; 355: 1822.
2 A Plan for Investment, a Plan for Reform. The NHS Cancer Plan. Department of Health, September 2000. www.doh.gov.uk/cancer/cancerplan.htm
3 Is Screening for Breast Cancer with Mammography Justifiable? Gotzsche PC, Olsen O. The Lancet 2000; 355: 129-34.
4 Blanks RG et al. Effect of NHS Breast Screening Programme on Mortality From Breast Cancer in England and Wales, 1990-98. Br Med J 2000; (321): 665-9.
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