On 1 October 2019, we were joined by 136 breast cancer patients, members of the public and healthcare professionals to find out about the latest research being carried out at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London (ICR). Breast cancer patient engagement event: panel discussion chaired by Prof Mitch Dowsett Hosted by Professor Mitch Dowsett, Professor of Breast Cancer Research at The Royal Marsden and the ICR, our patient and public engagement event aimed to share the progress being to help us understand the risk factors associated with breast cancer and the ground-breaking research that is changing the way that patients are treated. Download an infographic summary of the event. Understanding breast cancer risk Around 55,000 women and 370 men are diagnosed with breast cancer every year in the UK alone. With the number of cases of breast cancer rising, we need to better understand the causes of the disease, identify those at risk and how this risk can be reduced. Dr Minouk Schoemaker, a Senior Researcher at the ICR, is conducting research into the risk factors associated with breast cancer using the Breast Cancer Now Generations Study, which is gathering genetic, hormonal and lifestyle information from over 113,000 women over a 40 year period. The results of the Generations Study are helping to inform the development of a personalised risk score, which could be used to predict breast cancer risk on the basis of a range of biological and lifestyle factors such as age, family history of disease, menopause and use of hormone replacement therapy (HRT). A personalised risk score will also incorporate factors such as breast density, hormone levels and analysis of small changes in our DNA known as ‘SNPs’. Reducing breast cancer risk In addition to identifying risk factors, a key area of research is uncovering how we can empower women to take positive action to reduce their risk of breast cancer. The PIONEER study, will recruit women who have attended a new patient clinic with suspected breast cancer, but given the all-clear and discharged. The research team, led by breast surgeons Ms Jenny Rusby, Ms Katherine Krupa and Dr Rebekah Law, and patient representative Carol Pitches, believe that this scenario presents a ‘teachable moment’ for these women, as they have gone through the anxiety of attending a cancer hospital and may be receptive to advice on how to reduce their risk of developing the disease. The team want to equip trial participants with the tools and knowledge to make lifestyle changes to reduce breast cancer risk, find out what methods are most effective and how to keep participants motivated to achieve their goals. The PIONEER study aims to recruit 240 women: all participants will be given a personal risk score and half of the cohort will undergo genetic testing. The participants will be asked to set a goal, which they will work towards throughout the trial: two thirds will have access to the PIONEER website, which will aid the goal setting process and provide hints and tips for making lifestyle changes, the rest of the participants will have access to these materials through group coaching sessions. The study will compare these methods and establish the most effective way to empower women to reduce their risk of breast cancer through making lifestyle changes. Figure 1: Feedback from attendees at the breast cancer patient engagement event Early breast cancer - what are the latest treatment options? Dr Alistair Ring, Consultant Oncologist at The Royal Marsden, focused on treatment options for patients with early HER2-positive breast cancer. Outcomes for patients have significantly improved in recent years through the combinations of drugs – such as Herceptin (trastuzumab) and Perjeta (pertuzumab), increasing the number of patients who respond well to treatment and leading to better long-term outcomes. However, around 30% of HER2-positive patients don’t respond to these drugs as well and are at a higher risk of their cancer returning. Research into new options for these patients has led to the development of an exciting group of treatments known as antibody-drug conjugates. Antibody-drug conjugates are formed by physically binding an antibody drug, such as Herceptin, to a chemotherapy drug. The antibody drug specifically targets HER2+ cancer cells and is absorbed into the cell, releasing the toxic chemotherapy drug inside. These drugs have been shown to improve outcomes for breast cancer patients and the high-specificity for the tumour reduces damage to healthy cells and tissue. Practice-changing radiotherapy The Royal Marsden and the ICR have long been at the forefront of radiotherapy research, which has led to major changes in how patients are treated, both in the UK and internationally. Dr Navita Somaiah, a Consultant Clinical Oncologist at The Royal Marsden and Clinician Scientist at the ICR, discussed The START trial which confirmed that patients could safely receive radiotherapy over three weeks instead of five, a practice which has since been adopted as standard. The FAST- forward trial will determine whether this treatment period could be further reduced to one week: it is hoped that this one week regimen could be offered to patients from 2020. Dr Somaiah also discussed the research being carried out to tailor radiotherapy according to the patient’s prognosis and risk of their cancer returning. The IMPORT-LOW study has demonstrated that patients at low risk of their breast cancer returning could receive partial-breast radiotherapy instead of radiation to the whole breast, and the PRIMETIME trial is investigating whether some very low risk patients could avoid radiotherapy altogether. The KORTUC trial, led by Dr Somaiah, is also underway to establish whether a novel radiation sensitizer can improve outcomes for patients with locally advanced or recurrent breast cancer. You can view the first half of the presentations below Advanced breast cancer – what are the latest treatment options? Although outcomes are improving for breast cancer patients, there are around 100,000 women in the UK living with advanced breast cancer, which occurs when the cancer has spread to other organs around the body such as the bones, skin and liver. Stephen Johnston, Professor of Breast Cancer Medicine and Consultant Medical Oncologist at The Royal Marsden and the ICR, discussed the recent advances made in the treatment of advanced breast cancer and the challenge of ensuring that the side-effects of treatments are not counteracting the symptoms of the disease. Between 2012 and 2019 there have been 14 clinical trials in the UK, many led by The Royal Marsden and the ICR, which have changed the way that advanced breast cancer patients are treated. Patients with oestrogen-receptor positive (ER+) breast cancer can now receive a combination of drugs to prevent the production of cancer-driving oestrogen and to stop cancer cells from dividing. Several clinical trials, including PALOMA-2 & 3 and MONARCH-2 & 3, have shown that this combination not only shrinks and controls the tumour better, but extends survival for patients. Triple negative breast cancer is a particularly aggressive form of the disease, with a greater number of genetic mutations than other breast cancer types. Until recently, treatment options for triple negative breast cancer have been limited, however recent clinical trials have found that immunotherapy drugs, which enable to immune system to detect and destroy cancer cells, are showing promise for triple negative patients. Figure 2: Breakdown of attendees at breast cancer patient engagement event Liquid biopsies – a new way to detect and monitor cancer Research has found that we can gather detailed genetic information about a cancer from tumour DNA circulating in the blood (ctDNA), which could be used as a more effective and less invasive alternative to traditional biopsies. Liquid biopsies have the potential to be used throughout the patient journey from screening and early diagnosis to planning treatments based on the tumour’s molecular profile and detecting residual disease and relapse. Liquid biopsies could also be used for advanced cancer patients to identify genetic mutations in a tumour and plan the best treatment accordingly. Dr Maria Coakley, a Clinical Research Fellow at the ICR and The Royal Marsden, discussed the clinical trials currently underway to bring liquid biopsies to the clinic, including C-TRAK, which is investigating whether ctDNA can be used to detect residual disease and trigger intervention in patients with moderate to high risk early triple negative breast cancer. 'Research drives options, and options fuel hope' We were also joined by patient representative and research co-designer Carol Pitches, who shared her experiences of living with a breast cancer diagnosis and how she has been involved in shaping the future of breast cancer research. Following her own reconstructive surgery, Carol lent her voice and views to a funding application for research into the use of a specialist camera to predict physical appearance for women following breast reconstruction surgery. She then became involved in the subsequent SIM study to determine the most effective way to measure satisfaction post-reconstruction. Since then, Carol has been instrumental in a wide range of research activities, from helping to write protocols, devising web content and patient information materials to participating in patient steering groups and coaching research fellows. Carol is currently heavily involved in the PIONEER study, which will identify how women can be supported in making lifestyle changes to reduce their risk of breast cancer, described above. Please contact [email protected] if you would like to be involved in shaping research at The Royal Marsden and the ICR. You can view the second half of the presentations below.