Secondary Breast Cancer

Philippa Whitford Excerpts

Wednesday 21st October 2015 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I commend the hon. Member for North Warwickshire (Craig Tracey) for securing this debate, which marks breast cancer awareness month. Most Members know my interest. I was a breast cancer surgeon for 33 years. The hon. Gentleman said that secondary breast cancer does not gain from the focus that we put on primary breast cancer. I have to disagree with that. In Scotland, we collect the stage at diagnosis and one in five patients still have metastases at the time of diagnosis. That means that we still have a huge job to do to get earlier diagnosis through screening and raising awareness, which is what October is all about. We are limited for time and I will do my best to respond to as many points as possible.

Regarding audit, I chaired the discussions on quality improvement standards for breast cancer in 2001, at which time we discovered that about a quarter of units did not gather any data at all. By 2003, we had managed to change that and we were getting data on the primary treatment of patients. That was against the breast cancer standards that we had set for the entire journey that a patient would go through. In 2007, I was chair for the update of those standards and, at that point, it became a standard that all patients with recurrence or metastases must come back to the multidisciplinary team for discussion. At that point, those data are also gathered. As yet, we do not have a Scottish-wide, absolutely rock-solid way of providing the data. They are being collected through our cancer registry, from SMR01 data and from what we do in-house.

In my unit in Ayrshire, we had a follow-up page for the patient at the end of the data system. Every year when the patient came for the follow-up, a chitty was ticked, sent up to the office and on it went, showing that the patient was alive and well on whatever date they had come. For patients moving to mammographic follow-up, if the mammogram is clear and there are no issues, the procedure is the same. The data on patients with recurrence or metastases must be collected at the multidisciplinary team. That is something that we were doing. We have to look at the systems to make it easy and not burdensome, but that requires that hospitals and trusts have an audit team. Our auditor sits in the multidisciplinary team, where she captures all the treatment of the primary and secondary patients. That is really important.

The hon. Member for North Warwickshire mentioned CNSs. There are different approaches. In our unit, we treat approximately 400 new breast cancers every year, which means that a significant number of patients have recurrent and secondary breast cancer. We talked about whether we should split our teams and have one for secondary breast cancer. We decided against that because we have a breast cancer team, which the patient will have met at the beginning. I felt that meeting the same team—a friendly face or someone the patient knew from three or four years ago—is a benefit.

Many units have surgical cancer nurse specialists, who do not move into chemotherapy or oncology. Obviously, that would not work that way. Our cancer nurse specialists travel the whole journey with the patient, looking after the patient in the surgical part of the journey and in the oncology clinic during chemotherapy. They are also there if the patient is unlucky enough to face recurrence or metastases. I believe that this linear approach—as long as enough nurses are provided for that support—gives the advantage of continuity.

My hon. Friend the Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) mentioned looking at the wellbeing of patients. In Scotland, we use something called the distress thermometer, which is used for patients undergoing treatment for primary and secondary breast cancers. It is quite a quick, easy tool that, at least, allows us to pick out a patient who is not doing so well and therefore identify them for additional support. Our cancer nurse specialists have all had additional training. We have a specialist oncology psychologist on our health board, who provides additional training to the nurses. Therefore, for someone who needs it, that extra help and counselling is available. For someone with more complex needs, or where the diagnosis of breast cancer or metastatic breast cancer comes on top of mental health issues, the oncology psychologist would give us that back-up by taking on the patient.

The hon. Member for North Warwickshire mentioned palliative care. In Ayrshire, we are lucky enough to have a hospice. It is routine for us to refer patients at the point at which they are metastatic and symptomatic. We do not refer them as soon as they are metastatic because if a patient is hormone-sensitive, they have a 50% five-year survival with metastatic disease. That is because we have so many treatment options and breast cancer appears to behave quite differently from other cancers in that we can get it into a balance. The patient can be very well and active, yet the disease is sitting there. As soon as the patient starts to have symptoms, we have liaison nurses in our hospitals and we make a referral. Part of our GPs’ quality outcome framework is that patients who are defined as palliative must be discussed regularly in primary care and be on a palliative care register.

We had the debate on assisted dying just last month. The clear decision of the House was that we would not go down that route. That throws back on to the Government, and us all, the responsibility to ensure that high-quality palliative care services are there. We cannot vote that way as convincingly as we did and then not step up to the mark. That is really important.

I do not have a lot of time to speak, but I should say that we are doing good things in Scotland. Because we are smaller, we have been able to create a single day when all the teams in Scotland come together—actually, they come together for two days: a trial and research day and an audit day. Our whole audit—all the dirty washing—is put up in a PowerPoint presentation and we have a completely open learning discussion about it. A one-year project is starting now, so hopefully the data, including detail on secondary, recurrence and survival, will be available in autumn next year.

--- Later in debate ---

[Jane Ellison]

I am sure we would all agree with that important point.

I will finish by discussing the new guideline that the clinical reference group is developing. The guideline will state that all patients with primary breast cancer should have a consultation with a clinician at the end of treatment that will include advice on spotting signs and symptoms that might indicate secondary breast cancer. That information will be delivered together with an assessment of the patient’s physical, psychological and social needs—I am interested in the distress thermometer that the hon. Member for Central Ayrshire mentioned, as well as in the contribution of the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron). The overall recovery package is being developed in partnership with Macmillan Cancer Support. The evidence is that that work is very effective where it has been done well. The advice that has been given will be recorded in the records of every breast cancer patient so that we know it has happened and so that we can track it.

NHS England hopes to publish the new guidance as a cancer resource on its website in the next few weeks. We will promote that guidance through the usual channels, but we would appreciate it if hon. Members with a particular interest, and particularly my hon. Friend the Member for North Warwickshire—I congratulate him on his appointment as co-chair of the all-party group—could draw this important document to people’s attention.

The clinical reference group will also consider how the care and support of patients diagnosed with secondary breast cancer can be improved, including through the provision of clinical nurse specialists. Of course, we agree that clinical nurse specialists play an important role. The number of patients reporting that they have been given the name of a CNS rose from 84% in 2010 to 89% in 2014, including 93% of breast cancer patients. We are doing a lot better, but hon. Members are right to highlight that, in the case of secondary breast cancer, we have some distance to go.

Members have said that we need to step up on palliative care, particularly in the light of last month’s debate—the hon. Member for Central Ayrshire made an important speech in that debate. We are committed to ensuring that everyone has access to high-quality, personalised palliative care. Breast Cancer Care’s new report, “Too little, too late”, is an important contribution to the debate about what we need to do. The Government have introduced five new priorities for end-of-life care—those are five important new principles—and my ministerial colleagues will be taking that forward. Nevertheless, I welcome Parliament’s new focus on palliative care and quality end-of-life care, which is important.

In the few seconds that I have remaining, I want to give people confidence that a lot of research is going on in this area. There is more research into cancer than any other disease in terms of National Institute for Health Research funding. In particular, the NIHR’s clinical research network is currently recruiting patients for nearly 100 trials and studies in breast cancer. One is a global trial that aims better to control secondary breast cancer using a drug called a dual mTOR inhibitor. I am delighted to say that the network recruited the first patient in the world to this trial, which I hope is an indication of the importance of our research infrastructure.

[Dr Whitford]

Will the Minister give way?

[Jane Ellison]

I am afraid that I do not have time to give way. We can speak after the debate; I apologise.

A lot of other things are going on in that area, but I will leave just a few seconds to my hon. Friend the Member for North Warwickshire. However, I reassure Members that this subject is of huge importance to the Government.