In an operating theatre
in London's Middlesex Hospital, Linda Lines lies unconscious.
Sterile green gowns drape her body, leaving exposed only
her right breast and outstretched arm. Linda has breast
cancer; in the upper part of her breast, a mass of runaway
cells has grown to about the size of a pea. Given her age—55—and
the size of her tumour, Linda is typical of the 40,000 British
women expected to be diagnosed with invasive breast cancer
this year. But her experience is about to take a sharp turn
from the typical.
After the tumour is neatly excised, surgeon Jayant Vaidya
reaches for a slim probe with a tiny metal sphere at one
end and inserts it into Linda's breast. He is going to deliver
radio waves directly on to the tumour site.
Satisfied with the probe's position, he signals for the
electron generator to be switched on. To the sound of a
gentle bleep, it begins generating "soft" X-rays
which pass out through the sphere.
Five minutes, then ten. Twenty-five minutes. Vaidya removes
the probe and inspects the small incision. He nods to the
team: "Looking great." With a couple of stitches
he closes it up.
If all has gone well, not only has the tumour in Linda's
breast been destroyed, but any rogue cells have been mopped
up, eliminating the need for weeks of radiotherapy. This
is targeted intra-operative radiotherapy (Targit). It's
a far cry from the early days of treatment, when surgeons
routinely removed not just a woman's breast but the muscles
of her chest, lymph nodes and some fat and skin, disfiguring
and frequently disabling her. Targit is based on the premise
that, since 90 per cent of early breast cancer recurrences
occur at the site of the original tumour, it makes sense
to limit therapy to that spot.
This approach, part of a study, is just one of a number
of new treatments that are gentler on the body—and,
it is hoped, better able to save lives. With deaths from
breast cancer continuing to fall—from 15,400 to 12,800
in a decade—here are some of the most promising treatments
to be found in hospitals and research institutions across
A Total Treatment
The notion of bathing breast tissue with protective radio
waves at the same time as surgery is exciting, though still
experimental. Jayant Vaidya originally hit on the idea as
a way of offering treatment in one go for patients in his
native India. "Targit offers a degree of precision
impossible with traditional irradiation delivered externally,"
he says. "The surgeon can see where to direct the rays.
It delivers an even dose and doesn't endanger heart or lungs."
Three years into a UK-led global trial, results are promising—only
two patients of 185 treated so far have experienced relapses,
with tumours appearing elsewhere in the breast. (Patients
wishing to take part in the trial can ask to be referred
to the Middlesex or Guy's Hospital in London.)
Targit is set to transform treatment for early breast cancer
patients. It could be routinely available on the NHS in
five years and potentially save £15 million a year.
In 1983, after Jeanne Tassis had a breast tumour removed,
she had two months of radiation therapy and returned to
her life as a teacher and mother. But two years later she
began to suffer a painful side effect of her treatment:
her left arm started swelling, eventually growing to three
times its size. She became increasingly prone to potentially
life-threatening infections. For a time, she was being hospitalised
every few weeks. "All I could think of was I survived
the cancer and I'm going to die from this," she says.
Jeanne had a moderately severe case of lymphoedema. When
the surgeons cut out her tumour, they also took lymph nodes
from her armpit to check for spreading cancer cells.
One escape route for malignant cells is provided by the
lymph system, a fluid-filled highway for immune cells, oxygen,
nutrients and cell waste. Lymph nodes trap bacteria and
viruses so that white blood cells can kill them—that's
why they sometimes swell when a person has an infection.
And they collect cancer cells as well. For many years, surgeons
would routinely remove ten to 20 nodes from the network
under the arm and send them to the lab. If cancer was found,
it meant a whole-body treatment such as chemotherapy was
But all that cutting can damage the system of tiny vessels
that drains lymph fluid, and radiation can do further harm.
The build-up and stagnation of fluid can cause minor numbness
and swelling, or lead to great pain, dangerous infections
A new procedure may protect women. When Philomena Whittle
had a lumpectomy at the Royal Surrey County Hospital, her
surgeon, consultant Mark Kissin, removed just one lymph
node. The approach, known as sentinel node biopsy (SNB),
is based on the realisation that lymph fluid travels in
an orderly way from one node to the next. Find the node
first in line to drain the region and this sentinel will
signal the cancer's spread or give the all-clear.
Three days later, Philomena, from Godalming in Surrey, went
home with a small incision in her armpit, another in her
breast and without the drains that are needed after standard
node clearance. Philomena's node was found to be cancer
free. Over the next 18 months she had her arm measured regularly
to check for lymphoedema, but there was no swelling whatever.
While proof is still to come that SNB is as reliable as
taking the whole lymph network, a five-year trial of 1,000
patients across Britain seems certain to provide it. Four
years in, the cancer recurrence rate in patients who have
had SNB is less than five per cent. "It's a win-win
situation," says Professor Robert Mansel of the University
of Wales College of Medicine, Cardiff, who is heading up
the trial. "When women know these results, they'll
all want this treatment."
The skill and experience of leading SNB surgeons such as
Mark Kissin and Robert Mansel are crucial for a good result.
"Surgeons taking part in our trials must have performed
at least 40 sentinel node biopsies, achieving pinpoint accuracy,"
says Mansel. "Our success rate in locating the sentinel
node is 99 per cent—a world best."
Women across Britain are being recruited for this final
phase of the SNB trial. Mansel is confident that less than
five years from now an early breast cancer patient will
be a hospital day case. Small cancer, small incision, sentinel
node biopsy, home.
"Time and time again, I'd see patients who'd become
increasingly low even though they were clear of breast cancer,"
says Professor John Yarnold, clinical oncologist at London's
Royal Marsden Hospital. Something was badly wrong.
These patients were suffering the damaging long-term effects
of intensive radiotherapy. Though it's a highly effective
treatment, some patients can find that their breasts change
shape, become discoloured and chronically sore. So Yarnold
decided to search for a new way of delivering post-operative
Conventional radiotherapy beams waves along straight lines.
But a woman's breast is not geometrically shaped, Yarnold
reasoned, hence the potential for damage. His solution:
to sculpt radiotherapy dose volumes to suit the actual shape
of each individual breast—an approach called Intensity
Modulated Radiotherapy (IMRT).
The patient's details are fed into a special computer programme.
Using sophisticated imaging it judges the depth and density
of tissue, then works out a treatment plan that gives all
parts of the breast an equal dose.
After two years of a study comparing 300 women treated with
IMRT against conventional radiotherapy, the new treatment
is proving highly effective, particularly in women with
larger breasts where the radiotherapy dose tends to be more
uneven. Women are 30 per cent less likely to suffer side
effects or physical damage.
IMRT is offered at the Royal Marsden Hospital, Ipswich General
Hospital and in a modified form at Torbay Hospital in Devon.
But Yarnold hopes that a proposed national research trial
will lead to its introduction into routine clinical practice
in under three years. "IMRT will have a real impact
on a woman's quality of life," he says. Great news
for any woman with a battered self-image.
Starve the Tumour
In the fight against breast cancer, two recent drug developments
are making startling advances. The first belongs to a class
of drugs called aromatase inhibitors, and it may represent
not just a step but a leap.
As you might guess, the drugs inhibit aromatase, an enzyme.
Aromatase converts testosterone and related hormones into
oestrogen. Block the enzyme and you block the manufacture
Women think of oestrogen as the female hormone. But it can
also act as fuel to the 70 per cent of breast cancers that
are oestrogen-positive. So one approach is to kill breast
cancer cells by starving them of oestrogen. Breast cancer
patients sometimes have their ovaries removed to reduce
levels of the hormone. More often, following surgery, they
take tamoxifen, which does the job chemically by blocking
the cancer cells' docking site for oestrogen. Tamoxifen
cuts a woman's chances of relapse without causing the nausea,
hair loss and exhaustion frequently associated with chemotherapy
Now, after 20 years in which tamoxifen has been the gold
standard hormonal treatment, a new drug—an aromatase
inhibitor called anastrozole—is challenging its supremacy.
Four years into a five-year global study involving 9,000
women from 300 countries, researchers compared the results
from women who were taking either tamoxifen, anastrozole
or a combination of both.
While tamoxifen lowers the risk of breast cancer recurrence
by as much as 40 per cent with no add-on therapy, the scientists
found that women who took anastrozole brought down their
risk of tumour recurrence by another 22 per cent.
"These results are truly exciting," says Michael
Baum, emeritus professor of surgery at University College
Medical School, London, who is leading the trial. "It
means we can now offer women a viable choice of preventive
hormonal drug therapies."
Anastrozole's long-term safety is still being determined.
So far, it seems more likely than tamoxifen to increase
musculoskeletal disorders and fractures, but less likely
to trigger potentially deadly endometrial cancer and deep
vein thrombosis. Anastrozole appears to have the lead over
tamoxifen, says Baum—and the finish line in this race
is less than two years away.
The second advance is an impressive chemotherapy drug—epirubicin.
For oncologists such as Dr Chris Poole, a consultant at
Queen Elizabeth and City Hospital, Birmingham, chemotherapy
remains a vital line of defence for the majority of patients—particularly
younger women, whose tumours spread faster.
"Patients view chemotherapy with great reluctance,"
says Poole, "since it comes with a bucketful of side
effects. But it can be a key to survival"
Now results of the largest trial of its kind, involving
some 2,000 women at 75 cancer centres, have shown that when
women treated with a combination of chemotherapy drugs are
also given epirubicin, they are a third less likely to relapse
or die. "These are staggering findings," says
Poole. "And the wonderful thing is, this drug is licensed—so
every single woman who needs it can get it."
years ago, the official five-year survival rate for women
with a tumour in the breast was 54 per cent. These days
it's more than 90 per cent for early breast cancer. Even
when cancer has spread to nearby areas of the body, women
have a survival rate of 78 per cent.
Couple that news with gentler and more potent treatments,
and you can almost envisage a day when a diagnosis of breast
cancer has truly been sapped of its terror.
When businesswoman Linda Lines learned she had breast cancer,
she "refused to panic" and went ahead with a family
holiday in Thailand. There, Linda read up on treatments,
eating healthily and getting fit. When her London surgeon
asked her if she'd heard of Targit, a one-off therapy without
any follow-up, she said she'd have some of that. She became
the first patient to opt for the therapy—a courageous
decision that has paid off. Four years on, she is clear
Every woman should be aware of changes in her breasts. Philomena
Whittle's fears were confirmed when she checked out the
lumpiness of a mosquito bite which "felt different"
and a biopsy revealed a tumour. The 36-year-old Surrey nurse
volunteered to join a trial of a new, safer surgical technique
called sentinel node biopsy. After the lump in her right
breast was removed, surgeons took just one of the nearby
lymph nodes to see if the cancer had spread. It hadn't.
"I was so lucky, the whole procedure was relatively
mild." Four years on, her right arm is unaffected.
"I work out at the gym regularly, cycle. It never felt
A tragic family history of breast cancer meant that Margaret,
66, was not surprised when a tumour showed up in her left
breast. "I vowed there was no way I was going to die
of cancer like my mother and eldest sister," she says.
Margaret jumped at the chance to take part in the trial
of IMRT, a way of tailoring radiotherapy to the shape of
the breast, making treatment briefer and more effective.
She was happy to spend 15 minutes every weekday over six
weeks having a mechanical arm rotate for less than a minute
over her breast. "What really amazes me is that my
breast looks and feels marvellous—I can hardly see
A professor of epidemiology at Birmingham University, Christine
MacArthur, 45, was diagnosed with "multifocal"
breast tumours—tumours that had sprung up in a number
of places within her breast. Knowing there was a real risk
they might spread, Christine agreed to be injected with
a new drug being trialled—epirubicin—followed
by standard chemo. Seven years later, she is still cancer
Crucial to the early detection of breast cancer is X-ray
mammography, offered by Britain's national screening programme
to every woman over 50. In the next five years, even better
digital mammography (DM) should come on line throughout
DM still uses X-rays, but depends on sensitive digital receptors
to record images, and computers to help detect abnormalities.
The image is manipulated to change contrast and density,
making abnormalities easier to detect. But the biggest plus,
says Dr Robin Wilson, clinical director of breast services
at Nottingham City Hospital, is that "computers don't
get tired or lose concentration".
Two other imaging techniques offer hope for better diagnoses.
The first, magnetic resonance imaging, is offered to women
with a high genetic risk of breast cancer. It produces detailed
3D images made up of many planes or "slices".
The second, ultrasound, is a screening "add-on"
to assess mammogram queries. Both techniques can easily
"see" through the dense breast tissue that can
confound traditional mammography.