Cancer: less is more

Constantia oncologist, Dr Elizabeth Murray, opens up about her experience in treating cancer patients.

Dr Elizabeth Murray, a Constantia oncologist, believes less is sometimes better than more when it comes to cancer treatment.

If you can afford it, it is vital to belong to a medical aid because you will have better access to drugs for cancer than public sector patients, says Dr Murray.

She also advises women with breast cancer to see a specialist oncologist.

Since Dr Murray left Groote Schuur Hospital in 2011 to go into private practice, she has seen a dramatically different recovery rate among her patients. She believes this is due to the wider choice of treatment on offer.

“At Groote Schuur it was hard to get drugs passed by the drug and therapeutics committee and I would see patients relapse. In the end it cost more as patients who relapse cannot contribute to the economy or look after their families. Money has to be spent on palliative treatments and hospital care when those patients could have been saved by proper treatment upfront. Those with access to good, modern breast cancer drugs are living longer, even those with stage 4 disease – which is invasive cancer that has spread to other parts of the body,” says Dr Murray.

But Alaric Jacobs, spokesperson for Groote Schuur, says its oncologists do not agree. “From their experience with both private and state patients, the results don’t show a dramatic difference in overall recovery rate. Confounding issues are that private patients tend to present with earlier disease and have shorter waiting lists for surgery and other treatment.

“The basic breast cancer chemotherapy drugs are all available to state patients at Groote Schuur and are widely used,” he says.

Mr Jacobs says there is access to Herceptin in private practice but this only accounts for about 20% of patients and the benefit is realistically seen in the more advanced breast cancers.

“It is likely that Herceptin will be approved for state breast cancer protocols in the future. Other drugs like AIs, Xeloda, Fulvestrant, CDK inhibitors and Eribulin do make a relatively small difference.

“The Groote Schuur drug and therapeutic committee uses available evidence and available budget to decide on whether a drug should be used. Yes, the chemotherapy budget is not as high as we would like and this means that some of the very expensive modern drugs are not available.

“The biggest benefit in private health lies in getting screened, gaining immediate access to a doctor and not waiting for any investigations and surgery.

“In state hospitals this is often not possible, due to the pressure on service as a result of high numbers of patients,” says Mr Jacobs.

Regarding relapse in patients with advanced disease in state hospitals, he says the biggest problem lies in late presentation. But whether they would have been ‘saved’ by modern drugs is debatable. “Yes, in the private setting patients have more endocrine and chemo options, however these benefits are small in absolute terms,” he says.

Dr Murray suggests that patients should discuss with the oncologist whether less or more is better treatment and gave some examples.

Fewer tests are best during the early stage cancer and are not indicated by international guidelines. Nor would they recommend constant retesting of the organs after cancer treatment in early stage cases.

Sometimes, she says, chemotherapy is not necessary. A test called a gene microarray can make the call, such as MammaPrint which costs about R30 000. It examines the genetic profile of the tumour and may often show that the tumour is low risk and chemotherapy is not beneficial whereas pathological indicators would have suggested that chemotherapy was necessary.

Less radiotherapy is sometimes best. Some older patients with favourable tumours may have the cancer lump removed and not need radiotherapy. Other patients do not need the extra “boost” of radiotherapy to the tumour bed and many patients can be treated by shorter schedules than the traditional longer ones. Newer techniques target just part of the breast with radiotherapy, but this is more controversial.

Less surgery may also be a good idea. Often a mastectomy (removal of the whole breast) is not needed and biopsies would be best. However, even if there are cancer cells in this gland the surgeon may leave the other glands and this may mean more radiotherapy – but should reduce side effects of having axillary (armpit) surgery for glands.

Fewer double mastectomies should be done. A surgeon is placed in a difficult position when a woman demands both breasts be removed when cancer is found in one. Cancer is unlikely to spread to the opposite breast and removing the opposite breast does not stop it spreading elsewhere in the body.

Ashkenazi Jews are at risk of gene defects and they run in certain families of Afrikaner and Scottish origin and these patients need to see a genetic counsellor.

Asked if Groote Schuur is finding that more women are requesting double mastectomies Mr Jacobs said yes. “We offer it to patients with a strong family history of breast or ovarian cancer, in patients younger 35 years old, and in patients with known breast cancer susceptibility gene mutation.

“Other patients who ask for it, are advised that the risk of cancer in the other breast is 0.5% a year and the true risk is from the affected breast.

“After counselling, if they still want it, then yes we provide that service,” says Mr Jacobs.

Then there are cases where more is better. There are more anti-nausea treatments for patients on chemotherapy so the treatment is better tolerated.

Dose-dense chemotherapy where the treatment is given more quickly (with shorter gaps between treatments) play a positive role in breast cancer treatment and should be routinely used.

More endocrine (hormonal) treatment, ie longer courses, for example of 10 rather than five years, may be better for many women with hormone sensitive tumours. More treatment can be beneficial when drugs called Bisphosphonates are used for osteoporosis. They are recommended to reduce the risk of cancer coming back in post-menopausal women. This treatment is usually given in a six-monthly drip for five years.

Dr Murray says doctors also need to be more aware of the psychological, spiritual, emotional and sexual needs and problems of their breast cancer patients.

A large number of breast cancer patients are in sympathetic overdrive – that is, their body is constantly in “fight or flight” mode and sometimes even have symptoms of post traumatic stress disorder. Dr Murray advises breast cancer patients not to smoke and to minimise alcohol intake. She monitors their vitamin D levels and recommends omega 3 supplements.

Being overweight is not good, and sugar, red meat and dairy intake should be kept low. Exercise can reduce the risk of breast cancer and will help women complete chemotherapy courses and reduce relapse.

Mr Jacobs recommends that women should not smoke, and should drink less than 14 units of alcohol a week, and exercise (although this can be debated). Women with a history of breast cancer should avoid hormone replacement therapy. Screening for women between ages 50-69 is also important.

Dr Murray says whether we should be doing fewer mammograms is controversial and should be discussed with a family doctor if you are 40. “Walk-in” requests at mammogram units should be avoided, she adds.

Mr Jacobs says Groote Schuur does annual mammograms for the first five years after diagnosis, thereafter every two years. Screening mammograms are different, and depend on family history, risk factors and age.