Cure or Correlation?

Breast Cancer Hits Headlines

According to the latest news, the BBC reports that scientists investigating the levels of the RUNX1 protein, typically expressed in patients suffering from leukaemia, is also related to more deadly triple negative breast cancer. The BBC article suggests that this could be a cure if the gene was inhibited: I looked deeper into this headline.

The Research

Currently Oestrogen positive subtypes of breast cancer can be effectively treated using hormone therapy, whereas HER2- positive cancers can be tackled through use of the Herceptin drug. However both of these treatments do not have an effect on the breast cancer subgroup, triple negative tumours. This means that these tumours have to be treated using chemotherapy (generally using a combined drug) or through use of surgery or radiotherapy which may use chemotherapy as an adjuvant treatment. However the success rate of treating triple negative tumours with combined drugs has increased and is now capable of being able to help target patients with very sensitive tumours. As a result, this decreases the probability that a new treatment may be more effective than this due to the level of research and clinical development already associated with chemotherapy. Thus this may mean that any new treatment may require extensive research in order to allow it to be used more efficiently and hence therefore act as an improvement.

Nevertheless this may not be a significant issue as the rate of genetic treatments for cancer types and genetic tests to help with prognosis, has increased in the last decade and have helped to identify and remove 70% of all tumours. Consequently, considering the rate of advancement in this sector, a genetic approach to treating triple negative breast cancer may be more significant and influential in the long-term hence increasing the versatility of medicine in order to tackle a wider range of tumours and hence therefore offer more effective treatments.

The actual research suggests that, in a sample of 438 patients suffering from triple negative cancer, those with the RUNX1 protein being expressed were four times more likely to die. This is important as it demonstrates that over a large sample size the results were consistent. This implies that the results were not affected by chance and so therefore this suggests that the results are more representative and hence are reliable. This increases the credibility of the results because it increases my trust in the results. Nevertheless, the PLOS one journal, where the data was initially published, only regarded the increased probability of death occurring when the RUNX1 gene was expressed. This means that there is little data analysing other factors associated with breast cancer (e.g. whether the cancer was likely to return, whether it affected the success of chemotherapy, whether those who survived triple negative cancer when the RUNX1 protein was present had more severe symptoms), this limits the validity of the data as it doesn’t necessarily show that the presence of the RUNX1 gene can produce a more “dangerous” cancer; “dangerous” is subjective; what is “danger”?

In order to assess the significance of this discovery, we must also consider “what was the original risk?” According to www.breastcancer.org, women with triple negative breast cancer have a five year survival rate of 77%. This means that with the RUNX1 gene only 19.25% of women survive after 5 years. Thus, this could be argued as dangerous and so the significance of this discovery is increased. However, this website also suggested that after the five year period the risk is less. Thus the long-term risk to women is less. Nevertheless, this risk is still high and so this supports the importance of the research as it offers a better potential to save life.

In contrast, RUNX1 expression did not affect the result of “oestrogen receptor (ER)- positive or HER2-positive disease” in a multivariate test (a test where many variables can change). Thus this implies that realistically, when considering the variations and differences in chemical concentration in the body, different variables will change and so this means that the success of targeting the RUNX1 gene may be limited if it is only successful in a univariate test. In addition, this data only shows a correlation and does not suggest a causal mechanism how RUNX1 could cause more deadly cancer types. This was discussed by Dr Karen Blyth who stated “first we need to prove this gene is causative to the cancer”. Thus this implies that the data is very much uncertain and only shows a potential link. This reduces the viability of the research being used in treatment.

Adding to this, the gene has a complex role and (as stated by Wikipedia) “regulates the differentiation (change) of stem cells into blood cells”. Hence, arguably, by inhibiting the RUNX1 gene, which is a likely application if treatment was going to use this research, it may cause more serious side effects and so this may be more important and dangerous than the breast cancer in extreme cases; particularly considering that most women develop breast cancer between the ages of 70 and 80 where they may be infirm and susceptible to complications.

Even so research is particularly valuable in order to encourage further research which is important to this case as the PLOS one journal is an international, peer-review journal and so this means that it has been checked to ensure that the results are repeatable and that the interpretation of these results was correct. This means that errors and mistakes have been eliminated, increasing reliability. Adding to this, the area of research is particularly large considering that breast cancer is the “third most common cause of cancer death in the UK, accountable for more than 11,000 deaths in 2011 alone (www.cancerresearchuk.org) and an estimated 39,620 female deaths in the USA in 2013 (www.cancer.gov)”. In addition, 15-20% of those with breast cancer suffer from triple negative cancer. This means that more than 5943 people die from triple negative cancer in the USA (15% of 39620 though the death rate is probably higher than this as triple negative cancer has a higher mortality rate than other cancers).

My Verdict

To conclude, this is an exciting study as it shows the potential for genetic treatments or, at least, genetic prognosis by identifying the levels of RUNX1 protein in the body. Therefore this means that the potential for research is greater and hence increases the possibility that this will increase survival rates and hence continue the trend expressed in the graph. However, we must also consider other research, such as the scientists at University College London who believe that a blood test for breast cancer could be developed following research. Consequently, we must be careful not to exclude this area of research over a more ambitious potential ‘cure’ as both are equally as valuable. Despite these exciting developments though, the headlines can be misleading as “correlation” does not denote “cause”.

Sources

http://chemotherapytreatments.org/articles/chemotherapy-success-rates.html

http://www.cancertreatment.net/articles/breast/triple-negative-breast-cancer-survival-rate

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0100759

http://www.macmillan.org.uk/CancerInformation/Cancertypes/Breast/Aboutbreastcancer/Typesandrelatedconditions/Triplenegativebreastcancer.aspx

http://en.wikipedia.org/wiki/RUNX1

http://www.bbc.co.uk/news/health-28044146

http://cbcrp.org/publications/papers/BCinCA/page_03.php

http://minimolecule.com/2011/09/09/cancer-why-we-dont-have-a-cure-just-yet/

 

Simon Stevens Steps up to Service

 

As I am sure you are aware, the new NHS chief executive, Simon Stevens, has recently marked a “change in policy”, favouring a form of micro management of the country’s elderly population in regards to health. A new system of decentralised healthcare. The advantages of this approach will be discussed later in this post, however this change in policy is more significant regarding the confidence crisis within the NHS, particularly as community hospitals such as the ones below close.

 

Confident about Confidence

If we consider this context (the NHS’s growing waiting times and significant costs), the issuing a statement has suggested a more proactive response as opposed to adjustments to the NHS’s recent bureaucracy. This is significant as it implies that the CEO understands the growing concern which should, I believe, help to comfort many patients and offer more effective treatment. This is because, to some extent, the spiral effect that has occurred within the NHS has occurred due to a sudden realisation of the system’s backlog. This caused increased probing which has continued due to the lack of confidence. By addressing this through a more patient based focus, I think Simon Stevens will encourage more people to use the NHS which will lead to immediate treatment as opposed to dealing with the consequences in the long-term.

For Better or for Worse

However, the change itself is less clear. A localised hospital system would undoubtedly cost more if we consider the growing rate of research specifically within specialities (as hospital medicine is now growing at the fastest rate in healthcare). This, in the long term, is likely to cause a growing investment in medical specialities and so this requires a large hospital structure to apply this investment most effectively. Therefore, I think that investment into local hospitals will create an opportunity cost by preventing investment into these specialities. This would create long-term issues due to a shortage of medical specialities and GPs (indeed the family doctor service within Northern Wales needs GPs urgently according to a senior medical figure). Thus the advantage of a more widespread hospital system may be ineffective due to the lack of ability for these hospitals to specialise. Clearly, this would lead to a minority of patients having to be continually sent elsewhere hence leading to increased paper work issues which inflicts a hidden cost.

Nevertheless, this would only be a small section of patients and it is unlikely that the growing investment into local hospitals would undermine investment in larger hospitals, since this would reduce the burden on larger hospitals to provide basic care. Thus, larger hospitals may instead respond by increasing specialisation. In contrast, as outlined by Stevens, the UK has an ageing demographic so this localised system of care would be beneficial for the elderly which would allow them to feel more at ease. This would mean that they would be encouraged to discuss their health which would allow for the rise of a more considerate system where patients and their physician can learn together. This would lead to improving quality of care.

Even so, the care needs of the elderly are complex and are at risk of being forgotten. For example, surgeons may be reluctant to refer an 85 year old to have a coronary bypass operation. Thus this move towards a local system may have short-term implications such as reduced transparency, hence making it difficult to evaluate the effectiveness of care which is important considering the growing scepticism towards the ability of the NHS to reach targets.

Even so, Stevens suggests that this is not an issue and instead argues that waiting time targets promote a greater threat to patients being forgotten. I disagree. I do not believe that there is a conflict between efficiently managing waiting times and patient care. Instead, Stevens should instead target the growing cause for the inability to meet waiting times: paper work. This does not, necessarily, include cutting back on paper work as this is essential for fluency in care and the ability of physicians to understand the background of patients both physically and psychologically. On the other hand, waiting times could best be met by introducing efficiency tests for doctors that calculate their ability to work well and work fast. These two aspects should not be in conflict.

Therefore, the localisation of hospitals has the potential to cause growing waiting times as patients requiring A&E care are typically admitted to specialist hospitals; hence a reduction in investment is likely to place more pressure on targets specifically within A&E as studies have shown that “66 percent of patients are admitted to inpatient wards from A&E in the last ten minutes before the four-hour deadline”. This means that the situation may get worse.

 

However, there is a clear advantage of small scale care in that it can include the community. This is specifically seen within the growing need for palliative care and rehabilitation in the primary care sector. This has also been shown by research to have the same monetary cost as large centralised systems so decentralised care could have the benefit of being quick and easy to access as well as being cost effective.

My Verdict

Nevertheless, in summary, it is dangerous to believe that localisation will solve the issues associated within the NHS due to the variations between patients and the occasional need for intensive care in speciality units. However, with obesity predicted to rise to 50% by 2050 as well as our ageing demographic, traditional hospitals are not suitably adapted to dealing with small scale issues. However, significant investment into this community care scheme is unlikely to have a long-term impact on the success of healthcare due to the lack certainty. A lack of certainty over how it is to be funded. A lack of certainty over the role and limits these hospitals will cater for. At best this could relieve the pressure on speciality units yet at worse it could delay other reforms and be accused of diverting attention from other failures of the NHS. My verdict: it is too soon to tell.

Sources:

http://www.bbc.co.uk/news/health-27631081

http://www.bbc.co.uk/news/uk-wales-23538705

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/Waitingtimes/Pages/Guide%20to%20waiting%20times.aspx

http://www.kingsfund.org.uk/projects/general-election-2010/key-election-questions/performance-targets

http://www.theguardian.com/society/2014/mar/20/nhs-hospitals-failing-meet-targets-waiting-times-treatment

http://www.webmd.boots.com/diet/news/20140113/obesity-predictions-underestimate-crisis

 

(NB: This analysis of Simon Steven's comments, to involve local hospitals in the NHS more, are my interpretation and I would like to hear other views on this preposition)