Sarah Hymas was in the shower when she felt a lump under her right armpit and immediately knew something was wrong.
An ultrasound scan quickly confirmed it was a large 3cm tumour, which further tests revealed to be triple-negative breast cancer — a more difficult form of the disease to treat because it doesn’t have receptors for hormones such as oestrogen (for which there are targeted therapies).
‘It was such a shock. I’ve always been very health-conscious,’ says Sarah, 58, a psychotherapist, who is divorced with two grown-up children and lives in the South West. ‘Although I was diagnosed with triple-negative breast cancer, it was never found in my breast, only in a lymph gland in my armpit — but doctors were confident it had originated in my breast.’
At the end of 2020, her doctors put her on immunotherapy drugs for six weeks and chemotherapy for six months to destroy the cancer.
Women with this form of breast cancer — which accounts for 15 per cent of the 55,000 new cases each year in the UK — generally then go on to have surgery, in Sarah’s case an axillary lymph node dissection.
The search for smarter — better, shorter and less toxic or damaging — cancer treatments, with better outcomes, such as TAD is now a holy grail of cancer research
This involves removing most or all of the lymph nodes under the arm — these filter waste and toxins from the lymph fluid as it travels around the body — as a way to prevent cancer spreading.
The procedure is often successful but can also cause nasty side-effects such as lymphoedema, where parts of the body, such as the arm, swell because of damage to the lymph system, causing tightness and movement difficulties.
Sarah, however, was able to benefit from a ‘kinder’ version of the procedure called targeted axillary dissection (TAD), which she underwent in June last year.
This involves surgically removing only the abnormal lymph nodes rather than all of them (the number a woman has varies but can be up to 40) with conventional treatment — but with the same success rate.
Sarah was ‘delighted’ to have just five lymph nodes removed instead of her 20. ‘The procedure only involved an overnight stay and later I found out the cancer had completely disappeared, which was amazing.
‘The diagnosis and treatment really took it out of me; I lost a lot of weight and at times felt so unwell. So I was really pleased to avoid further side-effects. Seven months after surgery, my arm still hurts a little but I have full movement.’
The search for smarter — better, shorter and less toxic or damaging — cancer treatments, with better outcomes, such as TAD is now a holy grail of cancer research.
The first real breakthrough in this ‘de-escalation’ or ‘optimisation’ approach was a British trial published in The Lancet in 2005, which found a single dose of chemotherapy was just as effective — and less toxic — for treating early-stage testicular cancer post-surgery as three weeks of radiotherapy, the treatment offered for nearly 50 years.
This transformed the care of thousands of men, and now the search is on for similar gains across a range of cancers instead of ‘throwing the kitchen sink at the disease to try to treat it’, says David Cameron, a professor of medical oncology at Edinburgh University.
Professor Cameron explains: ‘What we are doing is changing the focus of research to see if we can get the same outcomes with less treatment and to improve the experience for cancer patients so they suffer fewer side-effects, can preserve their fertility or don’t develop heart muscle damage, in the case of breast cancer, as a result of their treatment.’
As well as reducing side-effects, de-escalation trials are about finding more effective treatments for patients with less intervention.
Last year, researchers from the Institute of Cancer Research and Manchester University revealed giving people with bladder cancer that has spread into the surrounding muscle a shorter, higher-dose radiotherapy regimen reduces the risk of the disease returning.
The study, published in the journal The Lancet Oncology in February 2021 found that patients who had 20 high doses of radiotherapy over four weeks instead of the standard 32 doses over six and a half weeks, had a 29 per cent lower risk of cancer returning after five years.
It’s thought bladder cancer cells regrow quickly, after about four weeks — so killing them off over a shorter period with a higher dose of radiotherapy, gives them less time to grow back.
The study authors called for the approach to be adopted by the NHS. Professor Robert Huddart, a consultant in urological oncology at The Royal Marsden NHS Foundation Trust and one of the
