19 June 2019
Moving towards precision public health – where prevention efforts are more tailored to individuals and groups – is seen by many governments as central to improving health and preventing diseases. The convergence of biotechnology and information technology, which is expanding the possibilities for healthcare personalisation, is driving this move.
Breast cancer is no exception, where the science, particularly the identification of genetic variants that contribute to risk and the widening scope of risk assessment are developing rapidly. Our work as part of the EU funded B-CAST consortium has been examining the potential for these innovations to contribute to personalised prevention of breast cancer.
Beginning with a review of the literature we set out the current pathway and policy landscape for breast cancer prevention. We found that although personalised prevention is a stated policy aspiration, there is very little consideration of how this would work in practice or practical examples available, especially for breast cancer. Working together with experts from science, public health, breast screening, primary and tertiary care, we explored how emerging and future developments could impact on breast cancer prevention pathways. Through this process we identified opportunities emerging science offers and considered issues that would impact on implementation.
Personalising prevention in breast cancer, the report from this workshop, has been delivered to the EU and is now available on the PHG Foundation website. For the next phase of the project we will analyse the knowledge we have gathered so far to generate policy recommendations to inform decision makers with respect to developing personalised breast cancer prevention pathways.
There was agreement that although emerging science and technologies are providing opportunities for personalisation, we still need broader public health initiatives to support more individualised interventions and reap the benefits for patients and the health system. In the future, we could expect to see a far greater range of tools and resources available to prevention efforts. For example, information for the management of risk in individuals may come from a wider variety of sources e.g. from clinical consultations or from people’s use of digital health apps or direct to consumer tests from commercial providers. Digitisation may make it easier to finely tune interventions to the needs of specific sub-groups within a geographical population.
While offering many benefits, the health system will undoubtedly become more complex, which can be a barrier to progress, especially if complexity is viewed negatively and if obtaining a rigorous evidence-base to support innovation becomes more difficult. We will have to come to terms with this greater complexity and develop our tolerance for a flexible system that can adapt to a rapidly developing evidence base. This doesn’t mean we should throw caution to the wind, but we will have to recognise that progress may at times mean accepting a less than complete picture of the impact of an innovation and a willingness to accrue evidence through practice. This also means a willingness to stop practices – when evidence accumulates that indicates a negative impact – and learn from these cases.
A range of interrelated issues must be addressed if we are to create health systems responsive to the needs of individuals and population that will improve health and minimise potential harms.
These include the potential for changes in healthcare to impact on inequalities, individual health choices, medicalisation and regulatory processes. For example, risk-based prevention requires greater engagement from individuals both in understanding risk and making decisions based on this information. Understanding and interpreting risk information may need to be approached differently for different users (e.g. citizens, patients, clinicians) and if not done well can be a barrier to equitable adoption. There is unlikely to be an easy resolution to these issues, nevertheless acknowledging them and ensuring they are addressed goes a long way towards achieving better healthcare for all.
Translating science into better healthcare is not simple. It demands an understanding of the science, its impact on healthcare pathways and the wider societal consequences, such as the risk of increasing gaps in access to some groups, in order to identify the most appropriate path to implementation. The interconnected nature of technological developments can make this a daunting task. The solution often lies in multidisciplinary working to create understanding and engaging policy makers early in the process to ensure uptake of novel strategies.
In the next stage of the project, we will be exploring these issues with the aim of creating consensus and recommendations to help policy makers take the next steps towards making personalised breast cancer prevention a reality.