A helping hand from Mithuruwela for cancer testing in A’ Pura Hospital
View(s):In June 2022, Mithuruwela, the Cancer Support Network moved away from its customary activities which included awareness- raising and caregiver support. Inspired by an appeal from Dr Nuradh Joseph, Oncologist, the organization helped to support the establishment of molecular testing at the Anuradhapura Teaching Hospital, the first time molecular testing for breast cancer has been instituted in a state hospital.
Of all the cancers affecting females in Sri Lanka, Breast Cancer is the commonest. According to data from the National Cancer Registry nearly 4000 new cases are diagnosed each year. Diagnosis is a complex process which includes findings from clinical examination and imaging such as ultrasound and CT scanning. If cancer is suspected, oncologists then seek through a biopsy whereby a core of tissue from a suspicious lump is analysed in the laboratory by histopathologists.
Explaining the process of diagnosis and treatment, Dr Joseph comments that if the diagnosis of cancer is confirmed, histopathologists then perform additional tests called immunohistochemistry which look to see if the cancer cells express certain proteins (called receptors) that may influence treatment. Routinely immunohistochemistry is performed for hormone receptors (Oestrogen and Progesterone) as well as another protein called HER2/neu. If the hormone receptors are expressed, oncologists will offer anti-oestrogen hormonal treatment while if the HER2/neu protein is overexpressed, patients will be treated with novel agents which specially target cancer cells. These drugs reduce the risk of cancer recurrence by 50% in tumours overexpressing the HER2/neu protein.
However, in some instances (approximately 10%) it is not possible to confirm whether the HER2/neu protein is abnormally expressed or not based on immunohistochemistry alone. When this happens the histopathologist reports it as an “equivocal” expression of the HER2/neu protein. It is uncertain if these patients will benefit from the novel targeted drugs and further molecular testing is needed for confirmation.
For these patients, one needs to check if the HER2/neu gene is present in abnormal amounts in the cancer cells. This is known as gene amplification. Testing for gene amplification is done by special techniques called in situ hybridization (ISH). About 50% of patients with equivocal expression of HER2/neu on immunohistochemistry will have gene amplification confirmed by molecular testing thus making them suitable for treatment with the novel targeted drugs.
Currently these molecular tests are available at a few private hospitals but not in the histopathology laboratories of government hospitals and many patients who cannot afford such tests in the private sector, miss out on potentially life- saving treatment.
In recent times, molecular testing for HER2/neu gene amplification using available equipment has been established in certain government sector hospitals in the country, including the histopathology department of the Teaching Hospital of Anuradhapura which has the equipment and also trained staff to perform the tests. The problem however is the cost of the consumables required.
According to Dr Joseph, to commence testing at Anuradhapura, the hospital would require a sum of US dollars 5839 just to purchase the minimum quantities of reagents needed. It was this that led him to reach out to Mithuruwela to request help in getting these funds.
In spite of the current challenging climate, Mithuruwela together with Dr Joseph and his contacts were able to collect the required funds, thanks to the generosity of donors such as the Tissa De Silva Trust, the Students Association of Edith Cowan University in Australia, well-wishers in Australia and New Zealand and a number of generous individuals in Sri Lanka. JL Morisons, the agents for the reagents also supported the cause by ensuring that the reagents reached Anuradhapura safely under refrigerated conditions.
The Anuradhapura Teaching Hospital can now commence molecular testing for HER2/neu. The tests will be carried out by Dr Jayanjana Ashanthi and Dr Sanjeewanie Jayawardena, Consultants to the histopathology laboratory at the Anuradhapura hospital.
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