Many oncologists have played a role in the astonishing developments in the field of cancer research and treatment in Europe over the past two decades. Few, however, can claim responsibility for shaping those developments, for having the vision to see what structures were needed to make best use of the rapid advances in knowledge, and having the drive to put them place. Such a one is Professor Veronesi. This celebrated Italian oncologist is the founding father of the European School of Oncology, the first institution to offer continuing medical education to Europe’s cancer specialists, and is also responsible for the world-renowned European Oncology Institute in Milan. His determination to create the best conditions for progress in healthcare even led him to taking on the position of Minister for Health for a period. He remains, however, deeply involved in the cutting edge of cancer research, currently pushing forward investigations in the areas of breast and skin cancer. CancerFutures editor Maurice Schneider caught up with him in Milan, and asked him about his many areas of work.
Maurice Schneider: The Euro- pean School of Oncology has become a worldwide success in the 20 years since you founded it. What plans do you have for it now?
Umberto Veronesi: At the time I founded the European School of Oncology, I felt that science was evolving at such a pace that doctors in Europe urgently needed a way to keep up to date with developments.
The gap between new information becoming available and patients be- ing able to benefi t from that infor- mation was too long. We’re talking about anything between fi ve and seven years, and this was something our service found very disturbing.
So ESO began by spreading the word around about setting up as many courses as possible. Groups were organised by region, each with their own offi ces, and the progress has been tremendous – mainly due to the Director of ESO, Alberto Costa.
He’s an organisational genius!
In additional to running these courses, ESO is now looking to cre- ate some means of being affi liated to universities or institutes of research to do more in-depth and extended projects – a Masters degree in cancer of the breast, or of the prostate, for instance, or a Master in other fi elds, with a six months permanent course for people with a residency period in an important unit of certain hospi- tals. Of course, this is a totally new
MS: I was very impressed by my visit to your European Oncology Institute in Milan. What is your policy now for the development of this Institute?
UV: Setting up the European In- stitute of Oncology was always going approach for ESO. It demands a much more complicated organisa- tional set-up – but I think this ap- proach may constitute the second phase of the development of ESO.
The problem is to fi nd a hospi- tal that will accept these projects within their structures. I fi rst have to approach the hospital and say, for instance: “I would like to use your urologic unit, to have our fel- lows work there for six months. We will discuss together a programme, and at the end you will provide them with a Masters degree”. This is a big request, because the specialist titles we have in Europe, for instance in oncology or medical oncology, cur- rently operate only at a higher level – there is no intermediate type of certifi cation.
to be a challenge. Nobody believed that I would succeed in developing an institute that differed from the others in its fundamental principles:
a different concept of patient care and an insistence on a high level of integration between laboratory re- search and clinical research. This institute is really European. We have members from fourteen countries working here, and having a large por- tion of the staff coming from outside Italy is a constitutional requirement.
We speak English when we work, when we have our meetings. So it’s a real European Institute. This was something totally new – there are no other examples in Europe. I think it provides a good way to integrate various colleagues, a cross-fertilisa- tion of ideas between members com- ing from different European schools of oncology research.
MS: Where do your patients come from?
UV: The Institute treats many patients from many parts of Europe, although the majority are, of course, Prof. Umberto
Veronesi (right) with the editor- in-chief of Cancer Futures, Prof.
Maurice Schneider
Italians. The EOI developed so fast that it immediately established it- self at the forefront of research, and this was perceived by the politicians and by the population, so we are swamped not only by patients, but also by fellows and researchers.
MS: Unusually for an oncology surgeon, you have also had the chance to formulate health policy when you served as Minister of Health. What was that like?
UV: That’s a diffi cult question.
I was probably too ambitious when I took over as Minister of Health. I had a very large number of projects I wanted to see implemented. If you have too many projects, you won’t be able to see them all through in one year. Many of them end up just being discussed in Parliament, but never getting approval because they run out of time. The fi rst law I worked on was probably the most effective – it was designed to protect non-smokers, by insisting that in of- fi ces, restaurants and anywhere, if
Schneider, Stéphanie van Duin, director of Springer-Verlag France,
Prof. Umberto Veronesi
you smoke you must do so in a sepa- rate area. This very simple law, very logical, very well received, didn’t make it through Parliament. A large number of amendments were discussed, and fi nally it just failed to reach the statute book. I did, on the other hand, succeed in having a proposal accepted by the Parliament on liberalising the controlled use of opioids. Morphine, for instance, is not used very much in Italy, partly because doctors are concerned about the risk of addiction and also because they are afraid that some- body may use the prescription for other uses – not for medical use.
However, we have to face the prob- lem that a number of patients suffer very severe pain. Thanks to the law I introduced, doctors are now able to prescribe morphine without too much diffi culty. This change in the law has been very benefi cial, and was very well received by the popu- lation. Regarding progress in areas unrelated to cancer, of course there were plenty of projects. One was a greater freedom to use frozen em- bryos for terminal cell research, as
cal education compulsory for all doc- tors. That was approved and is now in force. At the end of the year, all doctors in Italy now have to present 50 credit points, which they can earn by going to specifi c courses, or university seminars or congresses, or whatever. This is similar to the American system. These are the ma- jor issues arising out of my term as Minister of Health; there are plenty of other minor points but these are the most important.
MS: Did you enjoy your period in the Ministry of Health?
UV: I did and I didn’t! I enjoyed it because you have the pleasure of creating projects, developing new ideas and working in a good envi- ronment. Ministries in Italy, at least the Ministry of Health, are full of very motivated offi cers, very intel- ligent, very active. People tend to get the impression that they don’t work – it’s not true – they work! I am a surgeon so I was accustomed to going to the offi ce of the Minister of Health at 7 o’clock in the morn- ing. At the beginning it was a shock for the employees, then by the end of the fi rst week, at 7 o’clock everybody was there, and they stayed there till the end of the day – 7 o’clock at night. It was pleasant to participate in the development of important political decisions. The problem is that it is very diffi cult for a non-poli- tician to interact with these politi- cians, because they inhabit differ-
important, but it is the second objec- tive, not the fi rst. First of all – be re- elected; look for a good consensus among the population, so as to get into government, to remain in the government, to win the elections ...
This is the obsession of politicians everywhere in the world. Inside this framework, of course, you may have other important objectives, but for me it was diffi cult to understand why certain proposals were accepted and others were rejected, without a logi- cal reasoning – at least not one that made sense within my philosophy.
MS: I would now like to turn to your research into the use of the sentinel node biopsy procedure in breast cancer.
Tell me something about the results so far
UV: This research started many years ago, because we were not cer- tain whether the axillary spread of breast cancer would provide good anatomical conditions for diagno- sis by the sentinel node biopsy. The procedure was introduced for diag- nosing melanoma, and in this con- text it proved to be effective. But for the breast, we wanted to establish whether distribution of the cancer cells in the axilla would be appro- priate for using the sentinel biopsy procedure.
So we conducted a long study on 1500 patients, mapping all the nodes one by one, and in the end we concluded that the spreading ax-
illa involvement, by taking the senti- nel node alone, in 96.8% of the cases.
So the accuracy was 96.8% and the rate of false-negatives was 3.2%. A 3% false-negative rate is acceptable – it’s not very high – but we have to be aware of the possibility and we have to inform women of this very tiny risk.
After this validation study, we randomised 516 patients into two groups, exactly divided. One group received the sentinel biopsy and axillary dissection, the other group received the sentinel biopsy and, if it proved negative, no axillary dis- section. We concluded this study in 1999, and we have now completed nearly 4 years’ follow-up. For the moment, the two groups are doing more or less the same, but the group with the sentinel node biopsy only is doing slightly better. We lost two patients in this group, compared to fi ve patients in the axillary dissec- tion group.
This is very encouraging, we don’t know what will happen over the next 3 or 4 years, but it looks like the projection is favourable. That initial result gave us confi dence. We are now offering sentinel biopsies to all women as a routine practice, and we have carried out more than 3000 such procedures. We are very happy, the patients are very happy, the costs have been much reduced, our hospitalisation period is very
UV: I think melanoma is a dis- ease that needs two different ap- proaches.
The fi rst one is to fi nd a means of early detection. A number of projects have been developed for naevi mapping, very sophisticated, with a great number of variables in the computer. Once these are in place, then you’ll be able to screen and to see whether naevi are normal or suspicious for development. This bio-informatic progress is very im- portant, because if we can evaluate everyone with a periodic mapping, with these very beautiful, fantastic machines, we could really achieve a very early detection of melanoma.
And very early melanoma is cured in 99% of the cases; it’s not a very seri- ous disease when spotted very early.
The other approach is the immu- nological approach. Melanoma is, of course, probably one of the only tumours with specifi c antigens. We have to make use of this informa- tion and put in motion large stud- ies with vaccines or with the specifi c antibodies. This is the future of the projects in progress. For the mo- ment the results are not very strong, but a number of responses are there.
There are a number of cases where the melanomas have just disap- peared. They are not very many, but something is there. We must insist on fi nding the key, the fi nal key to the solution.
