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听INSIDE HEALTH

Programme 1. - Multi-morbidity, one-shot radiotherapy during surgery for early stage breast cancer

听TX:听 05.07.16听 2100-2130

听PRESENTER:听 MARK PORTER

听PRODUCER:听 ERIKA WRIGHT

听听

Porter

We鈥檙e back and over the next six weeks we鈥檒l be reporting on everything from the latest developments in hip surgery, to how happy accidents have changed the face of modern medicine. As well as answering your queries about health issues that you find confusing.

听Coming up today: Breast cancer, a new, quicker, cheaper and more convenient way of treating the disease which could benefit as many as 20,000 women in the UK every year. But if it鈥檚 really that good, why isn鈥檛 one-shot-radiotherapy more widely available?

听First, a subject that is very close to our hearts here at Inside Health. Twenty percent of adults in the UK are now on five or more medicines 鈥� twice as many as in the mid-nineties.听 It is a trend that has been accelerated by the burgeoning number of guidelines and a population that is living longer and developing multiple health issues, all of which have their unique treatment pathway. But how do all these different medicines interact?

听To help doctors optimise care for the millions of people receiving different drugs for different health problems the National Institute for Health and Care Excellence is about to release yet more guidance - only this is a bit different from what has gone before.听 Professor David Haslam, Chair of NICE and a driving force behind this latest initiative, explains why.

听Haslam

You only have to go to any hospital or look at the way healthcare鈥檚 organised to realise we鈥檝e tended to do stuff in single conditions.听 So you go to the hospital, there鈥檚 a sign for Respiratory Medicine, Cardiac or whatever but real people have lots of problems simultaneously.听 And the same goes for the sort of work NICE has done over the years, producing guidance on the management of individual conditions but the recognition is that we鈥檝e got all these people with lots of conditions.听 I spent most of my life as a GP and I can remember one of my patients 鈥� you both probably have similar patients 鈥� a guy who had diabetes and coronary artery disease and hypertension and hyperlipidaemia and chronic kidney disease and osteoarthritis and macular degeneration and hardly surprisingly depression.听 Now that lot all put together makes an individual human being whose care we absolutely have to focus on, not just on the individual bits.

听Porter

But if by focusing on the individual bits what might we be doing wrong then, I mean what are you worried about?

听Haslam

Well the real worry is first of all not focusing on the whole human being, which is what we鈥檙e all in healthcare for, so just focusing on the condition, not being absolutely sure what matters to the patient.听 And then the worry is are we over treating, if you add together all these conditions and all the possible treatments for them you then end up with an awful lot of drugs that may or may not interact in a helpful way.听 But on top of all that the way we organise healthcare, your entire life is going to be spent going to one clinic after another, so we really, really need to bring that altogether.

听Porter

Margaret McCartney, as a GP, I can see you nodding there, this rings a few bells.

听McCartney

I think I鈥檓 not just nodding but cheering to hear NICE sort of moving the narrative on towards patients as opposed away from them and into these single diseases.

听Porter

This fragmentation we talk about it being in hospitals but actually it鈥檚 happening in general practice now isn鈥檛 it.

听McCartney

Oh it is entirely happening in general practice and part of the problem, I think, has been this striving for excellence in some way, striving for excellence in managing certain conditions to standards that we aspire to that are those given to us by a guidelines.听 But in many ways, and it sounds counterintuitive, very often I think the best cure is not going to be given by following guidelines to the letter, instead it鈥檚 going to be about sitting down with patients and having conversations, not about how do I achieve a blood pressure of this number and that number but how do I achieve the quality of life that I鈥檓 really looking for here.

听Porter

Give us some idea of the burden 鈥� and David referred to the fact that 鈥� a lot of people taking a lot of pills.

听McCartney

Yeah and I think this is 鈥� it鈥檚 so easy for me to prescribe a tablet or to make a hospital referral, it鈥檒l take me minutes to do that but for a patient they have to keep living with that every single day.听 So one paper that鈥檚 come out looking at the impact of guidelines in the US found that patients who had six chronic conditions if they were following the guidelines to the letter they鈥檇 be taking 18 medications a day, having about six and a half to seven contacts with health professionals of various types per month and spending around 80 hours of their time following the guidelines that have been set down for them to do.听 So in many ways these aspirations are really pretty unrealistic, do we really want to be spending all this time, well some people might want to but many other people were wanting to put quality of life first and their quality of life might not involve making the same decisions as the guidelines would have made for them.

听Haslam

And of course NICE in its guidelines, all the individual condition guidelines that we produce, we say the same thing, every single time, which are that the recommendations represent NICE鈥檚 view arrived at after looking at the evidence.听 But we always say when exercising their judgement professionals are expected to take the guideline into account alongside the individual needs, preference and values of their patient.听 Now what鈥檚 worried me is seeing people forget that, I get this hunch that sometimes people treat that almost like the terms and conditions on a website, they click past to get to the important stuff like the dose of the drug, that is the important stuff, the important stuff is the individual.

听Porter

But herein lies a problem for me anyway David, I completely agree with you but I can see myself 鈥� I mean my nightmare scenario is being in a court somewhere where a QC holds up one of your guidelines, this was produced seven years ago Mark and if you turn to page 32 Dr Porter you鈥檒l see this patient should have been on this, that and the other.

听Haslam

Well Mark when you go to court I鈥檒l be very happy to come and join you and to explain what I鈥檝e just said because I don鈥檛 know anybody who disagrees with this, I mean it really is vital.听 Indeed the people who invented the whole world of basing your medicine around evidence said this right from the start 鈥� we must really work with patients not do medicine to them.

听McCartney

But at the start of evidence based medicine guidelines were simple, they were a page sometimes, you know two and a half pages sometimes and very few of them, whereas now we鈥檝e got huge amounts of guidelines.听 And the problem is that guidelines are very often used to judge quality in general practice and there鈥檚 a big problem where the guidelines are interpreted by the government or by the GP contract, really I think putting a lot of pressure on general practitioners to encourage patients to have treatments, rather than discussing what鈥檚 best for you.听 And I think it becomes a bit dehumanising for doctors as well when we are following instructions on a computer screen as opposed to talking to people about what they would and wouldn鈥檛 like to do. 听So I think there鈥檚 huge opportunities here, it should almost be like a rebirth of general practice, back to our core values, and rather than judging quality by the amount of prescribing we鈥檙e doing let鈥檚 judge quality by how good our decisions are.

听Porter

There鈥檚 a lot of pressure in general practice at the moment to try and encourage patients to come forward with one problem at a time and this sort of rather flies in the face of this doesn鈥檛 it.

听Haslam

Yeah well I think that鈥檚 wrong and I completely understand why doctors, who are incredibly pressurised at the moment, feel the need to do that.听 But鈥�

听Porter

They don鈥檛 have time to do more would be their reply.

听Haslam

But my personal feeling and again the way I practise was if I felt someone was going to have multiple problems I said can we get them all out the way at the beginning, so I know what I鈥檓 dealing with.听 Many doctors have tried to discourage patients bringing lists, for instance, it鈥檚 often seen as a really bad thing, I think it can be really helpful if it helps to plan the consultation at the start and then you don鈥檛 have any more time but you know what you鈥檙e dealing with.

听Porter

I think it fair to say that this draft guidance is going to be welcomed by pretty well everybody 鈥� patients and doctors.听 But let鈥檚 get down to some specifics, if we may, and one of the things that caught my eye in the initial press release when this was launched was the first point was to stop treatment of limited benefit, de-prescribing if you like, which is very much on vogue at the moment.听 Can you give me an example of the sort of treatments that you were thinking about?

听Haslam

Well there鈥檚 one very specific one we focus on which is bisphosphonates, which are a treatment that are used for prevention of osteoporosis and there seems to be absolutely no evidence that taking those for longer than three years is beneficial.

听Porter

But there鈥檚 lots of people on them for longer than that.

听Haslam

Yeah sure.听 What we also have said very clearly in the guidance is we need an awful lot more research into this.听 Hardly surprisingly there鈥檚 an awful lot more research about starting treatments than there is about stopping treatments and there鈥檚 all sorts of reasons that you can postulate why that might be.听 But we need to understand much more about this.听 But if feels very clear to most people that if you鈥檝e got, for instance, a very elderly patient you don鈥檛 need to start them on a drug that鈥檚 designed to prevent them having a heart attack in 10 years鈥� time.听 Now that鈥檚 not being ageist, it鈥檚 just being sensible.听 The other thing, having just mentioned age there, I want to stress this isn鈥檛 just an issue of the elderly, multi-morbidity or having multiple health problems is a problem across all age groups and particularly people with say learning disabilities, people with long term mental health problems who have an increased incidence of all sorts of physical health problems as well, it鈥檚 bringing these altogether.

听McCartney

And deprivation is a massive problem because deprivation means that you will get your multi-morbidity 10-15 years earlier than you would were you not suffering from the effects of inequality.听 So that鈥檚 a really big problem as well.听 And one of the things I think we really do lack is information about drug interactions, so poly-pharmacy, when people are on more and more medicines.听 So between 1995 and 2010 the number of adults taking five or more drugs per day doubled to 20%, so we鈥檙e seeing huge amounts of people taking lots and lots of medication, a quarter of people aged over 80 are on 10 or more drugs.听 And there鈥檚 a real dearth of information about the effects of this, in particular the effects on things like falls, which can kill elderly people, and also the effects on obesity, on hypertension, on low blood pressure conversely and on kidney function.听 So there鈥檚 big, big uncertainties around this, a real lack of information and we鈥檙e really struggling a bit in the dark in terms of what鈥檚 good to stop.

听Porter

It might come as quite a surprise David that we know so little about stopping therapy.听 We have lots of great guidance about how to initiate drug treatments for particular conditions but very little about when to stop it.

听Haslam

Well a lot of this comes down of course to the fact that as people develop other healthcare conditions and maybe other drugs are added in it鈥檚 that combination of drugs which is so often the issue, which then makes you wonder is this combination actually delivering enough benefit.

听Porter

Because the default position, if in doubt, is to continue existing therapy and you hear the term you hear people talking about is people being parked on their medication 鈥� that it just gets repeated and repeated and nothing gets changed.听 And what you鈥檙e pushing for perhaps is a more aggressive review?

听Haslam

No, what 鈥� I think particularly what the guidance is pushing for is more research into actually knowing the answer.听 The last thing I want is for listeners who are out there on sort of 10 tablets a day to stop them all because that almost certainly will be dangerous.听 And of course the importance of pharmacists, I think they could bring a really important role into these sort of reviews, working in partnership with the doctor and the patients.听 But I do want researchers 鈥� and the guidance is really keen on researchers to do more work into this.

听McCartney

We really are missing an awful lot of evidence, there鈥檚 huge gaps in it.听 And it would be really great to have better trial data, to be using data from big research databases, data that鈥檚 been gathered already in the GP database for example, and actually find out what happens when we stop things.听 It鈥檚 stopping things, it鈥檚 thinking about whether we need to continue things or not, what does the evidence say.听 A lot of the time we鈥檙e prescribing for someone 鈥� a drug 鈥� for 15 or 20 or 25 or 30 years now whereas the original trials might have just been for five or 10 years.听 And it does put big question marks over what we鈥檙e doing when we really should be having smaller question marks at this stage.

听Haslam

And of course the potential different combinations of different medications is almost infinite and particularly in care homes with research which suggested the average person in a care home is on nine different medications and we know very little about the interactions here.听 But as well, don鈥檛 forget, it鈥檚 not just the drug interactions, it鈥檚 the sheer hassle of taking all those pills and we鈥檝e all got elderly relatives who have their dosette boxes lined up with the pills they鈥檙e taking each time of day, it鈥檚 pretty darn impossible to get that right.

听Porter

Professor David Haslam and Dr Margaret McCartney, we must it leave it there. Thank you both very much. The new guidance is expected to be published in September. More details on the Inside Health website.

听

Breast cancer therapy is always evolving, but there has been a consistent theme in surgery over the last 40 years that less can sometimes be more. Prior to starting my career in the eighties the standard treatment for breast cancer was to remove the whole breast 鈥� a mastectomy 鈥� even for very early cancers. Then researchers discovered that for most women it was just as effective to only remove the lump 鈥� a lumpectomy 鈥� and then treat the remaining breast with radiotherapy daily for up to five weeks. It transformed breast cancer surgery for all involved.

听And now there is change in the air again, only this time it is the radiotherapy that could get the 鈥渓ess is more鈥� approach. Could a one-off dose of radiotherapy, given directly into the wound at the time of surgery, work as well as five weeks of treatment given to the whole breast? Well, the results of the Targit study - a randomised controlled trial comparing the two over five years鈥� suggests it might.

听Bernstein

My name is Marcel Bernstein.听 Four years ago, when I was 69, I discovered that I had breast cancer, early stages, and I was told by the first breast surgeon I saw that I should have a mastectomy.听 I reeled out of his office with my husband in a state of shock.听 The first thing we said was we need a second opinion.听 I heard about Targit and it sounded amazing.听 It sounded amazing because I鈥檓 a very busy woman 鈥� I teach, I鈥檓 a journalist, I鈥檓 a writer 鈥� I didn鈥檛 have time to be seriously ill, I didn鈥檛 have time for weeks and weeks of radiotherapy, which frightened me.

听Vaidya

My name is Professor Jayant Vaidya.听 I鈥檓 a professor of surgery and oncology at University College London.听 Back in 1990s I did some work in the laboratory in which I found that when I take a mastectomy specimen, and these were women who came to Tata Hospital in Mumbai who had small tumours and originally it has been six weeks of radiation for every day.听 So if someone came from outside Bombay from north of India to me, as a senior registrar, I had to tell the patient 鈥� you鈥檝e got breast cancer, can you stay in Bombay for six weeks.听 If she said yes, I said okay we can preserve your breast because we can do a lumpectomy and give the radiotherapy for six weeks.听 But as many of them couldn鈥檛 actually stay here because they were daily wage earners, they had to go back to their families, they said okay I can鈥檛 stay I鈥檒l have a mastectomy instead.听 And they didn鈥檛 want to have a mastectomy and many of them had small enough tumours that we could preserve the breast.听 And these patients鈥� mastectomy specimens is what I analysed in the pathology lab.听 And I found that these patients have one tumour, they also had other cancers all over the breast, in two-thirds of these patients had other cancers scattered in the breast, logically that would mean that everybody should have a mastectomy but what has been found in clinical trials is that if these patients, who normally have these other cancer spread, are treated with radiation and lumpectomy cancer reoccurs only around the tumour.听 So if cancer鈥檚 recurring only around the tumour why radiate the whole breast?听 That was the question in the paper which was published in 1996.听 And I came here to test a hypothesis that giving radiation only around the tumour is as effective as all breast radiation.

听Porter

Was it difficult working on a hypothesis in that you鈥檙e playing with fire effectively here, if you get it wrong it can have quite significant consequences?

听Vaidya

Firstly morally our duty was to make sure we don鈥檛 jeopardise patients鈥� outcome.听 Giving radiation at the time of surgery we didn鈥檛 know whether it was safe or not.听 So first we tested it was safe to do.听 After we tested it in these patients and we knew it was safe to do in 2000 we said well now is the time to do the trial.听 So it went through a standard ethics approval process and we started the randomised trial where we named the procedure called Targit, we called it targeted intraoperative radiotherapy or Targit for short.

听Bernstein

It was explained to me as being a one-stop treatment, that you had your surgery and during the time you were under the anaesthetic you got a big shot of radiotherapy directly into the tumour bed.听 So the rest of your body was not affected, you weren鈥檛 going to have heart problems, your lungs 鈥� all the bits of you with radiotherapy can be affected were in fact untouched.听 Also the fact that next day it was over.听 And what sounded marvellous to me was that instead of being ill for weeks or months I was going to be better almost immediately.

听Vaidya

At the time of the operation I would remove the lump with some normal tissue around it, then we would assess what the size of the tumour bed, what is left behind, the cavity is, and use the correct size of the applicator that goes in there.听 Then we tailor the cavity by putting a very meticulous stitch in this cavity and insert this spherical applicator inside the tumour bed.听 Then we switch on the machine for about 20-25 minutes, switch off the machine, take the applicator out and stitch the breast back.听 And the patient can go home the same day or the next day.

听Porter

And in terms of time what does it actually add to a typical operation?

听Vaidya

A typical operation it adds probably between half an hour to 45 minutes.听

听Porter

One of the problems that people might think about giving radiotherapy to a fresh wound is that that scar needs to heal and basically you鈥檙e giving it x-rays that kill the cells.

听Vaidya

Yes we were worried about it when we started this back in 1998.听 We found no evidence absolutely that there was any problem with wound healing. 听And in the randomised trial there was no difference in wound healing problems in these three and a half thousand patients.听 When you operate there is a wound, where there鈥檚 a wound the body tries to heal, when the body tries to heal it stimulates movement of cells.听 So the fluid that collects in the wound, we found, actually stimulates cancer cells.听 If you collect the fluid from a wound which has had intraoperative radiotherapy it doesn鈥檛 stimulate cancer cells.听 So we said well maybe that is actually a good thing, it was a good surprise because by that time the trial had already started.听 So we found the results were very similar 鈥� that if you receive intraoperative radiation at the time of lumpectomy the chance of remaining alive at the end of five years, without a recurrence, is 93.9%.听 If you had normal radiation it was 92.5%.

听Porter

Broadly the same.

听Vaidya

Broadly very similar at five years.

听Porter

The Targit trial has attracted a lot of attention from around the world, but the idea that a one shot approach could work as well as conventional radiotherapy remains controversial. Anthony Zeitman is Professor of Radiation Oncology at Harvard Medical School

听Zeitman

Anything that moves us away from lengthy inconvenient treatment, radiation to the heart, can only be a good thing.听 But if we鈥檙e going to give up something that鈥檚 been working very, very well for a long time we have to really kick the tyres and know that what we鈥檙e doing is as good as, if not superior.

听Porter

And looking at this trial at this stage my take is that it does appear equivalent to our current gold standard because we don鈥檛 know what鈥檚 going to happen over the next four to six years do we?

听Zeitman

Absolutely it does appear equivalent but as many oncologists remind us breast cancers often recur five years, 10 years, 15 years down the line.听 So many are arguing that yes this is intriguing but it鈥檚 not enough yet to overturn what we鈥檙e currently doing.听 If you just remove a lump 鈥� a lump of cancer 鈥� from the breast and just follow a lady, don鈥檛 give any radiation treatment at all, while the majority of recurrences occur right where the lump was certainly many women have recurrences elsewhere in their breast.听 This new device that鈥檚 been developed just irradiates the area where the lump was and doesn鈥檛 irradiate any other part of the breast.听 And many would predict that there will be an increased risk of recurrence when compared with whole breast radiation if you follow these women long enough.听 So for many sceptics they don鈥檛 quite believe in their hearts that this device is going to be as good as conventional treatment.听 But the surgeons are saying, on the other hand, we鈥檝e got a randomised trial, best form of evidence, can鈥檛 do better than that.

听Porter

If the surgeons are for this in general then I mean is there some resistance, is that what you鈥檙e saying, in the oncologists鈥� camp?

听Zeitman

Yes there is some resistance, it鈥檚 in the oncologists鈥� camp, because they are 鈥� they鈥檙e very reluctant to give up on a treatment that鈥檚 worked so well for 30 years 鈥� whole breast radiation together with a lumpectomy 鈥� without convincing solid evidence.听 And most believe that the results are premature.听 Having said that if these results do mature, in the way they seem to be developing, then I think it will potentially be a game changer.

听Vaidya

Now the interesting thing about radiotherapy is this that if you look at trials of radiation and if you see what effect radiation has compared to no radiation you find that the difference in the local recurrence starts appearing in the first two or three years.听 Most of it is over by three years and after five years the difference between the two groups remains the same however many years you follow.

听Porter

So you would hope that although the data鈥檚 not that old that actually this trend will continue and the local recurrence rates will remain the same?

听Vaidya

They may increase in both groups in a similar manner.听 That is what all previous data has shown.听

听Porter

But local recurrence isn鈥檛 the only problem鈥�

听Vaidya

No.

听Porter

鈥�what about secondaries 鈥� I mean recurrence occurring elsewhere in the body?

听Vaidya

That has not been any different between these two groups.

听Porter

So that鈥檚 exactly the same?

听Vaidya

It鈥檚 exactly the same.听 Breast cancer deaths in both groups is exactly the same.

听Porter

And what about outcomes in terms of the way that the breast looks, the cosmetic appearance?

听Vaidya

The cosmetic appearance is at least as good and in the first few years it鈥檚 better with intraoperative radiation.

听Sexton

My name鈥檚 Jenny Sexton and I鈥檓 65 years old.

听Porter

What attracted you to this one shot approach?

听Sexton

I had a lumpectomy the size of a golf ball removed and you would not know with a magnifying glass that I鈥檝e had anything done.听 There鈥檚 no marks, there鈥檚 no burns, there鈥檚 no 鈥� even the surgical things, so you can鈥檛 see.听 And in the other sense we live where I would have to do a 100 miles round trip daily for up to five weeks was just not on the cards.

听Porter

Not having to travel this 100 miles every day, which is a hell of a journey for anyone.

听Sexton

Well definitely, I mean great, who would want that?

听Porter

Well some cancer specialists it would seem. In the most part their reluctance is due to an understandable desire to see more proof but could conflicts of interest 鈥� both professional and financial 鈥� be a factor too?

听Anthony Zeitman:

听Zeitman

This always happens in medicine, I wish it didn鈥檛 but it does.听 So if you consider a general radiation oncologist鈥檚 business, for want of a better term, his practice, his or her practice, maybe a quarter or a third of that is managing women with breast cancer.听 So potentially there鈥檚 a big loss to their current practice, possibly even to their current income.听 Surgeons, of course, stand to gain from this in terms of extending their field of practice and what you might call an economic opportunity.听 So there is this little undercurrent that lies beneath the science.听 I mean I personally do think that time is going to resolve this.听 If this trial will stand up or it won鈥檛.听 It is likely that both sides will be winners and ultimately I think the patients will be winners.听 I think this device is probably going to be very useful for some women with breast cancer but probably not all.听 The oncologists will have to yield those patients to the surgeons.听 But I think there鈥檒l still be many women with many kinds of breast cancer who still require what you might call traditional treatment.听 So I think evidence will ultimately cause us to draw a truce line somewhere in between where both camps would like it to be.

听Porter

And here in the UK there appears to be another obstacle. Swindon breast surgeon Nathan Coombs was part of the team behind the Targit study.

听Coombs

As a clinician I鈥檝e got a moral responsibility to make sure I do no harm to my patients and that leaves me with a dilemma.听 Targit is a treatment that鈥檚 certainly as safe, possibly safer, in terms of breast cancer treatment.听 Can I actually not offer this treatment to my patients and force them to travel for standard external beam radiotherapy when a newer, as effective and safer treatment is actually available in the UK that is actually not being allowed to be given to our patients on the NHS?

听Porter

Well you say it鈥檚 not being allowed鈥�

听Coombs

It鈥檚 not being funded.听 So if a treatment鈥檚 not being funded, if I was to give this treatment, the hospital doesn鈥檛 get any money for it, which then means the hospital will be making a loss.听 Unfortunately hospitals in the NHS have to operate as a business.听 It hasn鈥檛 yet had the agreement of funding by NHS England.听 As a person who treats people in the smaller semi-rural communities our patients need to travel to local radiotherapy centres to receive their treatment.听 We actually did some calculations that if Targit IRT was used widely in the UK the number of miles that would be saved across the UK would be millions.听 I can only see an advantage for giving Targit IRT rather than a disadvantage.

听Porter

Because that鈥檚 one of the tricky things with the NHS isn鈥檛 it, it鈥檚 good for patients, it鈥檚 good for Swindon Hospital, it鈥檚 good for you 鈥� you provide a better service 鈥� but it probably means it鈥檚 bad for somebody else because that business is not going their way and by business I mean the resources, the equipment, the expertise, the staff.

听Coombs

NHS England are being very cautious to make sure that they don鈥檛 want to open Pandora鈥檚 Box.听 If this treatment was widely available there will be an impact of getting these machines available across the country and there will be a small cost implication for those hospitals and also they want to make sure it鈥檚 safe.听 But what we do know that it is safe and when it is used it is cheaper than giving the standard treatment.

听Porter

We asked NHS England for an update on the situation and was sent this statement:

听Statement from NHS England

We are committed to broadening access to innovative and effective radiotherapy services as a key part of implementing the Cancer Strategy, which seeks to save an extra 30,000 lives by 2020.

听We have assessed intraoperative radiotherapy for early breast cancer previously, and await further evidence on its effectiveness and advantages over other forms of radiotherapy before reviewing our position.

听

听Whatever the final decision intraoperative radiotherapy will never be suitable for every woman but it is thought that as many as 20,000 could benefit from it every year in the UK if it were to be fully adopted by the NHS. As ever, more details on our website.

听 Just time to tell you about next week鈥檚 programme which includes the latest developments in diagnosing asthma, and a radical new approach to treating the common skin complaint acne rosacea.听 Join me then to find out more.