Masterpieces 131 Interview with Umberto Veronesi Maurice Schneider

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- So ESO began by spreading the word pean School of Oncology has around about setting up as many become a worldwide success in courses as possible. Groups were the 20 years since you founded organised by region, each with their it. What plans do you have own offi ces, and the progress has for it now? been tremendous – mainly due to the Director of ESO, Alberto Costa. Umberto Veronesi: At the time He’s an organisational genius! I founded the European School of In additional to running these Oncology, I felt that science was courses, ESO is now looking to cre- evolving at such a pace that doctors ate some means of being affi liated to in Europe urgently needed a way to universities or institutes of research keep up to date with developments. to do more in-depth and extended The gap between new information projects – a Masters degree in cancer becoming available and patients be- of the breast, or of the prostate, for ing able to benefi t from that infor- instance, or a Master in other fi elds, mation was too long. We’re talking with a six months permanent course about anything between fi ve and for people with a residency period in seven years, and this was something an important unit of certain hospi- our service found very disturbing. tals. Of course, this is a totally new Masterpieces 132 Interview with Umberto Veronesi

Prof. Umberto Veronesi (right) with the editor- in-chief of Cancer Futures, Prof. Maurice Schneider

approach for ESO. It demands a to be a challenge. Nobody believed much more complicated organisa- that I would succeed in developing tional set-up – but I think this ap- an institute that differed from the proach may constitute the second others in its fundamental principles: phase of the development of ESO. a different concept of patient care The problem is to fi nd a hospi- and an insistence on a high level of tal that will accept these projects integration between laboratory re- within their structures. I fi rst have search and clinical research. This to approach the hospital and say, institute is really European. We have for instance: “I would like to use members from fourteen countries your urologic unit, to have our fel- working here, and having a large por- lows work there for six months. We tion of the staff coming from outside will discuss together a programme, Italy is a constitutional requirement. and at the end you will provide them We speak English when we work, with a Masters degree”. This is a big when we have our meetings. So it’s request, because the specialist titles a real European Institute. This was we have in Europe, for instance in something totally new – there are no oncology or medical oncology, cur- other examples in Europe. I think rently operate only at a higher level it provides a good way to integrate – there is no intermediate type of various colleagues, a cross-fertilisa- certifi cation. tion of ideas between members com- ing from different European schools MS: I was very impressed by my of oncology research. visit to your European Oncology Institute in Milan. What is your MS: Where do your patients policy now for the development come from? of this Institute? UV: The Institute treats many UV: Setting up the European In- patients from many parts of Europe, stitute of Oncology was always going although the majority are, of course, Masterpieces Maurice Schneider 133

From left to right: Prof. Maurice Schneider, Stéphanie van Duin, director of Springer-Verlag France, Prof. Umberto Veronesi

Italians. The EOI developed so fast you smoke you must do so in a sepa- that it immediately established it- rate area. This very simple law, very self at the forefront of research, and logical, very well received, didn’t this was perceived by the politicians make it through Parliament. A and by the population, so we are large number of amendments were swamped not only by patients, but discussed, and fi nally it just failed also by fellows and researchers. to reach the statute book. I did, on the other hand, succeed in having a MS: Unusually for an oncology proposal accepted by the Parliament surgeon, you have also had on liberalising the controlled use of the chance to formulate health opioids. Morphine, for instance, is policy when you served as not used very much in Italy, partly Minister of Health. What was because doctors are concerned that like? about the risk of addiction and also because they are afraid that some- UV: That’s a diffi cult question. body may use the prescription for I was probably too ambitious when other uses – not for medical use. I took over as Minister of Health. I However, we have to face the prob- had a very large number of projects lem that a number of patients suffer I wanted to see implemented. If you very severe pain. Thanks to the law have too many projects, you won’t I introduced, doctors are now able be able to see them all through in to prescribe morphine without too one year. Many of them end up much diffi culty. This change in the just being discussed in Parliament, law has been very benefi cial, and but never getting approval because was very well received by the popu- they run out of time. The fi rst law lation. Regarding progress in areas I worked on was probably the most unrelated to cancer, of course there effective – it was designed to protect were plenty of projects. One was a non-smokers, by insisting that in of- greater freedom to use frozen em- fi ces, restaurants and anywhere, if bryos for terminal cell research, as Masterpieces 134 Interview with Umberto Veronesi

in the UK. However, this measure ent worlds: it’s a different language, met with very fi erce opposition from politicians have different objectives, the church. So fi erce, in fact, that we their main problem is to be re-elect- were unable to proceed. ed next time. I discovered immedi- Another important law that was ately that the main problem was not passed was to make continual medi- the well-being of the country – this is cal education compulsory for all doc- important, but it is the second objec- tors. That was approved and is now tive, not the fi rst. First of all – be re- in force. At the end of the year, all elected; look for a good consensus doctors in Italy now have to present among the population, so as to get 50 credit points, which they can into government, to remain in the earn by going to specifi c courses, or government, to win the elections ... university seminars or congresses, This is the obsession of politicians or whatever. This is similar to the everywhere in the world. Inside this American system. These are the ma- framework, of course, you may have jor issues arising out of my term as other important objectives, but for Minister of Health; there are plenty me it was diffi cult to understand why of other minor points but these are certain proposals were accepted and the most important. others were rejected, without a logi- cal reasoning – at least not one that MS: Did you enjoy your period made sense within my philosophy. in the Ministry of Health? MS: I would now like to turn UV: I did and I didn’t! I enjoyed to your research into the use it because you have the pleasure of of the sentinel node biopsy creating projects, developing new procedure in breast cancer. ideas and working in a good envi- Tell me something about the ronment. Ministries in Italy, at least results so far the Ministry of Health, are full of very motivated offi cers, very intel- UV: This research started many ligent, very active. People tend to years ago, because we were not cer- get the impression that they don’t tain whether the axillary spread of work – it’s not true – they work! I breast cancer would provide good am a surgeon so I was accustomed anatomical conditions for diagno- to going to the offi ce of the Minister sis by the sentinel node biopsy. The of Health at 7 o’clock in the morn- procedure was introduced for diag- ing. At the beginning it was a shock nosing melanoma, and in this con- for the employees, then by the end of text it proved to be effective. But for the fi rst week, at 7 o’clock everybody the breast, we wanted to establish was there, and they stayed there whether distribution of the cancer till the end of the day – 7 o’clock at cells in the axilla would be appro- night. It was pleasant to participate priate for using the sentinel biopsy in the development of important procedure. political decisions. The problem is So we conducted a long study that it is very diffi cult for a non-poli- on 1500 patients, mapping all the tician to interact with these politi- nodes one by one, and in the end cians, because they inhabit differ- we concluded that the spreading ax- Masterpieces Maurice Schneider 135 illa of the cancer cells coming from short – one day, maybe two for an the breast is a regular spread. This important cancer – and in my opin- research was carried out between ion, this will be the future of breast 1985 and 1995. In 1995, we decided cancer surgery. to start using the sentinel node bi- opsy procedure at this Institute. MS: Finally, I’d like to ask you We started with a validation study, where we are now concerning which showed that we were able to research into melanoma? make a correct diagnosis of the ax- illa involvement, by taking the senti- UV: I think melanoma is a dis- nel node alone, in 96.8% of the cases. ease that needs two different ap- So the accuracy was 96.8% and the proaches. rate of false-negatives was 3.2%. A The fi rst one is to fi nd a means 3% false-negative rate is acceptable of early detection. A number of – it’s not very high – but we have to projects have been developed for be aware of the possibility and we naevi mapping, very sophisticated, have to inform women of this very with a great number of variables tiny risk. in the computer. Once these are in After this validation study, we place, then you’ll be able to screen randomised 516 patients into two and to see whether naevi are normal groups, exactly divided. One group or suspicious for development. This received the sentinel biopsy and bio-informatic progress is very im- axillary dissection, the other group portant, because if we can evaluate received the sentinel biopsy and, if everyone with a periodic mapping, it proved negative, no axillary dis- with these very beautiful, fantastic section. We concluded this study in machines, we could really achieve a 1999, and we have now completed very early detection of melanoma. nearly 4 years’ follow-up. For the And very early melanoma is cured in moment, the two groups are doing 99% of the cases; it’s not a very seri- more or less the same, but the group ous disease when spotted very early. with the sentinel node biopsy only The other approach is the immu- is doing slightly better. We lost two nological approach. Melanoma is, patients in this group, compared to of course, probably one of the only fi ve patients in the axillary dissec- tumours with specifi c antigens. We tion group. have to make use of this informa- This is very encouraging, we tion and put in motion large stud- don’t know what will happen over ies with vaccines or with the specifi c the next 3 or 4 years, but it looks like antibodies. This is the future of the the projection is favourable. That projects in progress. For the mo- initial result gave us confi dence. We ment the results are not very strong, are now offering sentinel biopsies but a number of responses are there. to all women as a routine practice, There are a number of cases where and we have carried out more than the melanomas have just disap- 3000 such procedures. We are very peared. They are not very many, but happy, the patients are very happy, something is there. We must insist the costs have been much reduced, on fi nding the key, the fi nal key to our hospitalisation period is very the solution.