NCRI 2014 conference summary – day 2

Once again, we woke up to some good conference coverage in the media.

• This research about eribulin, a breast cancer drug derived from sea sponges, was covered by the Telegraph and the Times.

• And a story about exercise and breast cancer risk made it into the Mail, the Times and the Telegraph too.

Cancer care in the UK – a brief history

Following an engaging couple of talks on cancer genes and palliative care, came a familiar face at the NCRI – Professor Sir Mike Richards, now the Care Quality Commission’s chief inspector of hospitals but previously the Government’s National Cancer Director (or ‘Cancer Tzar’ to the tabloids) and one of the architects of the NCRI ten years ago.

Before he began a whistle-stop history of 35 years of UK cancer care, Professor Richards was awarded a lifetime achievement award by Cancer Research UK’s chief executive, Harpal Kumar, who praised Richards as “incredibly passionate” and “one of the hardest working people I know”.

Richards started by asking, “what would I want for myself?” – the answers being effective prevention (i.e. not to get cancer at all if possible); prompt and accurate diagnosis; access to the best effective treatments; informed choice and convenient care; minimal side-effects; a good quality of life – especially at the end of life – and to be treated with compassion, dignity and respect throughout.

So the challenge, said Richards, is how to make sure all patients get this, particularly as cancer care grows ever more complex: one patient Richards spoke to could put names to 112 separate health professionals who had treated him. Making sure all a patient’s carers work together has to be a priority for designing an effective cancer system.

So how has the UK fared? “The 1980s were the dark ages,” said Richards – cancer wasn’t discussed openly, and was far from being a political priority. Over the next 15 years, there was a “long, slow dawn” until the “wake-up call” of the 1995 Calman-Hine report.

But the real awakening was the first EUROCARE cancer survival report, which ranked the UK bottom of the European average. “So the patient voice got louder, the charity voice got louder, the media voice got louder… and then the real turning point came in 2000: Prime Minister Tony Blair hosted a summit at 10 Downing St”.

This led “The Age of Enlightenment” between 2000-2012 – a series of Cancer Plans with clear commitments on resources and waiting times; Multidisciplinary teams became the norm in care; and Cancer Networks were set up to coordinate between GPs, district hospitals, and larger cancer centres. Services were reconfigured – complex surgery was centralised; chemotherapy and radiotherapy localised.

The result? Survival rates began to improve rapidly, although they still failed to keep pace with the best in Europe. Despite all these increases in staff and facilities, and improvements in survival, said Richards, there’s an ever growing demand and limited supply of hard funds to match, even in times of plenty. Funding has increased, but not relative to the total NHS budget: “cancer is still 6% of total,” he pointed out. And outcomes? “We’re still lagging behind, not catching up. By 2012, the UK had woke up to the problem of cancer, but we’ve still got a way to go.”

The most recent challenge has been what Richards called ‘The NHS Cultural Revolution’ – the recent massive upheaval in NHS services ushered in by the Coalition Government in 2012. There are encouraging signs though. The new focus on cancer data, audits and intelligence is revealing in detail where to divert scarce resources to make the most impact, while a new post-mid-Staffordshire inspection regime is showing – and beginning to fix – huge regional variations in care. Ultimately, says Richards, focusing on the basics – prevention, detection, access to treatment, quality care – should lead to even more improvements in the the future.

Sequence all the things

Professor Mike Stratton – director of the Wellcome Trust Sanger Institute in Cambridge – was next to offer a wide-ranging overview of cancer genomics – a really exciting area that’s been growing quickly over the past few years. Stratton explained that researchers have now mapped the entire genetic landscape of more than 10,000 individual cancers, across nearly all of the most common forms of the disease as well as many rarer ones.

Importantly, Stratton stressed, this type of research will be vital in uncovering new faults in cancer cells that could be targeted with drugs, but it’s also proving that cancer is a complex enemy. But international collaborations like the International Cancer Genome Consortium are helping make sense of the data, sharing information gathered from clinical trials and other research to ensure progress is as fast as possible. And as Professor Stratton emphasised, “the cancer genome is finite, and we need to exploit that finiteness.”

Developing new drugs

Taking what we’d heard about the cancer genome and translating this into the world of drug development, Dr William Sellers from the Novartis Institutes for Biomedical Research in the US was up next, focussing on the success of some “therapies developed based on genetic information.”

He discussed the big challenges that still remain for developing new drugs, and how future research must tackle these challenges. He highlighted a need to keep plugging away at molecules that have been difficult to target with drugs so far, and to also focus on important protective genes – known as ‘tumour suppressors’ – that can be faulty and switched off in cancer.

Sellers finished his talk with a discussion around what to do when tumours become resistant to the treatments we do have, something “clinicians have to deal with daily”. The question he posed was whether genetics can predict this happening. Focusing on a faulty molecule produced when two genes are fused together – known as BCR-Abl – Sellers showed that mice with a type of leukaemia caused by this fault were cured by combining two drugs that block different parts of the BCR-Abl molecule.

Circulating markers

Liquid biopsies – monitoring the blood for the presence of cancer – are currently a hot topic in the cancer field and it’s clear that the chair of the next session – Professor Caroline Dive, from our Manchester Institute – is excited about them. Professor Dive began by setting the challenge that ‘within five years, blood tests will be used to personalise treatments, detect relapses earlier and uncover the mechanisms of drug resistance’ – an exciting proposition that would benefit patients and scientists alike.

Researchers working in this field are focusing on two main phenomena: circulating tumour cells (CTCs), which break off from a patient’s tumour into their bloodstream; and circulating ‘free’ DNA, which similarly is released from a growing cancer as its cells die and are replaced.

In the session we heard from experts in both fields. Christophe Klein from Regensberg in Germany showed how measuring the numbers of CTCs might even be better than traditional biopsies, as they can reveal mutations not in the original cancer. And Dr Alain Thierry showed off new technology to measure circulating DNA that he predicts will be “about a year away” from prime-time.

Finally, Professor Dive told us about her pioneering experiments to understand ‘small cell’ lung cancer – a devastating form of the disease, for which treatment – and survival rates – have remained the same for more than 20 years. A key bottleneck for progress has been that tissue samples are hard to come by since most patients have disease too advanced for surgery. Dive’s got around this by extracting CTCs from patients, and using them to create tumours in experimental mice – allowing the disease to be studied in unprecedented detail. This is now accelerating research into the disease, and she hinted at exciting new data in the pipeline.

Cancer prevention – “it’s important to remember the size of the problem”

Given rising cancer incidence, there was a whole session at today’s conference looking at new horizons in cancer prevention.

We started off with a discussion of the use of drugs to reduce risk – so called ‘chemoprevention’, and the potential of the breast cancer drugs tamoxifen and anastrazole, as well as aspirin, to cut the number of people developing cancer.

Then Tim Lobstein, Director of Policy at the World Obesity Federation, highlighted the “huge and important issue to be faced” in tackling obesity and unhealthy diets.

Since the 1970s, the average UK citizen has got 9kg heavier – something we spend around 215 kcal and 54p a day maintaining – which translates into £10.8 billion a year spent across the UK just on staying as overweight as we currently are.

Far from pointing the finger at the individual, no less than the Director General of the WHO last year stated “the obesity epidemic is not a failure of individual willpower, but a failure of political will”. This was underlined by the alarming fact that the millions spent by the UK government promoting healthy lifestyles each year would only fund food and drink advertising for a matter of days.

In tackling this, it’s crucial not to become part of the problem, remembering gains do not lie in (further) stigmatising people who are obese. Rather, we must find ways to change the conversation as well as the make-up of the average high-street.

Feeling the heat

Professor Fran Balkwill led a session exploring the links between cancer and inflammation. She asked, if inflammation is a foe rather than a friend, can we attack it? And what might we need to do to do this? The three talks that followed illustrated just how complicated the relationship between inflammation and cancer really is.

First Dr Richard Vile exposed inflammation’s two-faced nature. He showed that, in primary tumors, inflammation can help to fight the tumour. But further down the line these tumours can come back more aggressively, and they appear to use inflammation to help them grow.

We then heard from Professor Michele De Palma, who is trying to starve tumours by destroying their blood vessels. Previous attempts to do this haven’t always been successful, but De Palma’s work suggests a multi-pronged approach may work – targeting three ways cancer cells grow blood vessels to ensure it has no where to turn.

The final talk by Dr Ilaria Malanchi, from our London Research Institute, outlined how specialist immune cells called neutrophils can help cancer spread to other areas of the body.

Stem cells and cancer

A session on stem cells, hosted by Dr Axel Behrens from our London Research Institute, threw up some interesting gems, including how Dr Vivian Li (who will be moving to the new Francis Crick Institute in London) is applying her knowledge of both healthy and cancerous bowel stem cells to the challenges of growing replacement small intestine tissue in the lab. One day this could lead to replacement organs for transplantation, demonstrating neatly how fundamental biological research underpins advances in different areas of medicine.

Also Dr Carla Kim, from Boston Children’s Hospital, showed that the rogue stem cells that fuel certain types of lung cancer seem to produce very high levels of a molecule called PD-L1, which helps them to hide from the immune system. This suggests that the new generation of immunotherapy treatments (which we’ve previously written about) that block PD-L1 might have good potential for treating lung cancer.

Drugs debate

Alongside some interesting sessions on current progress in prostate cancer (where researchers are moving on from focusing on hormone related treatments to understand more about the disease) and pancreatic cancer (where there’s a new focus on detecting the disease early and getting more patients on to trials), there was a debate about the controversial Cancer Drugs Fund (CDF).

Has this England-only Fund been good for British patients? The issue was hotly debated by clinicians from Scotland, Wales, Northern Ireland and England. Needless to say, this was an interesting one. At the beginning the audience was split with a 50:50 vote, setting the scene nicely.

Arguments for the motion said that the CDF has exposed a “policy gap”, which has been useful in prompting changes to the way patients access cancer drugs in all UK countries.

Its opponents argued that there was “no evidence” that the Fund has improved patient outcomes; that it has caused huge inequality in access, and that the cost of drugs is a key issue. “It’s impossible to put a price on life. It’s not impossible to put a fair price on drugs,” said Dr Tom Crosby.

In the end it was a convincing defeat of the motion, with the audience now believing the CDF has not been good for British patients. Here’s our recent post for more detail on how drugs are paid for in the UK.

What do points win?

The day closed with recognition of several researchers in the Cancer Research UK prize ceremony, notably Professor Ron Laskey, an expert in the ins and outs of the cancer cell nucleus, who gave an eloquent talk about his life’s work, and how he had a ‘deep and long’ affection for Cancer Research UK, who have funded him for more than a quarter of a century.

And, to cap everything off, our chief executive Harpal Kumar announced an exciting new initiative, about which you’ll be hearing much more over the coming year – a £20m ‘Grand Challenge’ to solve the biggest problems in cancer research, as defined collectively by patients and the public.

See you tomorrow.