Innovations in Oncology - Q2 2021

A Mediaplanet campaign focused on

Innovations in Oncology

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“If diagnosed early, 5,000 cancer deaths could be prevented every year for breast, colorectal and lung cancers alone.” ~ The British Association of Surgical Oncology (BASO)

Q2 2021 | A promotional supplement distributed on behalf of Mediaplanet, which takes sole responsibility for its content

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“Patients and doctors need to continue to educate themselves about AI and involve themselves in the development and regulation of new AI products.” ~ Royal College of Radiologists

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IN THIS ISSUE

The impact of the pandemic on cancer care

Improving early cancer diagnosis with better detection

~ Badri Wadawadigi Associate Vice President, Head of Growth Initiatives, Accord Healthcare

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Early diagnosis translates into longer survival for cancer patients.

A liver cancer diagnosis is devastating – but SIRT can help. ~ Vanessa Hebditch Director of Communications and Policy, British Liver Trust

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N WRITTEN BY Dr Afsana Elanko Director of Education, British Association of Surgical Oncology (BASO-The Association for Cancer Surgery)

How genomics is improving cancer care ~ Dr Marianne Grantham Head of Cytogenetics and Molecular Haematology Department at the Royal London Hospital

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ine out of ten people diagnosed with cancer visit their GP with vague symptoms in the year prior to cancer diagnosis. The UK two-week wait initiative, aimed at reducing the diagnostic and treatment intervals, is based on recognition of red flag symptoms.

However, only half of cancer patients ever develop these, whilst the other half present with non-specific symptoms until red flag symptoms appear/present as an emergency.

Interventions beyond clinical guidelines for ‘vague’ symptoms are needed to improve diagnostic timelines.

It is estimated that, if diagnosed early, 5,000 cancer deaths could be prevented every year for breast, colorectal and lung cancers alone.

Therefore, the Rapid Diagnosis Centres Programme was formed to help improve England’s cancer survival rates. This, however, requires clinicians to conduct tests on a greater number of individuals that turn out to have cancers which creates undue worry for patients whilst waiting for test results and may not be the most efficient use of NHS resources.

However, we know a significant proportion of cancers are diagnosed via other routes, often when it is too late to cure them.

NHS Long Term Plan The core aim of NHS Long Term Plan is to diagnose 75% of cancers at an early stage and save 55,000 more lives a year by 2028 (NHS Long Term Plan,

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2019). Thus, the NHS has supported rapid diagnostic centres in England and Wales to facilitate early cancer detection for patients with nonspecific symptoms (such as weight loss, fatigue, appetite loss, abdominal pain and “GP suspicion”) and provide streamlined investigations. These centres were nationally launched in 2020 with an aim to ensure that patients received a definitive diagnosis or ruling out of cancer within 28 days.

Biomarkers could facilitate screening To date, most studies aimed at identifying early-stage biomarkers of cancer have used samples from patients already diagnosed with cancer. They are therefore compromised by both late changes during cancer development that may not be seen in early-stage disease and the general poor health of patients with advanced disease. Future early detection research should include relevant early-stage, pre-diagnostic samples from tailor made cohorts in order to validate existing biomarkers and offer chances of discovering new biomarkers of early cancer. We need non-invasive biomarker tests, that help include/exclude patients for further imaging studies.

Investing in new technologies to facilitate early cancer detection is a prime need for cancer researchers and the ongoing efforts to underpin genomic and metabolomics signals could achieve the breakthrough very soon.

Contact information: uk.info@mediaplanet.com or +44 (0) 203 642 0737

WRITTEN BY Mr Zaed Hamady Consultant Pancreatic and Liver Surgeon, University Hospital Southampton NHS Trust, President elect, British Association of Surgical Oncology (BASO -The Association for Cancer Surgery)

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“Dr Alexa will see you now” – the use of AI in oncology/cancer care AI can and will help offset the increasing demands on the NHS by automating routine tasks and freeing up time for doctors to see patients.

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pioneering example of AI in clinical oncology is a partnership between Microsoft and Addenbrooke’s hospital in Cambridge. It automates the mapping of target areas for radiotherapy, isolating vulnerable organs to minimise side effects. Instead of starting from scratch, a doctor can review and adjust the measurements already pre-done by AI.

WRITTEN BY Dr James Wang Oncology registrar, Imperial College Healthcare NHS Trust The Royal College of Radiologists’ Clinical Oncology AI, Machine Learning and Digi-tech Agenda Group

Growing use of AI in research Other AI currently in testing and development includes programmes to discover new drugs for resistant cancers and to predict outcomes based on the individual physiology of the patient, rather than the disease. Though AI is still in its infancy in clinical practice, it is rife among research groups internationally and its time will come in cancer care.

The development landscape is not quite as lawless as the Wild West, but it is scattered. At the RCR, we have convened a working group of AI-keen oncologists so we can better understand the UK’s AI terrain and climate as well as champion the best emerging examples.

Everyday AI use is already the norm and we can look forward to Siri and Alexa’s inevitable graduation from medical school. Like a new drug, AI programmes will similarly have to pass safety, ethical and regulatory frameworks before they can be used in practice. Even then, the freshly graduated junior doctors, “Drs Siri and Alexa”, will still need the oversight of experienced consultants.

Like a new drug, AI programmes will similarly have to pass safety, ethical and regulatory frameworks before they can be used in practice.

Embracing the future of AI The evaluation, regulation and ethical considerations for AI in practice are still being worked on as it is new and unfamiliar technology to both doctors and patients. There will always be apprehension and cultural discomfort involved in a change to the way we practice medicine.

However, clinical interest and momentum are abundant and I am confident UK cancer clinicians and the wider NHS can navigate these challenges.

Patients and doctors need to continue to educate themselves about AI and involve themselves in the development and regulation of new AI products. The potential of AI is only limited by ingenuity, once the floodgates open, I hope we will treat new AI technologies with the same enthusiasm as we do with a new drug or surgical tool.

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Tumours evolve: can we predict the next move?

Tumour evolution is far more important than it was previously realised.

It is usually the reason why tumours are so hard to treat.

T WRITTEN BY Dr Nicholas McGranahan Sir Henry Dale Fellow and Cancer Genome Evolution Research Group Leader, UCL Cancer Institute, London, UK

raditionally, cancer development was seen as resulting in a relatively homogeneous tumour mass.

In this scenario, cancer treatment would be relatively straightforward – if you can target one cancer cell you can target them all. By understanding tumour development as an evolutionary process, we can learn why treatments fail and, potentially, how to improve them.

Understanding the cancer environment Our understanding of cancer is constantly evolving. One of the biggest areas we know more about now is the interplay between the cancer cell and the immune microenvironment. Ecology considers the ecosystem in which a species exists and evolves, the same principles apply to the cancer cell.

To learn how the cancer cell has evolved and why it is evolving in a

certain way we need to understand the environment in which it exists.

The success of immunotherapies, such as immune checkpoint blockade, illustrate how the immune system can be harnessed to treat cancers.

Disease evolution guides therapies Monitoring disease evolution could help guide the choice of therapy.

If you have explored a primary tumour you can build up an accurate picture of all the mutations present in every cancer cell. These can be then used to help monitor the patient’s disease and look for signs of relapse. Evidence from the research setting suggests that circulating tumour DNA (ctDNA) can be used to track a tumour’s development and potentially detect changes early. I think that is really going to revolutionise the way we treat patients and understand resistance as well.

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Introducing targeted therapies The ultimate goal of our research is to understand patterns in cancer development such that we can predict the next step. Conceivably, one day we may be able to proactively treat the tumour in such a way that it could be led down an evolutionary dead end – rather than waiting for resistance to occur. With targeted therapies we already have a much deeper appreciation of the next resistance mechanism that is likely to occur and what treatment to give. But we want an even deeper knowledge of the playbook that the tumour might use and what we can do in advance of its next move.

Read the full article on the digital magazine of the European Society for Medical Oncology (ESMO), the ESMO Perspectives, perspectives. esmo.org

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Adding a new digital health dimension to cancer support Badri Wadawadigi, Associate Vice President, Head of Growth Initiatives, Accord Healthcare explains how digital technology and apps can support cancer patients.

Q. Why is there value in an app for cancer patients?

SPREAD INTERVIEW WITH Badri Nath Wadawadigi Associate Vice President, Head of Growth Initiatives, Accord Healthcare

WRITTEN BY Mark Nicholls

We know the pandemic has increased feelings of isolation for some cancer patients. They may not have had the same opportunities to talk to their oncologists face-to-face or the ability to check their symptoms as regularly with a healthcare professional. We wanted to develop a source of support that focused on day-to-day physical and emotional symptoms, which is what patients tell us are the things they spend the most time worrying about.

An app (and the information and advice it offers) is always accessible, no matter whether it is night or day. That ‘always ready and available’ nature of a digital platform is a key advantage over a phone helpline or in-person clinic.

Q. What are the benefits of community-based cancer experts?

We designed Unify Health to not just be an app but act as an easy way to connect with a local pharmacist such as those who have committed to the Community Cancer Champion Charter, who can talk to you about your cancer care and other matters that living with cancer raises.

By providing additional practical training to pharmacists, we can empower them to feel ready and confident to answer questions from patients in their local communities.

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That ‘always ready and available’ nature of a digital platform is a key advantage over a phone helpline or in-person clinic.

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Q. How are community pharmacists being recruited and trained?

We are inviting all community pharmacists to become a Community Cancer Champion if they are ready to commit to further helping cancer patients, by pledging to a Charter. We’ll be working with pharmacies, NHS bodies and professional organisations to help get this message out to pharmacists. We want community pharmacists to feel empowered and confident when talking to patients about the treatments they are receiving in hospitals and what steps patients can take to help manage symptoms.

The Royal Marsden NHS Foundation Trust helped to create a curriculum of practical training to community pharmacists on how to talk to, and assist, cancer patients, particularly around managing symptoms and worries. This curriculum is being delivered through an interactive digital platform that is easy to use and bite-size.

Q. Why is it called Unify Health?

Unify Health is not just a brand, it’s our mission statement. Undergoing cancer treatment can be bewildering, it can be difficult to make sense of all the different things you might find on the internet, and all the different appointments, medications and symptoms and the many professionals and carers who interact with you. We want to start to connect these dots, to provide a single place to help pull the many threads of your treatment journey together. The idea is to make it a little easier to manage the day-to-day experience of living with cancer.

* Unify Health has been devised by experts from the healthcare industry working with hospitals, community pharmacists, clinicians, nurses, patient groups and charities to make support and advice more readily available to cancer patients. It provides a toolkit of tailored advice and information, plus a map to connect them with nearby local community pharmacists.

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The impact of the pandemic on cancer care Cancer patients have been among those most severely affected by the ongoing COVID-19 pandemic.

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any hospitals have had to be re-purposed to cope with the rise in COVID-19 patients, healthcare staff have been redeployed, surgical procedures postponed and screening programmes paused. Patients may have also felt the need to avoid healthcare facilities because they fear it would put them at greater risk of coming into contact with COVID-19.

During the acute stages of the pandemic, patients suffering from cancer, heart conditions and other chronic diseases found their care interrupted. “The pandemic had a really huge impact on cancer care across Europe,” says Badri Wadawadigi, Associate Vice President, Head of Growth Initiatives. “It is well documented that many patients have had delayed diagnoses or treatment.”

Anxiety and stress In the UK, in April 2020, urgent consultant diagnosis referrals fell by 60%, according to a Macmillan Cancer Support analysis of NHS performance data on cancer care.1 The charity estimates that it will take the NHS 18 months working at 110% capacity to catch up on missing cancer diagnoses and 15 months to clear the cancer treatment backlog.

It can sometimes feel like there isn’t enough time to spend with patients discussing dayto-day anxieties and symptoms, as focus is understandably on things like diagnostics and active treatments. During the last year, this imbalance became even more pronounced. A cancer diagnosis can be isolating for patients and even more so during a pandemic.

“This has had a knock-on impact on people’s fears, anxiety, stress and worry about their cancer diagnosis and has been highlighted in the rise in calls to cancer support charities,” adds Mr Wadawadigi.

The worry and anxiety that cancer patients have has always been a problem, but limited access to hospitals and care during the pandemic has simply exacerbated these issues. We need to also appreciate the impact it has people’s mental health. If they can face their cancer with more confidence and less worry, they are more likely to have better outcomes. We felt there was a gap in the care of cancer patients, and our aim is to try and provide daily support to patients to help them better look after their own health.”

Unify Health is available on both the Android and Apple app stores. You can download it from www.UnifyHealth.app

One aspect of that is Unify Health, an app that has been devised by experts from the healthcare industry working with hospitals, community pharmacists, clinicians, nurses, patient groups and charities to make support and advice more readily available to cancer patients. The app provides cancer patients with a toolkit of tailored advice and information, plus a map to connect them with nearby qualified health care professionals – notably community pharmacists – so they can discuss any issues face-to-face or by phone.

Accord Healthcare has been a partner in the Unify Health project, working with Macmillan Cancer Support and The Royal Marsden NHS Foundation Trust in London, a world-leading cancer centre and a teaching institution for oncologists and cancer nurses.

A curriculum of additional training and practical resources has been developed for pharmacists by the experts at The Royal Marsden, so that the community pharmacists can feel empowered and confident to provide their expertise to cancer patients.

Mr Wadawadigi says: “The idea is to provide a level of advice that is accessible on-demand from your phone but with the reassurance of easy access to a pharmacist from your own community and located nearby, in case you want to discuss your concerns.”

References 1. The Forgotten C? The Impact of COVID-19 on Cancer Care. Macmillan Cancer Support publication. Available here: https://www.macmillan.org. uk/assets/forgotten-c-impact-of-covid-19-on-cancer-care.pdf

New approaches Mr Wadawadigi says there is a need to develop measures for effective management of symptoms and to reduce the barriers for patients to seek medical advice. However, while access to care has been affected by COVID-19, the pandemic has seen greater acceptance in the medical community of new digital approaches to reach out to all patients, not just those with a cancer diagnosis.

GPs and hospital consultants have been conducting remote consultations, either by phone or video, and the healthcare sector has accelerated new ways of interacting with patients.

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Embracing the fourth pillar: How interventional oncology can help liver cancer CT scan showing targeted area of liver to be treated by SIRT (in orange), sparing surrounding healthy liver.

Hepatocellular carcinoma, known as HCC, is the most common form of primary liver cancer in England. Now NICE has approved a new way of treating advanced liver cancer using interventional radiology.

S INTERVIEW WITH Dr Praveen Peddu Consultant Interventional Radiologist, Kings College Hospital, London

INTERVIEW WITH Dr Nabil Kibriya Consultant Interventional Radiologist, Kings College Hospital, London

INTERVIEW WITH Mr Abid Suddle Consultant Hepatologist, Kings College Hospital, London

INTERVIEW WITH Dr Dominic Yu Consultant Interventional Radiologist, Royal Free Hospital, London

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elective internal radiation therapy (SIRT) is a new NHS funded option for treating HCC, yet is not necessarily a new treatment as it has already been used with great success in other areas.

It works by delivering high dose radiation treatment into the artery supplying blood to the tumour via a catheter and has now been greenlighted by the NHS for use in 11 specialist hospitals across the UK. Dr Dominic Yu, Consultant Interventional Radiologist at the Royal Free Hospital, London says: “Interventional radiology is where we use imaging to do procedures, usually those which are minimally invasive. This means the risks to the patients are lower, there’s less chance of bleeding and a shorter recovery time, which is important for patients as they are less likely to get a hospital acquired disease.”

He adds, “We’re calling interventional radiology the fourth pillar of cancer care. It’s an additional option when it comes to treating this type of liver cancer which we welcome – it’s going to change patient care.”

The treatment itself is done via a pinhole puncture and aims to control the tumour by stopping it from growing. This can allow further treatment options to be considered, prolong life care in general or offer a better quality of life before palliative care, where required.

Innovation in the field Dr Abid Suddle, Consultant Hepatologist, Kings College Hospital, London, says, “The innovative part about this treatment is that it can target specific areas such as the cancer, while avoiding complications in the healthy liver tissue. SIRT and other innovations are likely to radically change the treatment paradigm for patients and what NICE has done is to allow us as clinicians a position where we can define, under reasonable guidelines, where the use of SIRT should be in the treatment protocol. I think that has been a really positive step.”

Dr Praveen Peddu, Consultant Interventional Radiologist specialising in liver and pancreatic cancer at King’s College Hospital, London, is also positive about SIRT. He says, “The decision by NICE has been long awaited however, in the UK we practice evidence-based medication. Intuitively

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we’ve believed it’s been a good option, but we wanted good quality evidence before we can offer it widely. Now NICE has said we can go ahead and the hospital will be reimbursed where there’s a valid reason for carrying out the treatment. But we must use it wisely.

“My view is that we should see it as another important tool in our armoury against liver cancer, but it is a complex procedure that must be done in high volume centres that have the multidisciplinary expertise to treat these patients.”

We’re calling interventional radiology the fourth pillar of cancer care. It’s an additional option when it comes to treating this type of liver cancer which we welcome – it’s going to change patient care.

Exciting time for patients Dr Nabil Kibriya, Consultant Interventional Radiologist, Kings College Hospital, London, says, “If a patient is offered a SIRT treatment, it means that it’s positive news and that they are going to get the most appropriate treatment for their type of disease. We know it’s a safe treatment as we’ve previously used it before although it’s always good to ask about the side effects. Compared to other options, these can be much more pleasant and what’s more the patient will only be offered this procedure if it will provide a better quality of life.

“Right now there’s a limited number of sites in the UK offering it. We’re hoping that over time if it’s proved to be effective and hospitals have appropriate patients and set-up, then more will open. However, I think that there is currently a good distribution of sites across the country with experience in the procedure, which should allow everyone to be referred on and treated. I think it’s quite an exciting time, not just for clinicians but more importantly for patients.”

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A liver cancer diagnosis is devastating – but SIRT can help For the 5000 people in the UK that are diagnosed with primary liver cancer or hepatocellular carcinoma (HCC), treatment choices have been severely limited. Now there’s a new option.

Patient story

How SIRT gave Martyn back his life after liver cancer INTERVIEW WITH Vanessa Hebditch Director of Communications and Policy, British Liver Trust SPREAD WRITTEN BY

Gina Clarke

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he British Liver Trust has continued people diagnosed with liver cancer, they may also to work with the National Institute for have liver disease which complicates any treatment Health and Care Excellence (NICE) during plan. While liver disease is often known as a its examination into the use of selective bi-product of alcoholism, there are actually many internal radiation therapy (SIRT). Earlier this reasons why the liver might be damaged. year, NICE announced that it would fund SIRT on the NHS, meaning that an estimated 36% of HCC Improving access to treatment sufferers will be eligible for the treatment.

However, for those with primary cancer of the liver Vanessa Hebditch, Director of Communications or HCC, it is hoped that SIRT will stop the tumour and Policy at the British from growing further and Liver Trust was part of the hopefully shrink it ready team who helped NICE for removal without the compile evidence and need to take out any Liver cancer in the UK is one of those healthy liver tissue. testimony from current sufferers, highlighting the Hebditch says, “For us forgotten cancers that doesn’t seem current lack of options. this new treatment is really to get the same attention as other important, we’re delighted The forgotten cancer for patients who now have mainstream cancers.

She says, “Liver cancer access to this life-changer. in the UK is one of those Not only will it prolong forgotten cancers that doesn’t seem to get the same life but it also offers a better quality of life. We attention as other mainstream cancers. Not only only hope that all patients will have access to this does it have a grim prognosis – only 13% reach treatment, wherever they live. Hopefully a wider five-year survival rate, but it also comes with a large provision of the service will come in time, although stigma attached.” we acknowledge that at the moment it is still a Hebditch explains that for a large majority of specialist service.”

Vials of TheraSphere – the tiny radioactive beads used in SIRT treatment. Beads shown in size comparison to a human hair.

When Martyn Griffiths couldn’t stop coughing, he saw his GP to be on the safe side. A shadow on his liver revealed that he had primary liver cancer (hepatocellular carcinoma – HCC).

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t 58-years old, Martyn was given the dire news that he would most likely only have a maximum of five years left to live unless he undertook a radical new treatment, SIRT. This would include injecting tiny radioactive beads into the artery that supplied blood to the tumour, all through a catheter in his femoral artery. The aim was to reduce the tumour which could later be removed, while saving his healthy liver tissue.

Martyn decided after being given no option for alternative cancer treatments that he would need to accept the SIRT solution. “I said where do I sign?”, remembering the day he was diagnosed in 2014. But what Martyn didn’t know was that SIRT was yet to be made available on the NHS and was actually funded through a charity at Newcastle Freeman Hospital.

I didn’t want to fade away, I wanted to fight for my family’s sake – and anyone given the option of SIRT should absolutely go ahead and do the same.

Martyn says, “I didn’t want to fade away, I wanted to fight for my family’s sake – and anyone given the option of SIRT should absolutely go ahead and do the same. That’s why I want to speak out and encourage other people to have SIRT, which is a life saving treatment that should be readily available on the NHS.” While Martyn needed two treatments of SIRT to shrink his grapefruit sized tumour, he has now fully recovered after a major operation to remove the tumour by the skilled surgical team at the Newcastle Freeman Hospital. While he still has regular scans, for now he can mostly continue living his life as it was before the cancer diagnosis.

Although doctors have suggested he stay tee total from now on. “I do miss the social side of drinking” says Martyn. “Especially now I only have a soft drink with my Sunday pub lunch. But it’s a small price to pay for having my life given back back to me.”

INTERVIEW WITH

Martyn Griffiths Patient

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Images provided by Boston Scientific

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How genomics is improving cancer care Clinicians are embracing the power of genomics to help deliver targeted therapies and better treatment options to their patients.

T INTERVIEW BY Dr Marianne Grantham Head of Cytogenetics and Molecular Haematology Department at the Royal London Hospital WRITTEN BY Mark Nicholls

argeted therapies and a changing treatment landscape based on genomics are offering clinicians the chance to deliver better outcomes for cancer patients.

Speaking on a podcast hosted by Genetics Unzipped, “The Future of Cancer: How Genomics is Transforming Research and Treatment for All”, Dr Marianne Grantham says genomics has an “exciting and important place” in modern healthcare.

She explains there have been huge changes in recent years in terms of the different techniques available, the genetics and the number of cancers where genomics has become increasingly important.

Dr Grantham, who is Head of Cytogenetics and Molecular Haematology at the Royal London Hospital, notes that the number of tests being performed, and the cancers that can be tested, is also rising as clinicians embrace methodology such as next generation sequencing.

Treatment options Her department tests thousands of samples every year from patients with blood cancers, and solid tumours such as bowel, breast or lung cancers, to confirm a new diagnosis, help doctors select the best treatment, or see how disease is responding to therapy.

Rather than just looking at one particular gene or particular mutation, she and her colleagues are now able to look at many different genes at once.

“We understand how much more important this information is in the way we manage our patients,” she adds.

That, she continues, means that doctors now have the opportunity to give patients different options based on the genomics. Instead of just using generic treatments, there is now the opportunity to target a patient’s cancer based on genomic information and ensure the treatments are going to work, while also avoiding unnecessary side effects.

Survival improvement An example is with non-small cell lung cancer, where the treatment landscape has vastly changed as targeted therapies have become available.

Additionally, in haematological malignancies, biomarker specific therapies can enhance patient outcomes and reduce the side effects associated with chemotherapies.

“We’re seeing fantastic improvements in patient survival because we’re targeting the cause of that patient’s cancer,” says Dr Grantham. The turnaround time for results has also reduced.

Whereas previously, it could take a month to get a result, now that is possible within a week and possibly

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Instead of just using generic treatments, there is now the opportunity to target a patient’s cancer based on genomic information.

between 24 and 72 hours from receipt of sample to a meaningful result, which helps doctors make quicker and better decisions on the treatment options for their patients.

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Next generation sequencing Dr Grantham explains that with next generation sequencing technology, the number of targets that can be tested are not limited. The approach is also becoming more flexible.

Patients can be tested from the beginning of the process, after treatment to make sure that their disease has gone, but treatment can also be adapted if the disease returns or progresses.

She says: “We are doing that a lot already in terms of solid tumours and non-small cell lung cancer, but also in our haematological malignancies. We know that certain cancers develop these resistance mutations and we need to look for them to make sure that we tailor our treatment accordingly.”

Integrating information As for the future, Dr Grantham believes that it is an exciting time for the field.

She emphasises the value of having comprehensive genomic profiling available for patients in a clinically appropriate timeframe and a clearer understanding of what to do with that information.

But she also highlights how understanding that genomic data in isolation can be meaningless if not integrated with other disciplines within pathology and the patient pathway.

Using it in conjunction with morphology, histology, and immunophenotyping is crucial in order to give the patient the most effective diagnosis and treatment plan going forward.

“I think it’s going to be critical for the future,” says Dr Grantham. “Genomics has a really exciting and important place in a modern healthcare service and innovations are now making this possible.

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