Image: A PhD students on the Cancer Biology - Functional Proteomics team. (Credit John Angerson)
The Covid-19 pandemic has posed many challenges to the cancer research community, but also created opportunities to reimagine the way things are done. While the temporary closures of labs and in-person restrictions slowed research, they also accelerated the development of virtual collaborations and approaches to remote testing and treatment. Across the board, we have seen how the cancer research community can adapt quickly and that a different future is possible.
But what do we want the future of cancer to look like?
Last week, scientists, clinicians and patients gathered virtually for the UK’s largest annual cancer conference, hosted by the NCRI. One of the high profile sessions looked at cancer in the year 2035: together, speakers from some of the UK’s leading cancer research institutes envisioned a future where equality, diversity and inclusion are no longer an issue, where all GPs are equipped for an ageing population and clinical trials have taken a revolutionary turn. Most importantly, they explored what is happening now and how we can shape the future.
Here’s how researchers described the future – and some examples of how the ICR is leading the way in creating a bright future for cancer research.
An ageing population
Changing demographics mean that by 2035, the world’s population will be much older, delegates at the conference heard. Since cancer incidence increases with age, it is likely that we will see an increase in the number of cancer patients, who will be much older and could have other health problems alongside cancer.
“Around 46 per cent of people diagnosed with cancer are over 75,” said one of the speakers, Dr Shane O’Hanlon, a consultant geriatrician at University College Dublin’s Medical School. “And 90 per cent of cancers occur above age 50 – so cancer really is a disease of ageing.”
“In the UK at the moment, the population is roughly 60 million and around one fifth consists of people over 65, so 12 million people in that age group. At the moment we have three million people living with cancer in the UK. By 2035 that is projected to reach about 4.5 million.”
This increase in the number of cancer patients will have an impact on the way clinicians deliver treatment. Will these older patients be fit enough to undergo certain therapies? Is there a higher probability of complications?
Radiotherapy, for example, is often used in older patients – and, in fact, radiotherapy techniques have advanced hugely and could help tackle some of the challenges posed by an ageing population. Older patients can struggle with side effects though, so anything we can do to minimise those is valuable.
Researchers at the ICR have played a leading role in recent years in establishing new forms of radiotherapy in treatment, as well as developing new regimens that involve fewer doses of radiation and so reduce side effects.
One relatively new form of radiotherapy celebrated at the NCRI session, called stereotactic ablative radiotherapy (SABR), has improved treatment for patients with early stage lung cancer who are not fit for surgery. There is less risk of toxicity than with standard radiotherapy and a greater chance of cure. At the ICR and the Royal Marsden, the PACE-B trial is looking at the benefit of SABR in prostate cancer.
Targeted treatments, immunotherapies and drug combinations will be other new options for elderly patients in the future.
But what is the best way for clinicians to present options to patients? How can patients give informed consent? And how do clinicians evaluate ‘frailty’, which would help determine what treatment might be best?
Unfortunately, there are very few geriatric oncologists – the clinicians who evaluate the specific needs of older people with cancer – NCRI delegates. There may still not be enough in 2035 to deliver the assessment and follow-up needed for every patient.
On a positive note, by 2035 some of the assessments will be automatized thanks to artificial intelligence, saving geriatricians and oncologists a lot of time. But there’s a pressing need to train everyone involved in the care of older people in their specific needs.
“Oncologists don’t train on geriatrics and geriatricians don’t train on oncology – so that is a problem. There is a big need to upskill others too,” said Dr Fabio Gomes from The Christie NHS Foundation Trust.
It is not clear what the future holds, but what is certain is that there is a need for a systematic, comprehensive approach where GPs, geriatricians and oncologists work together, along with other team members such as advanced nurse practitioners, to offer the best treatment to an ageing population.
Another major theme of the Year 2035 sessions at the NCRI Festival – indeed of the conference overall – was reducing inequality. After delegates had been told of the need for a full “inclusion reset” in the festival’s opening keynote – by Banji Adewumi, Director of Equality, Diversity and Inclusion at University of Manchester – two sessions focused separately on diversity in cancer research, and in clinical trials.
The inequalities in healthcare and the lack of diversity in cancer research and clinical trials are not new issues, delegates heard at the session on research diversity. However, to really address them requires a new and more radical approach. We need to reflect the communities we serve and bring in diverse perspectives to shape research questions from the start, and although there have been a number of initiatives to improve diversity, these programmes cannot exist in isolation.
Speakers pulled out the importance of support on a cultural level at research institutions, or else running the risk of initiatives seeming tokenistic or failing to lead to lasting change. To build a more diverse research community in the future, we need to change the approach to professional recruitment and progression, which are built around systems that favour some people over others.
The ICR’s commitment to tackling racial inequalities in our organisation and beyond is set out in our Race Equality: Beyond the Statements Action Plan which shows how we are seeking to address the under-representation of Black, Asian and minority ethnic staff in leadership roles and in research careers within the ICR.
Diversity in clinical trials
Representation in clinical trials is another major challenge. Failing to include a broad and diverse representative range of participants means the result of trials may not be generalizable to the general population, and further widen gaps in healthcare.
The session on diversity in clinical trials looked at a number of new initiatives that aim to improve representation in clinical trials. One was the National Institute for Health Research (NIHR) INCLUDE Project, which aims to improve inclusion of underrepresented groups into clinical research.
Speakers including Professor Lynn Rochester, from Newcastle University and leader of the NIHR INCLUDE project, introduced some of the big issues facing researchers aiming to improve diversity in clinical trials – including the importance of scientists taking responsibility for improving diversity in trials.
At the ICR, our researchers are working to reach the communities most affected by cancer, including Black men who have faced increased risks of prostate cancer.
Cancer clinical trials in a post-Covid world
Another major theme of the festival, not surprisingly, was the Covid-19 pandemic. Covid-19 has caused a shake-up of clinical trials and a session examining its impact was chaired by the ICR’s Professor Judith Bliss, Director of our Clinical Trials and Statistics Unit (ICR-CTSU).
Not only did we see trials for Covid vaccines and treatment happen with unprecedented speed, attendees heard, but other, non-Covid related trials also experienced rapid changes. When the UK went into lockdown in early 2020, clinical trials units across the UK including the ICR-CTSU were forced to move to fully remote working overnight.
Trials that were planned with face-to-face follow-up appointments for patients had to shift to telephone and virtual appointments. Many NHS research staff members were redeployed to tackle the immediate threat of Covid. Many non-Covid trials, including cancer clinical trials, were put on pause.
Cancer trials are coming back to life, said Professor Nick Lemoine, Medical Director of the NIHR and Director of Barts Cancer Institute, and one of the session panellists. But, he said, things are tough, and we have to recognise that we’re conducting research in a tired NHS.
As Professor Bliss recounted, in March 2021 the UK government published its vision for the future of UK clinical research – giving a clear view of the government’s expectations for clinical trials moving forward.
Future cancer trials
So what does the future of cancer clinical trials look like, and what lessons can we learn from the clinical research that has taken place during the pandemic so far?
A resounding take away from the panel session on the future of cancer trials, and in keeping with the government’s vision for a future where tech enabled clinical research is the norm, was that there is a clear need for new digital tools in the field of academic clinical trials.
A system to allow patient reported outcomes (PROs) within academic trials to be collected via an app would be extremely desirable – with the challenge being the cost of this type of software, and the need for it to be regulated by the Medicines and Healthcare products Regulatory Agency (MHRA).
To round off the session, each panellist was asked to give their vision for trials in 2035. The picture painted was one where remote recruitment, conduction of interventions and monitoring of patients is the norm. A future where we are moving towards more novel, patient-centred trial designs, and where every barrier and inequality to access to clinical trials for every patient should be removed.
These were just a few key areas highlighted at the NCRI Festival where researchers need to make major changes: 2035 is in the not-so-distant future and we need to start now. We are at an exciting point in history where we have seen that researchers can come together and bring about transformative changes quickly – now, they need to seize this opportunity to build a brighter future.
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