Alastair Whitington speaks with Professor David Cunningham, Chair of the Association of Cancer Physicians, about the challenges currently facing cancer services and clinical research
In this short video, Professor David Cunningham, Consultant Medical Oncologist at the The Royal Marsden NHS Foundation Trust and Chair of the Association of Cancer Physicians (ACP), discusses the challenges facing cancer services and research, with reference to the impact of COVID-19.
To launch the new partnership between Specialised Medicine and the ACP, Alastair Whitington, Consultant Editor for Specialised Medicine, interviewed Professor David Cunningham to discuss the role of the ACP, the challenges facing oncologists, and the impact of the COVID-19 pandemic on cancer services and clinical research.
What is the role and function of the ACP?
The ACP is recognised by the Royal College of Physicians and DHSC as the specialist society for medical oncologists in the UK. The role of the ACP is to represent the views and concerns of consultant medical oncologists and trainees, support the continued growth and development of the specialty, and further the advancement of best practice to benefit patients with cancer.
Central to our work is the education and training of the next generation of medical oncologists. In conjunction with the Specialty Advisory Committee, the ACP is closely involved in the development of training curricula and the Specialty Certificate Examination. The ACP holds educational workshops for members and annual events specifically targeted at new consultants and trainees and, from autumn 2020, the ACP will host monthly teaching webinars for trainees. Finally, in partnership with EBN Health (www.ebnhealth.com), we have published an award-winning series of problem‑solving books for oncologists.
What are the challenges facing oncologists over the next few years?
Oncologists face many challenges in future. One of the biggest challenges is that the incidence of cancer continues to increase. Thankfully, there is much more that oncologists can do for individual patients—more lines of therapy and better drugs, delivering better outcomes—but this does mean that the workforce is heavily committed to delivering very high standards of care.
One consequence of this is the risk of burnout among oncologists. A survey conducted by the European Society for Medical Oncology between January 2013 and January 2014 found a high level of burnout, particularly among young oncologists, because of the challenges they face.1 We get to know our patients well, we’re involved in the patient journey, we get to know their families, and it’s difficult to remain remote. However, the progress that has been made in clinical care has been substantial, with significant advances across all malignancies. We are trying to make diagnoses much earlier because, certainly for common tumours, this does equate to better long-term outcomes.
NHS England has agreed to interim treatment changes in systemic anticancer therapy during the COVID-19 pandemic—how easy have these changes been to implement, and how have they benefited patients?
COVID-19 has presented so many challenges to society, patients with cancer, and the health service. The NICE COVID-19 rapid guideline on systemic anticancer treatments has been incredibly helpful, allowing us to switch to oral chemotherapy treatments, choose less immunosuppressive chemotherapy treatments, and use haematopoietic growth factors to limit the duration of neutropenia caused by cytotoxic drugs in eligible patients.2
In my own fields of gastrointestinal cancer and lymphoma, immunotherapy drugs can currently be used first line in place of systemic chemotherapy for the relatively small group of patients with colorectal cancer who are mismatch repair-deficient.2 Another important change is the ability to use treatments that target the BRAFV600E gene mutation, which is present in a significant number of patients with colorectal cancer3—the combination of encorafenib and cetuximab is looking very promising for second- and third-line treatment,4 but we’re now able to use it in much earlier lines of treatment.2
Implementing these changes has been very straightforward in my own organisation, The Royal Marsden, and I believe that this has been the case throughout the country. The ability to modify treatments to reduce the risk to patients with cancer receiving systemic anticancer treatment has been a great advantage, and patients have benefited enormously.
The ability to modify treatments to reduce the risk to patients with cancer receiving systemic anticancer treatment has been a great advantage …
How has COVID-19 impacted clinical research and cancer services?
COVID-19 has had a significant impact on cancer research for a variety of reasons. During the first peak, many research staff were redeployed to provide essential clinical services; as a result, recruitment was suspended to many research trials, and clinical laboratories engaged in translational research were largely closed. There has been a return of research activity, but not yet to the level it was pre‑COVID-19.
Fortunately, within The Royal Marsden, we have been able to re-establish both commercial and non-commercial trials to pre-COVID levels. However, for multicentre trials, recruitment is still well below where it should be, which probably reflects the situation around the country. The National Institute for Health Research has instructed that, although COVID-19 research is a priority, other research must also continue, but this remains a challenge.5 As the country moves into a second wave of COVID-19, we should endeavour to keep as many research protocols open as possible—it is essential that we conduct the research that will lead to improved outcomes for our patients.
One problem with recruitment to research studies has been patients’ perceptions that participating may mean increased contact with the hospital, equating to an increased risk of contracting COVID-19, and that’s understandable. However, the response to COVID-19 has developed and improved over the past 6 months. Organisations are much more COVID‑secure—patients and staff are regularly screened for COVID-19 and, once identified, the disease is now dealt with promptly. This should reassure patients that attending hospital is less risky than it was.
Another way in which the pandemic has impacted cancer research relates to cancer charities, which have experienced a substantial reduction in their income. As a result, their ability to fund research grants has been reduced commensurate with the reduction in income.6
The main clinical issue for cancer services, which has been widely covered in the media, is diagnosis—the pandemic has impacted both patients’ willingness to come forward with symptoms that may be cancer‑related for diagnosis, and also the diagnostic procedures themselves. Oncologists would strongly urge and encourage patients to come forward and seek medical advice when they develop symptoms that may be cancer-related. The service is ready and waiting. With respect to diagnosis itself, any procedures that are aerosol‑generating, such as gastroscopy, colonoscopy, and bronchoscopy, have been a particular challenge because we have had to create an environment in which the safety of our patients and staff is paramount. Substantial progress has been made, but there are still waiting lists, which the NHS is doing everything possible to bring down.
At the same time, the service is looking at different ways to diagnose cancer. For lung, pancreatic, gastric, and colon cancer, where aerosol‑generating procedures are required to make a diagnosis, we have been looking at circulating tumour DNA and using that as a surrogate for more invasive procedures. We know that circulating tumour DNA is present in many patients with these cancers, and a trial at The Royal Marsden is investigating the use of this technique as a way of making a diagnosis when it is difficult to access more conventional diagnostic processes.7
… it is essential that we conduct the research that will lead to improved outcomes for our patients.
COVID-19 has taught clinicians a lot, making them think about improving processes. Telemedicine has really taken off and is a very valuable tool. It’s not a complete substitute for face‑to‑face meetings, but many patients prefer it, and it does mean that footfall in the hospital is reduced. I believe that many of these changes are here to stay, and will allow us to deliver healthcare more efficiently and effectively. COVID-19 remains a challenge, but we have to learn from it, adapt, and use those learnings to improve what we do today and tomorrow.
What benefits will the ACP collaboration with Specialised Medicine bring to the oncology community?
Specialised Medicine provides a platform to promote the interests of the ACP, and oncology as a whole, to a readership that includes members of NHS England and NICE, commissioners, providers, and industry. We hope to regularly contribute features on innovation and best practice in cancer, and develop tools and guidance, to support our trainees and the wider oncology community.
Interested in more articles on oncology? Why not try:
- Proton beam therapy: a new radiotherapy paradigm
- Implementing the latest NICE colorectal cancer guideline
- Restarting cancer services will require stratification and coordination
- Cancer care in England: current status and future challenges
You can view all our oncology content here: www.specialisedmedicine.co.uk/clinical_area/oncology/
- Banerjee S, Califano R, Corral J et al. Professional burnout in European young oncologists: results of the European Society for Medical Oncology (ESMO) Young Oncologists Committee Burnout Survey. Ann Oncol 2017; 28: 1590–1596.
- NICE. COVID-19 rapid guideline: delivery of systemic anticancer treatments. NICE Guideline 161. NICE, 2020. Available at: www.nice.org.uk/ng161
- Bowel Cancer UK. New bowel cancer treatment approved by the European Commission. www.bowelcanceruk.org.uk/news-and-blogs/news/new-bowel-cancer-treatment-approved-by-the-european-commission/ (accessed 17 November 2020).
- NICE. Encorafenib in dual or triple therapy for previously treated BRAF V600E mutation-positive metastatic colorectal cancer. Guideline in development [GID-TA10496]. www.nice.org.uk/guidance/indevelopment/gid-ta10496 (accessed 17 November 2020).
- National Institute for Health Research. NIHR issues guidance to ensure research protected in a ‘second wave’. www.nihr.ac.uk/news/nihr-issues-guidance-to-ensure-research-protected-in-a-second-wave/25858 (accessed 17 November 2020).
- Laurence R. UK cancer research could see £167m drop in funding as a result of charity income loss. www.ncri.org.uk/uk-cancer-research-could-see-167m-drop-in-funding-as-a-result-of-charity-income-loss/ (accessed 17 November 2020).
- The Royal Marsden NHS Foundation Trust. Using liquid biopsies as an alternative diagnostic test to protect patients and staff. www.royalmarsden.nhs.uk/using-liquid-biopsies-alternative-diagnostic-test-protect-patients-and-staff (accessed 17 November 2020).