Wednesday, 16 November 2016

Reflective Monday

Monday at the NCRI Conference got off to a good start when I attended the plenary lecture by Cheng-Har Yip from Malaysia on the subject 'Challenges in the management of breast cancer in low and middle income countries'.  So much of the conference is about high tech solutions which are not always available in low and middle income countries so it was good to have this reminder.  We heard about challenges at all stages from late presentation because of fatalism and a preference for trying alternative therapies first, though lack of access to reliable pathology and onto low access to radiotherapy.  Some countries have a multitude of languages so patients may face a language barrier on top of problems such as distance and the cost of treatment.  The importance of a multidisciplinary approach was stressed along with collaboration between the high income countries and the LMICs.  It was very encouraging to hear the stress the speaker put on listening to what women say that they want.

This last point also came up in another excellent Monday plenary, namely Stan Kaye giving his Lifetime Achievement Award lecture on drug development and ovarian cancer.  He spoke about BRCA testing now becoming routine, the use of the PARP inhibitors and the management of recurrent disease. He also spoke about new targets, heterogeneity and the importance of listening to the patient.  One of his last points was 'never forget who you are treating.'

The Molecular Diagnostics workshop was a great opportunity to reflect on lessons learnt from several initiatives.  Louise Jones of Barts Cancer Institute reflected that the transformation of the NHS is a significant legacy of the 100,000 Genome project.

Monday evening saw the traditional Independent Cancer Patients' Voice lively meal in the local Pizza Express to which we invite a number of our friends an colleagues in the research and clinical practice community.

#NCRI2016

Thursday, 10 November 2016

Back in Liverpool

It has been a very long time since I last posted here; it has been a busy year on many other fronts and blogging rather slipped.  But November is NCRI Conference month and I was there again this year for 3 days of cancer conference, exhibition, posters and networking.  As usual, I will split this into bite-sized pieces as this makes it easier to write up!

For the last few years the conference has had a smart phone/tablet app.  It has been a bit of a novelty in the past but this year I found it extremely useful.  There is still room for improvement, but this year's new feature of being able to write notes of sessions straight into the session details was invaluable. It also supported online voting in the sessions where this was relevant and the ability to send questions to the session chair while the presentations were ongoing.  You could message other delegates - provided they were using the app, of course - and see floor plans and maps of the session room locations.

My journey up to Liverpool was not smooth.  I had to travel via London and my first train was delayed, the one before had been cancelled, it was half the stated length and Arsenal were playing at home.  On top of which, work on the track meant the train had to take the long route round and in spite of having 45 mins between trains I began to think I was going to miss my connection. Happily, I didn't and after that the journey improved no end.

The first and last days are half days, with two full ones between.

Sunday's highlight was the debate "New Tricks for Old Drugs", hosted by the charity Breast Cancer Now and chaired by Judith Bliss.  The motion was "This house believes research into repurposing existing medications and optimising use of current breast cancer treatments should be prioritised above research into developing novel agents".  Speaking for the motion were Robert Coleman and David Dodwell, while Paul Workman and Susan Galbraith spoke against.  A poll (with online voting!) at the start showed a large number of people declaring themselves as undecided, so the speakers had all to play for!

Rob Coleman started out with the bold statement that drug discovery was broke and not delivering for patients. He pointed out that while there had been a decline in mortality since 1990, this had now plateaued.  There have been no new adjuvant therapy drug approvals in the early setting for 10 years and new drugs for metastatic disease are not getting NICE approval. He could see no likely change in this position so money was being spent with little patient benefit and this was becoming unsustainably expensive.  He made the point that breast cancer is in practice a large family of rare diseases. Therefore drug repurposing deserves investigation and he cited the position in regard to bisphosphonates in this respect.

Paul Workman then spoke to make the point that while drug discovery is difficult, timescales are shortening and even with repurposing, discovery is still essential. He gave examples of rapid repurposing coming hot on the heels of discovery. There is still a mass of targets for investigation and drug discovery is vital in the field of overcoming drug resistance.

David Dodwell said that we need to do better with what we already have. He spoke about extended endocrine therapy, compliance issues and variations in practice.

Susan Galbraith started out by reminding us that while improvements start in the metastatic setting, the greatest effect is seen later when drugs move to early stage. This means that RCTs can underestimate benefit. She pointed out that UK spending on healthcare, and within that on cancer drugs, is lower than in much of the rest of Europe and that we could choose to spend more.

The questions from the floor pointed out that we need both repurposing and discovery. It also drew out that there are issues other than efficacy to consider, such as tolerability and that there are fewer unknowns with existing drugs.

I was a bit surprised that the proposers of the motion didn't make the point that they weren't suggesting repurposing instead of discovery but that, at least for a while, repurposing should take priority.  All in all it was serious but fun and conducted with great good humour.

In the final vote the motion was narrowly defeated but could claim the victory of having converted a greater proportion of the undecideds to their view. After which it was time to go down to the exhibition area for a glass of wine and chat with some of the exhibitors.

  

Saturday, 16 January 2016

European Commission Initiative on Breast Cancer

Back in early December I attended the plenary of the European Commission Initiative on Breast Cancer held in the beautiful setting of Baveno on the shores of Lake Maggiore.  Throughout the meeting there was plenty of opportunity at the breaks for networking.

Following the welcome, a series of speakers set out the project's current position in relation to developing a Europe-wide quality assurance scheme, guidelines for screening and diagnosis and a platform for further guidelines to cover care from screening to end of life.  The initiative has wider implications as it will be able to be used as a template for similar projects in relation to other cancers and diseases.

Pathology issues played a strong part on the first day, stressing that pathology is about so much more than testing (important though that is).

After watching a beautiful sunrise over the lake from the balcony of my room and fortified by an excellent Italian breakfast, I approached Day 2 in eager anticipation.  For me the highlight of the morning was the series of country profiles in which speakers from Hungary, Malta and Norway gave a fascinating insight into three very different sets of issues, challenges and solutions.  Long travel distances are a problem in some parts of Hungary.  That is not a problem in Malta, with its small landmass, but low numbers make clinical trials difficult there.  Norway appears to have high rates of interval cancers because all are captured, and informed consent in data collection has been a problem there.

The afternoon consisted of a choice of parallel workshops followed by a guided poster tour.  I could quite happily have attended any one of the 4 workshops, but eventually chose Communication in Person-centred Services.  This workshop involved presentations from 3 speakers and a good deal of participant participation.  It came up with some catchy images, parallels and metaphors, to which I will return later.

The conference dinner was excellent and provided a good opportunity for more informal networking.

The last day started with a keynote looking at evidence from qualitative research in guideline development.  This included asking 3 questions of proposals:
          Is it effective and safe?
          Is it acceptable to patients and others?
          Is it feasible to implement?

After the keynote each workshop fed back on they sessions, which was an excellent opportunity to catch up on the other options I'd rather have liked to attend.  I was particularly interested in the 'Volumes' workshop.  There is some evidence for a volume effect, but not as much as in complex surgery.  And should it be the surgeon or the hospital/unit volume?  In their feedback, the group posed the question - what do patients feel about volume?  My answer to that was - for anything complex, I really don't want to be operated on by the chap who was once known to do the procedure with the textbook propped open before him.  I want it done by the woman who can do it in her sleep, regardless of how far I have to travel for that - provided that she isn't actually asleep at the time, of course!  For something more straightforward, generic experience is probably fine.

The closing presentations included one on equity of access to screening; one of methodological standards for guidelines; and my own presentation on involving patients and the public in the difficult decisions using the over diagnosis/over treatment issue for illustration.

An interesting question was posed in relation to personalised screening, taking personalised medicine to the pre-diagnosis stage.

The issue of palliative care and the need for this to be included was raised several times; years to live, not years to suffer.  Another point that came up several times was the need for whatever is agreed to be attainable by all and not just the richer European countries.

I said before that the Workshop came up with some good images and metaphors.  Several of these resonated with me, including the following:

Luzia Travado presented on psychosocial support and used the analogy that diagnosis takes you to a new country for which you don't have the map and don't know the language.  I can relate to that and was fortunate enough to find both map and phrase book, but not everyone does manage to find those vital tools.

Kathi in her presentation suggested that patients practice telling their narrative in 75 words to support quick, easy and efficient communication of the vital issues.  She also spoke about the internet as being the blockbuster drug in patient engagement in their healthcare.  This, of course, does raise the question of how engagement can be achieved for those without (for whatever reason) good internet access.  Kathi also referred to the e-patient - Empowered, Engaged, Equipped and Enabled.

It was an excellent meeting; realistic but optimistic.  The patient voice was welcomed throughout the plenary; Susan Knox of Europa Donna spoke in the welcoming session on patient expectations, the Communication workshop included the presentation from Kathi Apostolidis of the European Cancer Patient Coalition, and I presented in the last presentations.

It isn't an easy project, especially given the economic climate, but it is one that could deliver a good standard of care wherever you live in Europe.




Thursday, 14 January 2016

Another Milestone

I'm afraid that posters and Baveno are a bit delayed; this is a personal post following a much longer than usual appointments season.

This week, exactly seven years after I first met my oncologist to discuss radiotherapy and endocrine medication, I have been discharged from follow up and will re-join the National Screening Programme.

It has been a slightly strained appointments season this year.  Following my annual mammogram in mid November I was due to receive the results at my follow up appointment three weeks later.  However, this appointment was cancelled by the hospital due to planned strike action by junior doctors.  The re-scheduled appointment was for five weeks after the mammogram and while happy to wait for the appointment I viewed it as an unacceptably long time to wait for the results.  It was further complicated by the fact that I couldn't make the new date as I had a meeting I really did not want to miss and had spent the last eleven months working my diary around keeping the original date free.  Eventually I got another appointment, which was for eight weeks after the mammogram.

After something of a struggle I managed to get the results by phone from one of the unit's breast care nurses, who clearly did appreciate my point about the length of the wait.  However, I do find it worrying that she appeared to be in the minority and the unit as a whole didn't appear to acknowledge that leaving me waiting eight weeks for the results was not acceptable.

That aside, it was a good appointment and after I made my points I reviewed with my consultant my diagnosis, treatment and notes in addition to the usual examination.  All was fine and I'm now discharged, with thanks from me to him for his neat surgical work, his good wishes to me and a friendly handshake.

It feels a bit odd but strangely liberating.  For the last seven and a quarter years I have never been longer than a few weeks without being in possession of a hospital appointment letter or two and with the second Tuesday in December booked.

Obviously I'm not fool enough to think that this actually changes anything.  I'm fully aware that for ER+ breast cancer the risk of recurrence remains at 10, 15, 20, 25 etc. years after treatment and the "all clear" beloved by the tabloid press is a myth.  Side effects can linger and lymphoedema lurks, but follow up won't actually prevent any of that.  It is time for me to take over the responsibility for monitoring my own health.

I walked out of the hospital with a smile on my face, a feeling of satisfaction and the memory of the words spoken to me by an excellent oncology registrar when I finished radiotherapy, "You have done well."

At Christmas my brother gave me the CD 'The Race for Space' by Public Service Broadcasting.  One track is entitled "Go" and addresses the Apollo 11 lunar landing from the mission control side, featuring the Go/No Go calls of those responsible for various areas.  As I drove home from the hospital I listened to this, with the line "Surgeon - 'Go'" taking on a very personal meaning.

Thursday, 17 December 2015

Uncertain, but encouraging

The UKTOCS ovarian cancer screening trial presented its impact of screening on cancer mortality results this morning at the Royal College of Obstetricians and Gynaecologists in London. They live streamed the event, so I was able to dip in and out as the meeting took place.

While not definitive, the results certainly suggest that screening may well reduce mortality.  Another three years will be required to confirm the presence of a late effect of reduced mortality.  In the words of Professor Ian Jacobs, who chaired the meeting, there is "encouraging evidence of mortality reduction".

Diagnosis at an earlier stage was shown and may be encouraging, but it is really only a breakthrough if in practice that leads to a reduction in the number of women who die from the disease.  Otherwise the harms of screening (which include complications from what turns out to be unnecessary surgery) will not outweigh the benefits.

The meeting heard from, amongst others, patient Sarah Smith, Professor Usha Menon on the background, design and implementation of the trial, Professor Lesley Fallowfield on the psychological outcomes and Professor Max Parmar and Dr Steve Skates on the mortality results.

The background information to this trial includes types of screening, ultrasound only or multi-modal and the personal CA125 algorithm for each woman rather than using an all purpose cut-off point.

Professor Fallowfield presented data on anxiety, the effects on the lives of the participants (especially those recalled for additional testing) and those who left the trial.  This presentation was particularly interesting for me as I could relate it to my own feelings while in the 'sister study' UKFOCSS (which has yet to report on the second phase in which I took part).

The mortality results were presented in several ways, with the multi-modal arm showing a reduction in mortality of 15% overall.  There were clear differences in results for 0 to 7 years and 7 to 14 years of screening, which chimed with pervious studies showing that any benefits were seen in the long rather than short term.  One presentation of results excluded prevalent cases by looking at the point at which levels of CA125 rose in order to exclude those where ovarian cancer developed prior to entry into the trial.

While there is no definitive evidence that screening saves lives, there is evidence of a late effect and this reflects what was found in the earlier PSA marker trial for prostate cancer.  It is consistent with a finding in UKCTOCS that there was an 8-9 year period for ovarian cancer deaths to show up in the control arm and the finding that the curves are still diverging.  We need another three years of follow up to observe this late effect and therefore we are still in a period of uncertainty.

In his summing up, Professor Jacobs pointed out that the trial started with some pieces of the jigsaw in place, while we can say that the trial has now been able to add some others such as a high level of compliance, sensitivity and a shift in diagnosed disease stage.  The pieces relating to reduced mortality and cost effectiveness are still to fall into place and complete the picture.

Both Professor Menon and Professor Jacobs paid tribute to the trial participants with Professor Menon making the point that it cost the women in both time and money, as the trial was unable to pay the expenses (travel, parking costs) of attending sometimes late running appointments.  Professor Jacobs closed the meeting by inviting applause for the participants.

So the conclusion is that we are not yet in a place where population screening for ovarian cancer can be recommended, but that day may come.  A bit disappointing not to have a recommendation but, in view of the benefit v risk controversies that have arisen in relation to breast screening, it is better to get things on a firm footing at the outset.  Given that it has taken 30 years to get to this point, it is worth waiting another 3 for a definitive answer.

CRUK's Scienceblog has an excellent graphic indicating where we are with this at the present.

#UKCTOCS

Wednesday, 16 December 2015

Ovarian Cancer Screening Trial results

A few weeks ago when blogging about the last day of  I mentioned that results of the UKCTOCS trial would be live streamed this month.

That will happen tomorrow between 10.00 and 12.30 hrs GMT.  Further information, including the agenda and a link to the live stream can be found on the trial web site at:  http://www.instituteforwomenshealth.ucl.ac.uk/womens-cancer/gcrc/ukctocs

This is population screening trial for ovarian cancer with, in some cases, more than 13 years follow up.  There was also a screening study for high risk women - UKFOCSS - but that is not yet ready to report as the last woman was recruited into the trial in only 2010.

Monday, 14 December 2015

Change of Plan

Things got a bit busy and I am sorry that I haven't yet posted on the NCRI conference posters.

Then last week I was in Baveno for the European Commission Initiative on Breast Cancer's Plenary meeting.  There were posters here too, so my aim now is to gather my notes from the Plenary and then to do blog post on posters from both events.