Cancer Diagnostics: Can Cancer Be Diagnosed Earlier and If Yes What Are the Consequences? Date and Location: 11Th July, 2017 at the Royal Society
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Cancer diagnostics: can cancer be diagnosed earlier and if yes what are the consequences? Date and Location: 11th July, 2017 at The Royal Society Chair: The Earl of Selborne GBE FRS Chair, The Foundation for Science and Technology Speakers: Sir Harpal Kumar Chief Executive, Cancer Research UK Billy Boyle Debate Record Note Record Debate Chief Executive Officer, Owlstone Medical Dr Clare Turnbull Clinical Lead for the Genomics Enland 100,000 Genomes Cancer Programme Panellists: Dr Suzanne Jenkins Director, Diagnostics Expert, Personalised Healthcare & Biomarkers AstraZeneca Sara Hiom Director of Early Diagnosis & Health Professional Engagement, Cancer Research UK Sponsors: AstraZeneca, The Kohn Foundation and the National Physical Laboratory The Foundation for Science and Technology Science and for Foundation The Audio Files: www.foundation.org.uk Hash tag: #fstcancerdiagnostics SIR HARPAL KUMAR said the imperative cancer was £3,373. For a patient with late stage for early diagnosis of cancer was clear. cancer it was £12,000. Even without new technologies it would A range of possibilities suggested themselves improve both outcomes and resource as approaches to improving rates of early utilisation. In bowel cancer, for example, diagnosis. There was scope for better uptake 5 year survival rates were 90% for early in the current screening programmes – stage disease, but less than 10% for late particularly for bowel cancer – if patient factors, stage diagnosis. The differentiation was system issues and the test quality could be similarly stark in the case of lung cancer. addressed. Regional variations in diagnosis This was compounded by the fact that, rates and variations related to gender, age, socio for these tumours, the rate of last stage economic factors and efficiency were obvious diagnosis was higher than in comparable opportunities. Lengthy waiting times for countries – over 50% in the case of bowel pathology and imaging services (operating with cancer. Moreover the average cost of less resource than comparable health systems treatment for a patient with early stage internationally) were a significant contribution Page 1 www.foundation.org.uk to late diagnosis – which could and should be to testing. On the other hand it could increase if addressed by increased investment. A faster standard community based testing became practicable. for time to diagnosis – 4 weeks – had now been All this pointed to a clear conclusion: earlier established; and a series of other measures to improve diagnosis of cancer should lead to better outcomes diagnostic pathways, including new rapid, one–stop- and better resource utilisation; and progress was shop diagnostic assessment centres for people with achievable if the current and future possibilities non-specific symptoms, were being developed and for improvement were explored and consequences piloted across the system. There was certainly scope for patients and the system were recognised and for more active surveillance of patients in higher risk carefully managed. For that reason CRUK would be groups. Finally and encouragingly, new technologies prioritising research in this area as it looked to the were emerging which showed promise for supporting future. earlier, faster and better diagnosis – including BILLY BOYLE said that this his company, Owlstone circulating biomarkers, volatile compounds, new Medical, was seeking to develop the science of breath imaging modalities such as low dose CT and ultra biomarkers to support earlier, more accessible and sound, cell capture and AI/machine learning (using non-invasive diagnosis of cancer. The company had existing large datasets). its origins in a spin out from Cambridge University Earlier diagnosis had consequences both for which had developed applications for military use. patients and individuals and for the health system. This further spin-out into the medical field was, For patients there were risks associated with both therefore, founded on well-established technology false positives and false negatives. In one recent and a proven team. The technology – current and programme, for example, the use of low dose CT for next generation – for capturing good samples of diagnosing lung cancer had reduced mortality by breath biomarkers and analysing them to high levels 20% but, astonishingly, resulted in a false positive rate of sensitivity existed. The challenge now was to move of 96% - with all the risk that carried of individuals to collection at scale with samples that were stable going forward for unjustified and potentially harmful enough for analysis. interventions. On the other hand increased volumes He agreed with Sir Harpal that early detection was of early diagnosis might increase the risk of false our greatest opportunity. One in two of us would be negatives: giving unwarranted assurance to a patient diagnosed with cancer in our lifetime. Sir Harpal which might inhibit them responding to symptom had already highlighted the poor outcomes in lung development, leading to late stage presentation. and colon cancer linked to late stage diagnosis. There was always a risk, too, of over diagnosis, Both tumour types were obvious opportunities particularly with slow growing cancers. For example, for improvement through early detection; and there was clear evidence that the breast screening his company were currently targeting specific programme saved lives (1300 – 1500 a year in the programmes in those areas. They were running a UK). But it was also the case for every life saved 3 trial (LuCID) for a lung cancer breathalyser with women were diagnosed and often given extensive, the aim of improving rates of early diagnosis. The treatment for cancer that left undetected or unrelated opportunity was clear. Over three years an increase would not affect their life span. On the other hand in detection rates of stage 1 disease from the current earlier diagnosis might offer real possibilities for 14.5% to 25% could save over 9,500 lives and £246m. better identifying the tissue of origin in cases where The trial, funded by the NHS, was the largest breath later presentation made that intrinsically more biomarker trial ever undertaken in the world, different. recruiting up to 3,000 patients from 21 clinical sites For the health system, earlier diagnosis would across the UK and Europe. Moreover, this was a require investment in new technology and workforce global opportunity. China had for example, had more expansion to support growth in the diagnostic lung cancer cases and deaths than any other country infrastructure. It would also lead to more surgical because of the rise of its population, with mortality treatment. This shift in resource should, however, highest in urban East China. be balanced by significantly reduced costs in the He echoed, however, Sir Harpal’s comments treatment of metastatic disease. There would be about some of the problems associated with earlier implications, too, for primary care. On the one hand detection, also citing the high volume of false its role might diminish if better symptom awareness positives associated with the US national lung cancer and more diagnostic capacity could lead straight screening trial using low dose CT (LCDT) and the Page 2 www.foundation.org.uk consequent overtreatment of indeterminate lung a result of surgery – which meant catching a tumour modules and the associated harms (with 17% of when it was small (enough), localised and before low risk patients having a biopsy and 28% having it ‘bolted’. Earlier detection across the population surgery , and with surgery being performed on 35% of enabled more frequent successful surgical resection; benign modules irrespective of assessed risk). Breath enabling cure and reducing costs. Prevention was, of biopsy could, therefore, definitely have a role in the course, even better than early detection. management of indeterminate pulmonary modules This pointed to the need for the delivery of revealed by LDCT: using a non-invasive technology effective screening programmes; for public education offering high compliance could be used at least rule around uptake of screening symptoms awareness; out tests for a suspicious module. for public health intervention around life-style The nature of the diagnostic test also really change (smoking, alcohol and obesity); for expansion mattered. Again, Sir Harpal had already referred and development of vaccine programmes; and for to the low compliance rate in current colon cancer the expansion of chemoprevention. In addition, programmes (48%). That was undoubtedly related to targeting sub-populations at elevated risk would the nature of the test. Low compliance rates were then improve early detection and prevention. For compounded by poor test sensitivity (66%) – which example, screening was currently focussed by age meant that out of 100 patients with colon cancer only and gender. It should be possible to use genetics (and 31 cancers were detected. Their Intercept programme non-genetic life style factors) to focus screening on was therefore targeted at early detection of colorectal those at higher risk. cancer through breath biopsy. The majority of cancers arose in the genetically However, early detection was a financial pre-disposed; and next generation technologies for engineering problem as well as a scientific one. genetic sequencing would enable cheaper, rapid, The funding ‘valley of death’ between product high throughput – supporting reduced thresholds for development and testing and market authorisation screening and significant