By Jacqui Thornton

In the last decade, there have been impressive technological advances improving cancer diagnosis, treatment and care, with innovations in robotic surgery, the delivery of radiotherapy, imaging and more.

Drug development has led to immunotherapies and other targeted drug treatments. Digital transformation is further revolutionising the impact of cancer, while Artificial Intelligence holds enormous promise.

At the same time, resources are stretched like never before, the NHS is creaking in parts and the push for environmental sustainability, while essential, is seen by some as a further burden.

So - can innovation in cancer ever be compatible with sustainability and affordability?

That was the question posed to an eminent panel representing researchers, clinicians, patients, media and the pharmaceutical industry, in an event jointly organised by London School of Hygiene & Tropical Medicine, King’s College London and London Global Cancer Week.

The ‘great debate,’ at the Science Gallery on the Guy’s hospital campus on November 27, took place in front of a live audience including Prof David Collingridge, editor-in-chief of Lancet Oncology, and representatives from Cancer Research UK and Macmillan Cancer Support.

Professor Richard Sullivan, Director of the Institute of Cancer Policy, and Co-Director of the Centre for Conflict & Health Research, King’s College London, who moderated the event, opened by arguing that this was the most important existential question affecting cancer care globally. “There are people that believe this is a zero-sum game: for technical innovation to win, sustainability and affordability must lose.

“With all these new technologies, it's fantastic when it comes to patients, and for our clinical colleagues, because there's so many new resources to use now. But if you're a Minister of Finance, or a Minister of Health anywhere in the world, this is frightening territory.”

Patient expectation

Emma Kinloch, co-founder and chair of patient group Salivary Gland Cancer UK, said it was ‘imperative and should be compulsory’ for innovation to be compatible with sustainability and equitable cancer care.

Currently she said there was a lack of equity, with ‘amazing’ innovations such as proton beam therapy, subject to a postcode lottery. “If you live in the Scilly Isles, you're more likely to get it than if you live in Glasgow. That doesn't make sense to me.”  Access to clinical trials and whole genome sequencing, the reporting of [gene] panels, similarly are only available in certain geographic locations.

She added that policy makers should not be blinded by ‘shiny new toys’ when innovation can also be about doing existing things better – and notes that these ‘toys’ can drive inequalities in the locations where they are not provided.

Although there is much excellent data, it is not replicated across the board.  So, while innovations can empower some patients and reduce inequalities, Ms Kinloch said we need more real-world data and registries to inform such new ways of working, and input from patient experts, particularly in rare diseases. Sadly, as Prof Sullivan concluded, all too often patients are seen as passive users of innovation.

How the media sees innovation

Journalist Deborah Cohen, former Science Editor at ITV News, and now Senior Visiting Fellow at LSE, said innovations in diagnostics and screening had led to multi-cancer early detection tests, available widely to consumers. But these topics, she said, were ‘one of the hardest thing to report on…. with false positives, false negatives, positive predictive value, sensitivity, specificity… being able to communicate that is a real challenge.”

It is equally difficult, she continued, to report on the mainstream media and question innovation when a celebrity gains traction regarding an issue which has limited evidence. She added: “When a patient group comes to you, arguing for an intervention, and there's possibly a lack of robust evidence, it's hard to push back.”

Ms Cohen touched on the issue of sustainability and impact on the NHS.  If consumers cannot afford further care in the private sector when consumer screening tests indicate a concern, they will turn to the public sector. For those who cannot afford the tests in the first place, who might more deserving than the ‘worried well,’ this can drive further inequality.

Investment and support in medicines

Richard Torbett, Chief Executive of the Association of the British Pharmaceutical Industry, and a former economist, said there was a lot more innovation to come in terms of cancer medicines, if investment and support is available. He said: “Innovation can be sustainable, as long as we have good policy frameworks and decision-making frameworks to support it. And that's difficult.”

He said of the new molecular entities that were approved by the European Medicines Agency only 28% were approved in the UK, for a restricted population, and 35% were not made available at all. That compares with Germany, where 90% of all new molecular entities are fully available. That makes innovating medicines here far less likely.

For innovation to succeed, there must be two elements - scientific opportunity to do something useful, and market demand, with adequate payment, he argued. If there is the first without the second, as with new antibiotic development to combat antimicrobial resistance, it will fail.

Implementation lagging behind

All too often, people who implement innovation have no experience of using the services targeted, Bernard Rachet, Professor of Cancer Epidemiology at the LSHTM, who leads the Inequalities in Cancer Outcomes Network (ICON) group, said.

Dr Rachet, a doctor turned epidemiologist, said instead it should be led by those who work within and use the NHS, who understand the real-world context. He called for a strong national strategy coordinating the implementation of innovation, driven by population and patient needs, and by the best available evidence, rather than by the historical capacities of specific regions or hospitals, which tends to maintain or even widen inequalities.

For that to succeed we require a strong NHS, limiting the outsourcing of health services to the private sector. He said that should happen only under certain conditions, to bridge temporary capacity gaps, or for existing staff to acquire new skills, but there should have a defined plan to rebuild NHS capacity to avoid reliance on commercial companies.  

The importance of the right research and data to allow innovation to flourish was a theme that dominated the discussion. A cancer R&D ecosystem should span all disciplines integrating social sciences such as health economics, Health Policy and Systems research and implementation science.

Professor Ajay Aggarwal, a Consultant Clinical Oncologist at Guys and St Thomas’ NHS Foundation Trust, said this would provide the evidence to enable the necessary investments into infrastructure to pay for associated costs of innovation, such as more chemotherapy day unit space, more nursing staff and pharmacists when it comes to cancer medicines.

 “We have fantastic technologies and practice-changing studies – it’s not that there is no good innovation. We're just seeing time and time again that we're not implementing them correctly downstream…. so people are not receiving life-changing treatments,” he said.  

Dr Aggarwal, who is also Clinical Director of the National Cancer Audit Collaborating Centre (NATCAN) said it was critical that innovation was led by the needs of patients and clinicians but again, research was lacking in health inequalities and policy development to inform this.

Although the UK has the NIHR, he said there was a ‘shrinking federal funding for cancer’ in terms of research into topics such as how to make health technology assessments more effective, to reduce treatment variation, to centralise better. He said people were researching into robotics and better drugs, but yet lacking the fundamental research needed to ensure technologies become embedded within health systems to deliver the health benefits they are intended to. A lot of this research can be done at the time of the development of innovation.   

Novel solutions

In the audience debate a range of issues were brought to the panel, including where innovation should be sited, how can we make sure that innovation will bridge the gap in low and middle income countries than making it worse, and whether low-cost, high-value innovations such as ‘exercise, nutrition, healthy neighbourhoods’ could do more for the public good?

Dr Rachet notes that that, at the population level, most improvements in cancer outcomes observed in high-income countries are not driven by super-expensive, cutting-edge innovations. They largely reflect the complex organisation of health services and the core infrastructures to deliver prevention, screening, timely diagnosis, and timely treatment (even basic). This also depends on strong systems for data collection and analysis, which are essential for identifying needs, allocating resources effectively, and measuring the impact of policies.

Professor Peter Johnson, Chair of the Office for Life Sciences Cancer Goal, and National Clinical Director for Cancer at NHS England, commented that we want to have it both ways:  a command economy and central decision-making to ensure that we have absolute equity; and also local preferences to make sure that our particular populations are being effectively served.

So, what are solutions to some of these complex problems?  Prof Sullivan asked whether the NHS, pharmaceutical companies or the wider private sector had most influence in setting the innovation agenda? 

In response, speakers called for a more balanced approach and a more equitable platform for agenda setting with greater reflection of true need - amplifying the voices of NHS staff, patients, and communities.

Ms Cohen said the media, often seen as the eyes and ears of the public, played an important role and added that she as a journalist was often lobbied. Dr Aggarwal agreed, citing media influence in education about gut health. “Everyone here is aware of their microbiome, and probably they weren't more than two years ago.”

Mr Torbett said Governments had a prime role in agenda setting. “There seems to be a very significant, deliberate push on the part of many governments in the world to say to the industry, we want you to think more about prevention and population health,” he said.

He accepted that pharmaceutical companies do have ‘high level conversations’ with the Government but emphasised that society’s needs were central, with ‘good intent’ on all sides.

Dr Aggarwal said he believed impressive and useful solutions to system-level problems were coming from the bottom-up from clinicians, but it was much more difficult for them to get traction with policymakers compared with the marketing practices of industry. He said: “I'm amazed by the number of people from industry employed in external affairs, whose job is to lobby government to talk about their products.

He added despite his expertise in health systems, the likelihood of him or other clinical colleagues with relevant expertise meeting with a cabinet minister was low, which results in an imbalance in being able to set the policy or research agenda. “That is the issue for me.”

 Moving forward, biomedical research centres could play a more equitable role in pursing entrepreneurial ambitions of academics and clinicians, not just in individual teaching centres, but in a particular geographical patch, bringing industry and the clinicians together to work at speed.  Scale-up could be achieved by having 6-8 national hubs based around teaching hospitals, carrying out pipeline testing, whether it's a medicine, an AI-related technology or a medical device, Dr Aggarwal said.

In conclusion, the speakers gave a final thought on one thing to change to improve the likelihood innovation is going to be sustainable and equitable. Evidence-based policymaking; co-production in the implementation of innovation, with real world data; a strategic approach to overall allocation of NHS resources; and the consideration of low-tech, low-cost innovation were all highlighted.

Significant methodological advances have been made in policy implementation science, the evaluation of complex systems, and real-world evidence. Dr Rachet said: “It would be a missed opportunity for health authorities not to draw on this expertise to ensure the sustainable and equitable implementation of cancer care innovation.”

In the final intervention, Ms Kinloch received applause for her appeal for a ‘shift of thinking’ and to get everyone round the table, not just ‘most people,’ to discuss these issues.

“It's a case of doing the hard work to reach them in whatever way they need to be reached, and capturing their data, their stories, so it can be included in all the thinking.”

Source: The Institute of Cancer Policy