Highlighting Welsh Cancer Research

Cancer care in Wales - challenges and opportunities

Prof Malcolm Mason - Cardiff University, Cardiff, UK

I was asked to just give a brief overview and to just give you a couple of thoughts about challenges and opportunities with cancer care in Wales. These are just a few thoughts peppered with a few observations and facts here and there but the warning is that a lot of this is my opinion and I hope that where I am being maybe a little controversial it’s there to stimulate some discussion, stimulate some thought. As you’ll see from the programme we have a veritable line-up of stars and every one of them I would say, unlike me, is a proper doctor so you’re in very good hands today.

Now, Wales, the importance of being Wales as well as being Earnest. Of course this has been said many times but it is absolutely true – we may be small in size but NHS Wales is a single entity. We are not NHS England. We have our own structures. It really, really irritates me when I hear NHS Wales being slammed. I heard something on air on Any Questions on Radio 4 over the weekend where the defence for something poor happening in England is, ‘Ah yes, well at least we’re better in Wales.’ Well you know what? There are many parameters to performance of healthcare systems and if there are some in England which happen to be better in Wales there are an awful lot in Wales which are a damn sight better than they are in England. We are small, we’re a single NHS, we are well-connected and we are a community, we all know each other in Wales in a way which they cannot do in England. So I think there are some real opportunities there.

For all that we know that the NHS faces some unprecedented challenges and I’m not diminishing that at all. Yes, there are some major hurdles that we have to overcome but we have some real importance. In terms of the challenges and the sorts of things, well this is just a sort of everything; we’re not going to cover all of this. Cancer prevention is still something which surely challenges us all and must be something where we do better. Tobacco control is a huge concern but, of course, it’s all the other things – it’s diet, exercise, lifestyle as well. Early and timely diagnosis – we all know that that is a problem in Wales as it is a problem in other parts of the UK but we may be able to bring some peculiarly Welsh solutions to bear on this. Introduction of new technologies, and that’s not just drugs and therapeutics, it’s also introduction of new hardware; you’ve heard a little bit about it already. How do we get some joined up and holistic care? Actually we all know about some of the problems and it’s not only about getting joined up care between secondary and tertiary care, it’s about joined up care right the way back to primary care, the community, but it’s also community services and social care. It’s a challenge for the health service everywhere but it’s also a challenge for us in Wales.

Then another really important challenge, and something which I feel particularly keenly, perhaps, after the last couple of months is we have to train and we have to invest in the next generation. So it’s a real joy to see the strides that have been made in education and you’re going to hear more about that.

OK, let’s blow our own trumpet. We have some notable successes in Wales: we do have world-leading research in a number of areas. I’ve picked on breast, prostate, leukaemia and colorectal cancers, it’s not to say there aren’t others but there are some obvious and immediate things we can talk about there. We actually have good communication, I think, between the front-line services and government. I really think that’s true and I think that’s partly because of the structure, partly because of the motivation of our colleagues in government just down the road. It is very different. I always said, and I used to say to people who were in England, ‘You know what, if I really needed to see somebody in government, if I had a really good reason to want to go and see the Health Minister, I could probably do that in Wales; I bet you couldn’t do that in England.’ And I stand by that, I think that is still true.

We have some absolutely state of the art kit, really world-leading stuff. CUBRIC 2, one of the most powerful MRI scanners everywhere, it’s one of the most powerful in Europe and, of course, as Gordon has said, we have the proton facility coming here. Who would have thought it, little old Wales? There’s a real opportunity. We have this place, the Chris McGuigan Life Sciences Hub. We have the links to drug discovery, something that we have uniquely in Wales that also gives us the opportunity to work with colleagues in academia, in the funding bodies and in the commercial sector and that’s a huge opportunity. And we have international leadership, as you’ve heard, in teaching, in training and in cancer management. Gordon, thank you for mentioning the TNM which is a particular source that’s important to me.

Well, what about research and what about healthcare policy?  We do, at the moment, continue to have major clinical trial leaders embedded in Wales in the NHS sector and that is extremely important. It’s important, though, if we take advantage of it and that means that we potentially have very good intelligence and advance warning of some major trial developments when they’re coming. Of course in Wales we have the structure, the AWMSG, the All Wales Medicine Strategy Group, which is very, very powerful and again we have lines of communication with them. But we do need to ensure that our patients in Wales can continue to access state of the art treatment and that includes state of the art clinical trials which need particular infrastructure. It may be that it’s going to need particular sorts of molecular infrastructure and of the sort that you’re going to be hearing a little bit about later and that’s a challenge, I think.

Finally, we have to attract the best and the brightest people to Wales and we have to keep them here. I would stick my neck out and say that probably some of the best and brightest in England are a tad disaffected just at the moment in the medical profession. If we played our cards right we could make Wales a very attractive place for them to come and live and work.

It’s not all brilliant, of course, and here’s just a little case study which I happen to know something about. You won’t be able to read all of this but this was an announcement that we have, and never mind how the campaign was and who did it, but actually we’ve now got agreement that patients with metastatic prostate cancer in Wales can have access to chemotherapy first line alongside their hormone therapy. What you can’t see so well but in that circle there is the date of this and it was at the 15th August 2016. Why am I telling you this? Right, well, actually I and others tried to give a heads up on this when I first knew about this which was in April 2015 which was when we had the analysis from the MRC. This is not a criticism, I’m not being critical of any colleagues anywhere, I’m not being critical of colleagues in Welsh government, but I gather the response to the heads up, ‘You know, this is coming and it’s going to be a major impact on clinical practice and on patterns of patient care,’ and the response, I’m told, was a fantastic phrase which I could hear coming from another sector. I could hear Sir Humphrey saying, ‘Prime Minister, yes, Malcolm Mason’s always banging his drum, isn’t he? What is the provenance of this information?’ Now, the challenge to us is that’s our fault every bit as much as it’s anybody else’s fault. We have to persuade our colleagues in government that if we give them the heads up about something it is not Mason banging his drum for his own glorification, it’s because there is something genuinely coming along down the line and we have an opportunity to work early on it.

So I’m sticking my neck out again. OK, why don’t we propose some sort of provisional technology appraisal process that responds to that sort of intelligence? Because we could have done the meta-analysis, we could have got it in line. OK, yes, I know that the people who have done the trial should not be doing the meta-analysis but actually there are ways of doing these things. We could have worked with the MRC, they could have produced the meta-analysis within a matter of weeks that would have actually said very clearly, ‘This is coming, it’s going to be a major change in healthcare policy. Let’s start planning for it now.’ You don’t have to make a decision, you could make a provisional decision with boundaries. One of the challenges here was, of course, it was a conference abstract and yes, for all sorts of reasons, people don’t like making policy decisions based on a conference abstract rather than a peer-reviewed paper. But hang on chaps, if the conference abstract is a major multi-centre international clinical trial that’s been spearheaded by the MRC it’s not quite the same as a conference abstract that’s a single centre study on a cohort that’s not even randomised. So we’ve got to get some perspective on this. We may have an interim policy that can be implemented in a final policy, as before subservient to NICE of course. I think there are ways that we could do these things better.

Being joined up – I’ve mentioned the links between primary care, secondary, tertiary care, third sector but it’s also about joining the strands between diagnostics, molecular pathology, clinical informatics. We do have challenges in being joined up in terms of acute oncology and I think that’s something which is true not only here but is true elsewhere in the UK, elsewhere in the world. I do have a soft spot for bio-banking with my links to the Wales Cancer Bank but I do think there are opportunities for us to score a win in Wales. Why can’t it be a routine and what about opt out consent which is something that with colleagues and Ian being very supportive of this maybe this does have some traction.

I think we have to look forwards and we have to expect the unexpected. I can tell you for sure there are contingency plans somewhere for something like a chemical, biological or nuclear terrorist attack in Cardiff. God forbid, it’s a horrible thought. There are plans for that, why are there no contingency plans for developments where we will have major shifts in patient flow to or from oncology services, to or from other sectors in secondary care? Why not? I hope it’s a much more likely eventuality than a major terrorist attack in Cardiff but I think change is the new norm, things are not going to stay as they are.

I’m nearly finished. IT, I think, is both a challenge and a solution and Gordon has mentioned this already but I left my iPhone there. Why aren’t we taking advantage of the potential? It’s not rocket science anymore, there are all sorts of things we can get there in terms of monitoring health status, in terms of collecting the data, but in terms of having some sort of joined up IT solution. Yes, I’m not minimising it, I know how difficult it is but it must be easier in Wales than it is in other parts of the UK.

You’ve heard about TNM, the eighth edition of TNM is coming, it will be implemented from the beginning of next year. One of the major successes from UICC’s point of view, for which we are immensely grateful, have been the training modules that have appeared on the ecancer website. I just want to say, Katie, Gordon, thank you very much for your support in getting them out there. It’s viewed by UICC as a major success. Of course we are now going to have to go and change them and get it ready for the eighth edition but that is underway.