It’s time for the cancer community to come together. To come together in how it responds to the challenge of bringing the benefits of artificial intelligence to fruition in cancer care.

Professor Stephen Hawking was a thinker of vision respected across the world and across generations. Respected for his insights to share on all manner of topics.

Therefore, we should take note on those matters upon which he urged us all to reflect. On Artificial Intelligence he cautioned us that, “when considering the future of computer technology, computers will overtake humans with AI within the next 100 years. When that happens, we need to make sure the computers have goals aligned with ours.”

Artificial intelligence in cancer care is now well in fact past the realm of science fiction. It is here already. For instance some examples include:

• The use of AI to evaluate whether an X-ray is normal, allowing radiologists to focus their time more effectively on the analysis of abnormal images;
• Machine learning techniques to improve the identification of DNA mutations within cancers and even to forecast future genetic changes;
• A surge of start-up companies focused on using AI and machine learning to accelerate new drug discovery and optimal use of technology in surgery and radiation oncology.

AL into cancer

However, as might be imagined, and with Professor Hawking’s message much in mind, the introduction of artificial intelligence into cancer care is not without controversy nor unresolved issues.

For example, a report by STAT claimed so called ‘supercomputers’ have been making invalid conclusions about cancer treatment, raising concerns about whether healthcare professionals will be able to detect and prevent such new forms of potential error in treatment decisions. Equally, there is a need to manage effectively the shift in healthcare professional roles that must surely follow the introduction of artificial intelligence in the conduct of tasks currently conducted by humans.

As Co-Chair of the ECCO 2019 European Cancer Summit, I am convinced that the cancer community needs to come together in this case urgently to focus on this topic.

We must further shape our collective response to this irresistible force for change. And in so doing, shape the future well. We need to maximise the benefits of AI for cancer care, while simultaneously taking action to prevent unintended harmful impacts.

That is to say, to steal some phrasing from that Oxford mathematician whom I mentioned, we need to better align the goals of computers with those of the cancer community.

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We are standing in the cusp of a new dawn of personalised treatments. This could revolutionise the way we treat cancer – but a lack of investment threatens to hold Ireland behind.

Rapid advances in medical science mean we now understand more about cancer than ever. A new generation of personalised medicine stands at the ready.

But as innovation comes to a global head, a lack of clinical trial investment means Ireland risks getting left behind, said Professor Bryan Hennessy, Consultant Medical Oncologist and Clinical Lead at Cancer Trials Ireland.

He says: “Cancer treatment is moving towards a position where it’s based on a detailed understanding of the molecular abnormalities that drive cancer.

“Cancer is many different diseases and everyone’s cancer is unique. The more we see and understand these differences, the more targeted and personalised treatments we can develop.”

Clinical trials need more government funding

The only way to develop these innovative new treatments, he went on, was by conducting robust clinical trials – but a lack of government and Department of Health funding is making that increasingly difficult to do in Ireland.

“The biggest barrier to carrying out cancer trials at the moment is funding; pure and simple. We have a National Cancer Strategy that aims to increase the proportion of people with cancer who go onto trials, but we are going in the wrong direction.

“Cancer Trials Ireland have seen significant cuts, of 20%, in funding since the economic recession. The percentage of people we are able to put onto cancer trials is actually dropping.”

It means that Ireland risks being “left behind” in terms of the introduction of new treatments.

What’s more, it contributes to a disparity in the options available to people with the more common cancers, such as breast, lung and bowel, and those diagnosed with rarer forms of the disease, like pancreatic and kidney.

More focus on less common cancers is needed

Professor Hennessy explains that Cancer Trials Ireland, which runs most of the country’s oncology studies, relies on funding from the Health Research Board and generous donations from the Irish Cancer Society, St Luke’s Institute for Cancer Research, the pharmaceutical industry and philanthropists.

“Industry funding ticks most of the boxes for common cancers, because that’s where they get the biggest return. While the industry has its own policies to support independently run home-grown trials by funding Investigator Initiated Trials in research groups like ours, it’s the government and Department of Health funding that allows us to keep the momentum going in less common cancers and offer options to patients that have none right now.

“So, we’ve got this new generation of innovative treatments coming out for a certain number of cancers, but it’s not the case across the board,” said Professor Hennessy, whose department is currently working on treatments for common and rarer forms of cancer.

“People with cancer on cancer trials generally do better than those who are not”

It’s not just about planning new treatments for the future but improving outcomes today, he went on. Less money means fewer trials, which has the effect of blocking access to potentially life-saving treatments.

“If you’ve got a smaller proportion of people on cancer trials, you’ve got fewer people with access to brand-new, cutting-edge innovative treatments that have a good chance of improving the standard of care,” said Prof Hennessy.

“There’s no question that people with cancer on cancer trials generally do better than those who are not, so the potential impact of this is that the outcomes of people with cancer in the country would suffer.”

Want to be part of a clinical trial? Just ask!

Raising public awareness of the importance of clinical trials is a vital plank of the organisation’s plan to overcome this issue.

Launched as part of 20 May’s International Clinical Trials Day, the “Just Ask Your Team” campaign encouraged cancer patients to speak to their healthcare team about getting involved in research, for example.

“Clinical trials are the only way that we improve cancer treatments, the only way that we can prove that new treatments are better than standard or older treatments.

“They’re the only way to get new treatments safely and robustly evaluated in people with cancer so we can improve how we treat different cancers,” concluded Professor Hennessey.

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Lung cancer patient, Ann Baker, was told that conventional chemotherapy would not be suitable treatment for her disease. Thankfully, a drug trial yielded positive results.

One night in 2016, 70-year-old Ann Baker developed severe pain in her shoulder. “I went to my GP who sent me for a chest X-ray,” remembers Ann. “That’s when it was discovered that I had a tumour on my right lung.” It was devastating news and a complete shock, because Limerick-based Ann — a regular at the gym — wasn’t displaying the symptoms of breathlessness or coughing usually associated with the disease.

Worse was to come. Unfortunately, after having part of her lung removed, it was discovered that the cancer had spread to the pleura (the thin membranes covering the outside of the lungs), which meant the disease was stage four and unsuitable for conventional chemotherapy. “My brother and sister had survived cancer,” says Ann. “So I assumed I would sail through it, too.”

Experience of a cancer drug trial

Her oncologist suggested the possibility of receiving treatment from a trial drug; but more worry followed when Ann began developing double vision. At first she put this down to macular degeneration, but an MRI showed it was due to a small tumour on her brain. “Before I could receive the trial drug, I was told I needed radiotherapy to shrink the brain tumour,” she says. “Which it did, thankfully.”

Ann admits that she didn’t know much about cancer trial drugs, but had read about the experience of former US President Jimmy Carter, who had seen huge improvement in his cancer after going on a trial for a new immunotherapy drug.

She agreed it was the way forward and received her first treatment with a trial drug in January 2017. “It meant going to University Hospital Limerick every three weeks, which I was supposed to do for three years,” she says. “But after 13 months, I started experiencing side-effects including nausea and dehydration so I stopped receiving the treatment in March 2018.”

A way to help future generations

Even so, Ann considers the trial to have been a complete success and “wouldn’t hesitate” to do it again if necessary. “I’m stable and have been since the trial began,” she says. “And I feel great!

“I’m monitored with a CT scan every 12 weeks and a chest X-ray every six weeks. I’m 73 now and doing everything I did before. I don’t have children myself, but I do have nieces and nephews and cancer is so prevalent these days. That was another reason I decided to go on a cancer trial: apart from saving my own life, I saw it as a way to help future generations.”

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An explosion of technological advances and data gathering is taking personalised medicine to the next level.

When it comes to treating patients, there’s a general consensus that holistic care, where a patient’s complete needs are taken into consideration, is preferable. Until recently, this has been little more than wishful thinking.

Technology opening up potential

Technology is opening up the potential to completely rethink patient care. The catalyst driving this major shift is ‘big data’ or, as Mary Maguire from Roche – a pharmaceutical company innovating in the field of personalised medicine – more accurately calls it,  meaningful data.

There is a growing number of electronic medical records and patient repositories, so we have more information than ever before at our fingertips. But information in isolation is meaningless.

Intelligent analytics

Furthermore it’s the advent of machine learning and artificial intelligence that has opened up the opportunity for digital pathology and advanced analytics to better understand the links between genetic mutations, disease and the relevant treatments.

“It’s all about asking the right questions and then linking these mass repositories so, when we look at these data sets, the insights we’re getting can be applicable to a lot of patients,” says Maguire.

Cancers underlying genetic signature

Such information has already led to a shift in the way disease is categorised. In terms of cancer, we generally think about its location in the body – bowel, skin and breast, for example. However, with greater insights, physicians are now looking at the underlying genetic signature of the cancer and how that can be treated. This, in turn, is opening up new treatment possibilities.

Wearable tech and apps to support patients’ treatment plans

The personalisation of medicine has the potential to go even further than assisting diagnositics and treatment planning. There is now a plethora of wearable technologies and medical apps that have in fact made it much easier to track a patient’s ongoing health and response to medication

A physician may only see a patient every month, and yet, with wearable technology, they can track fluctuations in their health continuously. Such information can then be used to make appropriate adjustments to a patient’s treatment plan.

“We’re trying to leverage different sources of information that are available, so care is optimised at every stage for the patients,” confirms Maguire.

Sharing information across the health care sector is vital

Many healthcare teams are already taking a more personalised approach to care, but Maguire is under no illusion that industry-wide adoption will be easy.

The technology is indeed available, and much has already been deployed, but until there is connectivity – across hospitals, pharmaceutical companies, research institutes and beyond – its potential won’t be optimised.

“It can be overwhelming,” acknowledges Maguire. “But fundamentally we’re trying to make the patient journey and the physician’s journey with the patient as easy as possible.”

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Collaboration with all stakeholders is needed to ensure patients don’t miss out on potentially life-saving clinical trials in Ireland.

Ireland can become a European leader when it comes to conducting clinical trials. If we collaborate and focus on reducing delays and improving recruitment targets, according to the Irish Pharmaceutical Healthcare Association (IPHA). Research recently conducted by IPHA shows that, despite being home to nine of the 10 largest pharmaceutical companies in the world, Ireland is not currently as strong a location for clinical trials in comparison to similar-sized countries, such as Denmark.

Clinical trials are vital for boosting innovation

The research shows interesting results. For instance, on average, it takes about eight months to recruit the first patient into a clinical trial in Ireland. That figure is in detail based on 90 trials set up between 2013 and 2018 across 11 therapy areas and all four phases of the clinical development process.

This delay has in fact potentially far-reaching consequences. Most importantly for patients who are missing out on opportunities to access what could be life-saving medication. And also contribute toward the development of improved detection techniques and diagnosis.

Dr Itziar Canamasas, Managing Director of global life sciences company Bayer and IPHA strategy board member, explains the importance of clinical trials: “As well as the positive impact for patients, clinical trials enhance the value proposition for innovation on which Ireland needs to keep working to secure future global investment in manufacturing and discovery activity against significant competition.”

Following Denmark’s example

Furthermore, looking to Denmark, a country of similar size, it had approximately three times the number of registered studies at the end of 2018 compared with Ireland. Notwithstanding these higher numbers, it currently takes six months to recruit a patient into clinical trials in Denmark compared to eight months in Ireland.

Canamasas, on the other hand, sees no reason why Ireland can’t emulate Denmark’s success and become a more attractive location for clinical research.

Working together to realise a shared ambition

Canamasas is quick to point out that pharmaceutical companies alone can’t drive progress. Change requires commitment from a far broader cohort of stakeholders including, policy makers, hospitals, patient groups and university institutes.

To further the discussion on collaboration, Canamasas presented the IPHA survey findings at the Health Research Board – Clinical Research Coordination Ireland (HRB CRCI) conference on 13 May. Reporting on the conference feedback, she says, “There was a strong consensus that there is scope for us to further build Ireland’s credentials as a location for clinical trials and that this will require active collaboration among us all.”

Standardised clinical trial agreements

However, as a starting point, IPHA are proposing we look to implement standardised clinical trial agreements. These are already in place in a number of other EU countries. For instance that we protect research time for clinicians and hospital staff; and we use more realistic targets when starting clinical trials, this means meeting a lower recruitment target is better than partially meeting a higher target.

Overcoming challenges

The task in hand is considerable, but Canamasas believes Ireland has all the ingredients for success. “We have all the major international pharmaceutical innovation companies in Ireland. We also have highly regarded health professionals who are seen globally as key opinion leaders. There are positive signs that the public policy environment is shifting favorably to supporting this ambition for Ireland,” she says confidently.

ECRIN represents huge opportunity

Her position is buoyed by Ireland’s recent decision to join the European Clinical Research Infrastructure Network (ECRIN), opening opportunities for pan-European clinical trials which has the potential to give us access to large populations of patients and collaborations across countries.

Moreover, on a broader scale, there has never been a more exciting time for innovation within the pharmaceutical industry. Across the industry, new technologies, such as artificial intelligence, are opening up opportunities within clinical research. Such developments could help to support the new wave of clinical trials that Canamasas hopes to see in Ireland very soon.

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Snapshot from the Irish Association for Cancer Research annual meeting. Ireland’s premier cancer research conference brings together top Irish and international cancer researchers and patients to discuss progress.

Novel fields of research

Conventional cancer treatments such as surgery, radiotherapy and chemotherapy have been combined, for decades. This has been an effort to treat cancer patients. The emergence of novel fields of cancer research have in fact led to a renewed interest in combining conventional treatments with more innovative approaches.

The realisation that cancer progression is not exclusively due to changes in the cancer cells, but also involves changes in the tumour surroundings as well as in the immune system. This realisation has for instance opened new avenues for combination treatments.

Novel treatments were a focus point. These included: immune metabolism, epigenetic therapies and physical exercise. For example, the positive effect of physical exercise in combination with conventional therapies of cancer treatment. All stages of the cancer survivorship pathway highlighted this.

Tailor treatments

Novel technologies were presented to better tailor individual patient treatments. These included digital pathology and precision medicine.

The 55^th IACR conference presented several examples of these novel combinations. This is a shared platform for patients, researchers and clinicians. Survivorship and patients’ quality of life after treatment had a great emphasis.

Patient and public involvement at the IACR annual meeting

While clinicians have regular meetings with cancer patients, cancer researchers very rarely get the opportunity to meet them. At the same time, cancer research might seem difficult to grasp for the general public, including patients.

So, this years’ conference was opened with an award designed to encourage early-stage researchers to engage with the general public to talk about their research: ‘The Professor Patrick Johnston IACR Award for Excellence in Cancer Research Outreach‘.

Six researchers were in fact selected to present their findings. They had the hard task of presenting their research to the general public, including secondary school pupils. A judging panel and the audience then voted for the most accessible presentation.

Patients and researchers working together

The great success of this public session was in no small part due to a public engagement workshop held two weeks before the IACR meeting. During this workshop, pairs of researchers and patient mentors worked together to make science communication more accessible to the general public.

This workshop was a great occasion for patients and researchers to meet and talk to each other. It was especially useful for early-stage researchers who learnt to look at the bigger picture and to value what really matters to patients. The ultimate goal of the IACR is to improve the patient journey from diagnosis, through treatment to the lived experience of cancer.

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Surface guided radiotherapy (SGRT) is a technique that uses non-ionising and non-invasive camera technology to track patients’ surface in 3D. Both for setup and motion management during radiotherapy treatment delivery.

SGRT is a radiotherapy technique designed to improve the accuracy of patient treatment. During the treatment, a camera shines a red speckled pattern on the body surface of the patient to monitor exact positions for precisely targeted radiation. This process ensures that the treatment area receives the maximum dose of radiation therapy. While the surrounding, healthy tissue receives a much lower dose.

Initially this technique is available to certain categories of patients. Particular diagnosis determines eligibility for this technique.

Fewer permanent tattoos

All radiotherapy patients currently require permanent tattoos on their skin. This marks the area(s) where the radiation treatment needs to be delivered. During radiotherapy treatment, it is vital that radiation is administered to the same area each time. Therefore, marking the planned positions with a permanent tattoo eliminates potential errors in relocating the planned positions for future treatments.

Replicating exact positions on the body using cameras

The SGRT system will allow for a reduction in the number of tattoos given to patients. The SGRT cameras can reproduce the exact planned position. This system allows for real time monitoring of patient position so, if the patient moves during treatment, the radiation can be automatically paused until they are back in the planned position.

The aim in the future is in fact to become a tattoo-less centre for certain treatment sites. This would significantly reduce treatment time and improve the overall patient experience. Only by taking away these permanent reminders of their treatment and also their disease.

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Just 20 years ago – the cusp of the millennium – cancer in Ireland looked very different. Now, we have much to celebrate, but we must be proactive in our approach to cancer.

Two decades ago, four in ten people with cancer in Ireland survived their diagnosis. To the general public, the idea of preventing some cancer cases through vaccination was a distant dream. Cancer screening in Ireland was in its infancy, with breast screening in its early days.

Today, major innovations in oncology have changed all this. Now, six in ten people with cancer in Ireland survive their diagnosis for at least five years.

HPV vaccine is hugely effective

The safe and hugely effective HPV vaccine is saving lives of future generations from HPV-caused cancers. And, despite recent public controversies, our cancer screening services are saving more lives than ever since the expansion into cervical and bowel cancers.

Advances brought about by research empower us with the knowledge to make choices to increase our chances of not getting cancer.

The Irish Cancer Society has been working to spread the benefits of these advances through public awareness since its inception more than 50 years ago. But we’re also the biggest voluntary investor in cancer research in Ireland.

Public donations are so beneficial for research

The generosity of the public allows us to invest in research made vital because there is so much we still don’t know about cancer. Finding those answers is essential to stopping cancer, and as a well-educated and prosperous society, Ireland has the ability and duty to be front-and-centre in this work.

Mention of cancer often brings a sense of fear and foreboding but there is much in our own control to stack the odds in our favour.

Cancer screening saves lives

Screening is life-saving because, by detecting the pre-cancerous changes in our body that we know can lead to cancer, it gives us the chance to stop a cancer before it starts.

As cancer research looks into new ways that screening can save lives from cancer, health systems like Ireland’s, need to be ready to implement new screening tools as quickly as possible.

Saving an extra 350 lung cancer patients a year

Lung cancer is a case in point. Global research is pointing to CT screening as having the potential to spot lung cancer sooner among at-risk groups, thus potentially saving lives. By examining this research, the Irish Cancer Society believes that more than 350 lives in Ireland every year – effectively one person a day – could be saved by lung cancer screening.

As research in this area continues, we’re asking the government to put the infrastructure in place that can seize on opportunities that innovations in oncology like this can bring. The promised National Screening Committee, recommended in Dr Gabriel Scally’s scoping inquiry into our CervicalCheck programme, should give early consideration to the introduction of lung cancer screening.

As research in the areas of prevention and early detection continue, hopefully more positive advances of potential benefit to patients will be made. Through the National Screening Committee, Ireland has an opportunity to evaluate and seize on these opportunities and ensure as many lives in Ireland are saved thanks to these advances.

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