Hannah Turner

Senior Radiographer, Wexford General Hospital, IIRRT Council member

Radiographers and radiation therapists are at the heart of technological innovations of cancer diagnosis, staging, treatment and post treatment care.

At every stage of the cancer journey, patients interact with diagnostic radiographers and radiation therapists. This includes X-ray, CT scans, MRI scans, ultrasound, nuclear medicine or in cancer treatment in the form of radiation therapy.

The importance of imaging

Innovations in care have allowed for early diagnosis of cancer across the multitude of imaging platforms, from low dose CT scanning for lung cancer screening, or digital mammography and its enhanced cancer detection rates. Imaging is the eyes of cancer care and careful planning and execution of scans by radiographers provides the best diagnostic result with the least amount of exposure to ionising radiation.

Radiographers play a pivotal role in the delivery of efficient, compassionate and lifesaving care to all those on their cancer journey. Latest updates include clinical 3Tesla MRI scanners, photon counting CT and contrast enhanced ultrasound, further aiding in both the structural and functional information provided to the patient’s team.
The role of radiation therapists

Radiation therapists (RTTs) are centrally placed in the delivery of cancer care. RTTs are highly educated and skilled cancer experts who are fully integral to the delivery of radiation treatment to people diagnosed with cancer They are involved in the education of patients at the beginning of their radiation therapy journey.
RTTs prepare the patients for planning and treatment. They are present daily during treatment which can range from one treatment to six weeks. RTTs are uniquely positioned to encompass emotional wellbeing, provide holistic support and referrals to other health professionals as required as responsibilities of their professional role.

Radiographers play a pivotal role in the delivery of efficient, compassionate and lifesaving care to all those on their cancer journey.

Adapting practices for patient benefit

Aside from supportive care, RTTs are integral to the accurate preparation, planning and treatment with autonomy but within a complex multidisciplinary team (MDT). Innovations in cancer treatment mean RTTs continuously upskill by adapting practices for the benefits of the cancer patients. New innovations include MRI linear accelerators, SABR (stereotactic ablative body radiotherapy), DIBH (deep inspiration breath hold) for left sided breast cancers and HDR for prostate and gynaecological malignancies.

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There is an urgent need for advanced practice radiation therapists (APRT) in radiation oncology in Ireland.

Cancer incidence is expected to increase 50% by 2050, with 50% of those cases requiring radiation therapy. With the expected increased demand on radiation therapy services, there is an increased need for more radiation therapists (RTTs). RTT’s have a pivotal role with clinical expertise along the patient pathway in radiation therapy and are ideally placed to improve patients’ quality of care.

Use of APRTs in gynaecology

Endometrial cancer (womb cancer) is the most common gynaecological cancer in women between the ages of 50 and 64 years. Common symptoms are postmenopausal bleeding, which is the presenting issue in most cases. Treatment initially involves hysterectomy, or removal of the womb followed by internal radiation called brachytherapy. This treatment can be uncomfortable for the women experiencing it, both mentally and physically.

Literature documenting the importance of a reduction in delays between treatment preparation and delivery, was as a direct result of designated APRTs providing the service. Consistency in staff performing the procedure was also reported by patients as important and led to a more positive experience. APRT in gynaecology is one example of an area in RT where enhanced services are necessary and should be provided by APRTs.

Consistency in staff performing the procedure was also reported by patients as important and led to a more positive experience.

Improvements in service capacity

Countries such as the United Kingdom, Australia and New Zealand that have implemented advanced practice (AP) roles for RTTs, have seen significant improvements such as enhanced service capacity and improved patient satisfaction are documented. More than two decades of peer reviewed evidence supporting implementation of APRT exists.

Here in Ireland, these roles are being developed with support by the radiation oncologists and radiation therapy services managers, to improve the overall service for cancer patients undergoing radiation therapy. Engagement and investment by government agencies is essential as how best to implement the APRT role for the benefit of the patients and service alike.

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The fight against cancer in Ireland has gained some significant ground in recent years, but there is still plenty to be done to reform the system.

With over 30 years’ experience, Professor John Crown, Consultant Medical Oncologist, St Vincent’s Hospital, says there have been extraordinary changes and improvements in cancer treatment as a result of global research efforts. Among the results are substantial reductions in breast cancer mortality rates, particularly the HER2-positive form.

“I believe that is virtually entirely due to better treatments, rather than screening,” Professor Crown says. “I’m proud to say we’ve done a lot of research on this at St Vincent’s and in the research organisation formerly called the Irish Cooperative and Oncology Research Group (ICORG).”

Progress in immunotherapy

One of the biggest surprises is the success of immunotherapy, according to Professor Crown. “There have been extraordinary advances in the understanding of how the immune system interacts with cancer and how it can be changed.”

Overall, breakthroughs in the fight against cancer in recent decades have been striking, Crown says. “I’m very grateful that I’ve lived and practiced long enough to see the extraordinary changes in improvements in cancer treatment which have occurred as a result of worldwide methodical research efforts.”

I’m very grateful that I’ve lived and practiced long enough to see the extraordinary changes in improvements in cancer treatment.

Putting changes into action

However, progress is slower on some forms of cancer, including pancreatic and prostate. Professor Crown voices concern over the Irish health system’s ability to put some findings into action.

“There have been clear data showing CT screening scans for smokers and former smokers can dramatically reduce the chance of dying of lung cancer,” he explains. “It’s really promising, but we’re desperately badly set up to deal with it. In a country where you can be waiting six months to get a CT scan when you’re sick, how can we do screenings? Do we have enough radiologists and pathologists to read the tests? Do we have enough lung physicians and surgeons to do the follow up tests?

“We’re really behind the ball on this, and it will continue to fester until we fix the health service. All we’re doing at the minute is playing Whack-a-Mole.”

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Ireland’s global leadership in biopharma manufacturing is an excellent foundation on which to build a new leadership position in the development, manufacture, supply and adoption of advanced therapies and vaccines.

Over the last 15-20 years Ireland has established itself as a global leader in biopharmaceutical manufacturing and has had great success in attracting multinational companies to establish manufacturing operations across the country. Biopharma foreign direct investment (FDI) has topped €10 billion over the last decade, with over 40,000 people now directly employed in a sector that contributes over €40 billion in national exports annually¹.

The next wave of growth

It is predicted that advanced therapy medicinal products (or ATMPS) will become the main driver of biopharma growth over the next decade. They are a biopharma category that comprises a range of highly innovative medicines that includes cell-based therapies, gene-based therapies, engineered regenerative tissues and oligonucleotide-based (e.g. RNA) vaccines and therapies.

ATMPs treat diseases at a fundamentally molecular level and represent a potential step-change in the precise personalised nature of treatment and in the capacity to deliver a sustained disease response or even a cure.

Biopharma foreign direct investment (FDI) has topped €10 billion over the last decade, with over 40,000 people now directly employed in a sector that contributes over €40 billion in national exports annually.

The power of ATMPs to offer substantial long-term benefits for patients is exemplified in the story of Emily Whitehead, who became the first paediatric patient in the world treated with the engineered autologous cell therapy CAR-T for ALL in 2012, and 10 years later is cancer-free and living a normal life².  

An opportunity for Ireland 

The manufacture of these highly sophisticated therapies is complex, with the efficient and safe scaled-up manufacture of cell-based and gene-based therapies, in particular, presenting unique challenges. Building on our successful track-record in monoclonal antibody manufacturing, our existing infrastructure, experienced workforce and new investments, Ireland has a strong role to play in optimising and presenting solutions towards the efficient, cost-effective and safe manufacture of ATMPs.  

Future investments in ATMPs

NIBRT has recently commenced an expansion of its training and research facility in Dublin. The expansion is funded by a capital investment from IDA Ireland / the Government of Ireland of €21 million. It will create dedicated additional space, including an extra five laboratories and two new training suites, for training and research in cell and gene therapy manufacturing. The new facility is scheduled to open in the first half of 2023 and NIBRT is currently hiring additional principal investigators for its research team and additional training staff.

[1] https://www.idaireland.com/doing-business-here/industry-sectors/bio-pharmaceuticals
[2] https://journals.lww.com/oncology-times/fulltext/2022/03200/the_incredible_story_of_emily_whitehead___car.1.aspx

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The era of magnetic resonance radiation therapy began in the UK, when the first prostate cancer patient was treated with a new innovative therapy.

Back in September 2018, a 65-year-old patient became a medical pioneer, by volunteering to be the first in the United Kingdom to receive his radiotherapy treatment for prostate cancer on Elekta Unity. A revolutionary magnetic resonance radiation therapy (MR/RT) system that enables delivery of highly personalised radiation treatment.

Elekta Unity combines a state-of-the-art 1.5T MRI with an advanced radiation delivery system. The MRI provides superior visualisation of the day-to-day changes in the anatomy which enables the clinical care team to reshape the radiation dose for every treatment to account for changes in shape and position of the tumour and surrounding healthy tissue. It ensures an accurate dose is delivered to the tumour, while minimising the radiation dose to healthy tissue and surrounding organs.

Since MRI imaging does not involve the use of x-rays or ionising radiation, the care team can continuously image and monitor the patient’s anatomy throughout the treatment. This way the patient receives personalised treatment every day.

The MRI provides superior visualisation of the day-to-day changes in the anatomy.

Right patient at the right time

“The patient came along at exactly the right time,” recalls Alison Tree, MD, Consultant Clinical Oncologist at The Royal Marsden and Team Leader in Uro-oncology Clinical Trials at the ICR. “We began recruiting patients to participate in a clinical trial in July 2018 and we needed a first patient.

“I had discussed the study with the patient a couple months before because I anticipated he would be finishing the initial phase of his hormone therapy. Since he wouldn’t need long-term hormone treatments, had a relatively small prostate and no urinary symptoms, he was an ideal candidate.”

The Royal Marsden and the ICR were the third site in the world to begin treating clinically with Elekta Unity. There are now 45 systems in use around the globe and more than 4,000 patients have benefitted from it.

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Sinead Lawlor

Haematology Clinical Nurse Specialist, University Hospital Limerick

Building a network of nursing specialists is key to supporting the growing number of people who are both being diagnosed with and surviving cancer.

In the last decade, cancer treatment has changed dramatically. The increasing use of oral anti-cancer medication has taken care out of hospitals and into the comfort of patients’ own homes.

Through this community-based approach, patients are also benefitting from the support of clinical nurse specialists (CNSs) in the hospital who act as a link between support in the community and hospital. Many more patients are receiving specialist care in the community through tele-health clinics run by advanced nurse practitioners (ANPs).

But, as Fidelma Hackett, who leads an ANP haematology clinic in University Hospital Limerick, admits, there is still work to be done when it comes to understanding what this critical group of nurses do.

Understanding specialist nursing roles:

ANPs are specialists, with years of experience in their field and master’s degree level qualifications. Through regular clinics they do everything from prescribing treatment and managing medication to conducting examinations, and planning follow-up support with other healthcare professionals.

“Nursing by its nature is holistic,” explains Hackett. “At a clinic, yes, you’re looking for signs of disease progression and any side effects of treatment but you’re also looking at the social, economic and mental health of patients as well as quality of life.”

Sinead Lawlor, Haematology CNS at University Hospital Limerick, highlights the crucial role of the CNS in providing advice and support for patients during their cancer journey. “Patients can become daunted before their initial consultation. They can be anxious. We advocate and empower patients, helping to prepare them for, what at times can be, a difficult consultation especially when breaking bad news. Patients appreciate having a specific person they know and trust and someone they can call on later from home. We get great feedback all the time about that service.” 

As nurses, we are very close to patients so we hear their problems and can work to improve the solutions.

Sinead Lawlor

Putting patients first

“Everything we do is patient focused,” continues Hackett. “It’s about streamlining the services and getting patients where they need to be. As nurses, we are very close to patients so we hear their problems and can work to improve the solutions.”

Lawlor also highlights: “We coordinate patients’ care with different services, such as dieticians and physiotherapists, and are the link between the hospital and the community. We help to improve their quality of life in the community and reduce unwanted admissions to hospital.”

As survivorship improves and new medical and technological innovations are developed, it is inevitable that the role of specialist cancer nurses will become more and more central to every patient’s cancer journey.

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A founding member of the Irish Lung Cancer Community and lung cancer researcher at Trinity College Dublin, Anne-Marie Baird, discusses the origins, goals, aspirations and mission for a newly formed patient advocacy group.

How did the organisation come about?

As there is no specific lung cancer support group in Ireland, a group of us got together last year and formed the Irish Lung Cancer Community (ILCC). ILCC is a mix of people living with lung cancer, caregivers and people who are interested in advocating for the lung cancer community.

What is the situation with lung cancer in Ireland?

There are about 2,700 cases a year and 1,800 deaths. Lung cancer is the leading killer of males and females in Ireland, causing more cancer-related deaths than any other cancer type. Five-year survival is around 20%, which is very low compared to other common cancers, such as breast or prostate cancer.

Lung cancer is the leading killer of males and females in Ireland.

What is the vision and mission for the group?

Our vision is that all people impacted by lung cancer in Ireland will have the best chance of survival and live life as well as possible. Our mission is to be the united voice of people impacted by lung cancer and provide them with information, education and support. We also aim to work on promoting more positive perceptions of the disease and tackle the stigma associated with it.

What are the key goals to be achieved?

We want to empower people living with lung cancer to be involved in their treatment decisions and receive the best care possible. We also want to raise awareness about lung cancer, promote earlier diagnosis and ensure there is a strong patient voice around lung cancer services in Ireland.

How do people access and connect with the ILCC?

We have a Twitter handle (@LungCommunity), Facebook page and Instagram (Irish Lung Cancer Community) and our email address is irishlungcancercommunity@gmail.com. Please get in touch!

We have a virtual Fireside Chat on the first Thursday of every month, developed leaflets for hospitals/clinics and as we set up as a charity, we would like to hear from anyone who can potentially help us.

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Today, there is more hope than ever before for those who receive a cancer diagnosis. Patients have more options available to them to treat their cancers and are surviving for longer.

Despite the progress being made, cancer isn’t going away. The number of annual cases of cancer in Ireland is expected to almost double by 2040 and the situation has been further complicated by COVID-19 and the full impact it has had on Ireland’s health system.

The good news is that there is still much which can be done to support patients in the fight against cancer and the quality of care within our health service is improving all the time.

Improving cancer outlook

MSD have been in Ireland for more than 50 years and in that timeframe outcomes for cancer patients have dramatically shifted. New treatments, increased awareness of cancers and timely diagnoses have led to improved patient outcomes.

The patient is at the centre of all that we do at MSD. We are proud that our medicines are supporting patients in their battle against cancer throughout Ireland and across the globe.

Putting the patient first

Looking at some of the great innovations which have taken place to support patients, doctors are now able to target tumours with more than one treatment at once, using different mechanisms of action to increase the chance of a patient’s cancer being kept under control or even cured.

Treatments are also becoming more targeted as doctors can use biomarkers and gene sequencing to determine which patients have the best chance of responding to particular medicines. This not only increases the chances of a positive outcome for the patient; it also allows healthcare system resources to be used more efficiently.

Figures show approximately 45,000 people across Ireland receive a cancer diagnosis every year.

Innovations require access

However, innovation without access is meaningless. Despite making potentially life changing treatments here in Ireland, we’re still lagging behind many of our European counterparts. No patient should have to hear that a potentially beneficial treatments might be available to them if they lived in another country. Especially when many of these treatments are made right here in Ireland.

We at MSD, as well as the wider industry around us, recognise that innovative medicines can present affordability challenges to healthcare systems. We want to work with the Irish Government to come up with solutions that work for both patients and the health service alike.

Collaboration with patient organisations

We also regularly collaborate with patient organisations on campaigns focused specifically on raising awareness about cancer, particularly when it comes to cancer prevention. We have supported several campaigns to try and strengthen the voice of patients across Ireland by supporting health literacy and fighting the stigma some diseases and cancers unfortunately still carry to this day.

This includes working with the Marie Keating Foundation as co-sponsors of the Making Moments Matter campaign. The initiative saw patients and families from all over the country tell the stories of significant moments in their lives since being diagnosed with lung cancer or losing a loved one. Further, we’ve collaborated with NALA (The National Adult Literacy Agency) and the Irish Cancer Society (ICS) to produce several health literacy awareness videos to support cancer patients and their families.

Helping people through challenging times

Figures show approximately 45,000 people across Ireland receive a cancer diagnosis every year. A cancer diagnosis is news that nobody wants to hear and represents one of the toughest challenges a patient, their loved ones can experience in a lifetime.

At MSD, we are committed to supporting all those touched by this disease in any way we can. We firmly believe that the most important thing we make is a difference, which is why we are so passionate to remain at the forefront in the fight against cancer in Ireland.

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Professor Aedín Culhane

Professor of Biomedical Sciences (Cancer Genomics) in the UL School of Medicine, University of Limerick

The COVID-19 pandemic showed us that real-time data sharing is essential for health research.

Access to novel treatments through clinical trials can lead to improved outcomes for patients with cancer. Here, at University Hospital Limerick, we are partnering with our university and national networks to improve access for patients to novel treatments and new diagnostic platforms. Strong collaboration with the Limerick Digital Cancer Research Centre at the University of Limerick aims to embed data driven cancer research within our hospital. This will ultimately shift the research focus from the laboratory to the clinic.

Improving clinical trial recruitment

The Limerick Digital Cancer Research Centre All-Island eHealth Hub for cancer is a forward-thinking approach that hopes to improve recruitment to clinical trials by understanding the true demographic of cancer in the Irish population.

During the COVID pandemic, frontline health care workers in the Cancer Centres of Ireland witnessed the effects of limited services and delayed diagnoses. Recognising the importance of data intelligence in cancer, the e-health hub will directly address these challenges with data-driven healthcare. This program will facilitate tracking of cancer statistics in real-time by harmonising cancer data across the island and linking with global consortia.

The hub, funded by a €4 million grant under the Shared Ireland North South Research Fund, combines the strength of the Limerick Digital Cancer Research Centre and Cancer Research in Queens University Belfast and will study frameworks and international standards for sharing of electronic health data.

This is a great opportunity for patients in the Mid-West region to join the global research community.

International cancer collaboration

Professor Culhane’s ambitious, all-Island research programme with Professor Mark Lawler at Queen’s University, Belfast aim to link cancer data on the island of Ireland and connect Ireland to the international cancer community.

This is a great opportunity for patients in the Mid-West region to join the global research community, helping to save lives through the application of data science and digital health. Sharing data brings enormous benefits to Ireland as it provides the ability to leverage the knowledge of bigger countries, participate in global clinical trials that study new medicines in cancer and work together to develop better national, EU or global policy in disease treatment and prevention.

Promoting investment and collaboration

Expanded data sets including molecular tumour data will be built into this program. Professor Clifford states: ‘Data will save lives because access to accurate data will lead to more targeted clinical trial recruitment, which in turn will attract more investment from sponsors such as the pharmaceutical industry or international collaborative groups. Partnering with Cancer Trials Ireland and the Blood Cancer Network Ireland, we will promote greater investment in clinical trials in Ireland’.

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There are precious few good outcomes from the pandemic, but one of them is widespread public appreciation of clinical trials.

The appreciation is clearly reflected in the public response to two surveys about clinical trials that we undertook, one in 2020 and another in April 2022. It is unlikely that the public’s awareness, understanding and appetite for clinical trials has ever been higher. Here are the headlines:  

• Three in five (60%) people in Ireland would participate in a trial (48% in 2020). 
• Nine in 10 (88%) think trials are a good idea (72% in 2020). 
• Approximately 85% agree trials provide access to treatments that are not otherwise available (72% in 2020). 
• One in four (26%) would participate in a trial specifically to access treatments that are not otherwise available (15% in 2020). 

There are a number of solutions needed in overcoming the barriers to accessing cancer trials.

Overcoming barriers to trials 

However, there are a number of solutions needed in overcoming the barriers to accessing cancer trials, which unfortunately are numerous and structural.  

• We need to embed health research in health planning – so that the system values health research, and what it can do for patients and patient outcomes. 
• We need to resource research governance, so that hospitals, groups and the system as a whole actually has the staff and frameworks to support embedding health research in health planning.  
• We need to employ full-time data protection officers, give them proper training and support them with research governance officers.  
• We need to streamline and harmonise the data protection documents hindering clinical trials in Ireland right now.  

• We need to properly resource the Office for National Research Ethics Committees, so that trials can open in a predictable, timely manner in Ireland.  
• We need to offer protected time to the surgical, radiation and medical oncologists and haematologists who want to do research.  

Reaching cancer trial targets  

None of these problems have an easy solution. But they are what stand between us and enough clinical trials to reach the target of cancer patients on trials set in the National Cancer Strategy (6%). But while we press the Government for more investment in cancer trials, it is actually the people of Ireland themselves who have made new trials possible in recent years, through philanthropy and donations. However, we should not and cannot rely on public generosity to reach our targets. There remains a shortfall in public funding. Without it, we will never overcome the issues I described above and we will never hit our 6% target.

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