November 2011 podcast transcript

This month we bring you news from the National Cancer Research Institute conference in Liverpool - the UK’s biggest cancer conference. Plus advice on diet and weight could help bowel cancer patients, research reveals that lifestyle affects the chances of suffering side effects from prostate cancer treatment, and we listen in on a discussion at the conference between two top cancer doctors, as they discuss cancer care on both sides of the Atlantic.

Welcome to the Cancer Research UK podcast. I’m Dr Kat Arney.

People who work in health care are failing to give patients crucial information about the link between obesity and cancer. That’s despite obesity being the biggest preventable cause of cancer after smoking.

Professor Annie Anderson and her team at Dundee University carried out several studies looking at how much guidance was given to bowel cancer patients about their diet, and how comfortable doctors felt discussing the issue.

Professor Anderson talked us through her results, which she presented at the NCRI Cancer Conference.

“In the qualitative work by cancer survivors, a very mixed bag of responses with some people saying they would have really welcomed very specific advice about diet, particularly in the immediate post-surgery period – being very uncertain what to eat, what their bodies could cope with.

But in the longer term, being uncertain about how physically active they should be – would it do them harm to start jogging, or should they be looking after themselves by being more sedentary? So confusion, inability to source appropriate literature about what they should be doing and find guidance on that topic – the nurse specialists they would see were not necessarily specialists in lifestyle, so [they had] the feeling that they were lost for guidance.

But also patients saying they ate very well and were physically active before they got the cancer, so why would that help them at all? We want to avoid the victim blaming – “oh they’re big and fat, they’re being picked on because they’re fat” – and recognising that obesity is a very sensitive subject. We had this patient say they would welcome advice to try and stack the odds against recurrence. We cannot say that by changing lifestyle we can absolutely prevent recurrence, but let’s try and do what we can to reduce the risk.”

Researchers have found that men with poor lifestyle habits are more likely to suffer serious side effects from prostate cancer treatment than those with healthier lifestyles.

Men who had radiotherapy for prostate cancer who walked briskly for more than two hours a week, played sport regularly or attended a gym, were twice as likely to have no side effects and normal sexual function after treatment as inactive men.

Professor Rob Thomas, who led the study, gave us his recommendations for men going through treatment for prostate cancer.

“If you get a diagnosis of prostate cancer, particularly if you need radiotherapy or hormones, get referred to the gym, buy a pair of training shoes and try and move more every day – at least 20 minutes every day if you can or about 3 hours a week.”

Blocking a key DNA damage repair enzyme, called APE1, could provide a new way to kill cancer cells with faults in specific genes. The scientists showed that switching off APE1 could target cancer cells carrying faults in so-called BRCA genes, but left healthy cells unharmed.

Although it’s still at an early stage, this discovery is being likened to the discovery of PARP, which is now targeted by drugs in clinical trials to treat women with inherited forms of breast and ovarian cancer.

Cancer Research UK’s senior science information officer, Nell Barrie, explains more about the discovery.

“What these scientists have done is looked at a new way to block DNA repair in cancer cells with faulty BRCA genes. We know that faulty BRCA genes already mean that the cancer cells are having a hard time repairing faults in their DNA, so if you block another pathway that helps them to do that, you’ve taken away that ability completely – they can’t repair their DNA any more and they’re not going to be able to grow and divide and cause problems in the body.

We’re hoping that this could be a promising way to treat cancers that are linked to faulty BRCA genes – things like breast cancer, ovarian cancer, and even some types of prostate cancer. And it could be a good strategy for treating these types of cancer in the future.”

And you can listen to a full interview with lead researcher Dr Madhusudan Srinvasan, from the University of Nottingham, in special Naked Scientists podcast broadcast from the NCRI Cancer Conference on the 6th of November. Just search the Naked Scientists website – that’s nakedscientists.com to find it. 

Finally, Professor Paddy Johnston, a Cancer Research UK scientist based at Queen’s University Belfast, caught up with Dr Murray Brennan, top cancer surgeon from America, at the NCRI Cancer Conference. We listened in on their discussion about the pros and cons of working in cancer care in the UK and the US.

PJ: I’m Professor Patrick Johnston and I’m dean of medicine at Queen’s University Belfast.

MB: And I’m Murray Brennan, from Memorial Sloan Kettering in New York City, where I was chairman of surgery for 20-plus years and now run their international programmes.

PJ: Murray, it’s a real pleasure. Obviously surgical oncology has moved dramatically over the last 20 years, and in a lot of ways you’ve been at the cutting edge, to use a pun. What do you think the big lessons have been in surgical oncology and where it’s going?

MB: the greatest advance I think is that we’ve made surgeons understand that they need to know more about what they do than [just] the technique. I don’t mean that they just need to know about radiation therapy or chemotherapy, they need to understand – which I think they now do – that getting the diagnosis right (which is highly pathology-dependent) is crucial.

PJ: So understanding the biology of the disease as well?

MB: Yes – we’ve said this phrase as many other have – biology beats technique every single time. But if you don’t understand the biology and you do the wrong technique, whether it’s what you do with a drug, or a radiation therapist, or us with a knife, it won’t work. And the second thing is that whoever’s looking after the patient has to have a very acute awareness of natural history – if you’re going to intervene in a disease process, and you don’t understand what the natural history is, you’re almost always going to get it wrong.

We want to put the multidisciplinary piece in when we’re deciding what is the appropriate care for an appropriate patient, and then we want when the patient walks in the door that happens. There’s a trend in the United States to say that the patient should come and have four of five different consultations during the day with four or five different disciplines. As a chairman that is totally cost-impossible – I cannot afford that. I don’t have the clinic space, I don’t have the people-power, so I actually don’t want that to happen.

So when people say “Oh we’ve got a multidisciplinary clinic and every single patient’s reviewed by 6 or 8 people at a time” I can’t afford it. So I think it’s naive to think I can afford it, let alone the confusion for the patient.

PJ: And I don’t think the patient wants it either. The other big thing that’s happened, especially over the last 10 years, has been the whole development of robotic surgery and imaging. What are your thoughts in terms of where we are now with robotic surgery and the difference it’s made, and where do you see that going in the future?

MB: It’s actually a real risk because we have young surgeons who are fascinated by the technology, and it’s very hard for them to place that technology in the context of it still being the same disease. There’s no question that the advent of minimally invasive, small incision surgery is a huge plus for many patients.

Robotics adds another dimension to that, but they key is to understand that it’s still the same procedure. It’s done with less morbidity, less side effects – that’s terrific – but it’s extraordinarily expensive, it’s commercially driven at the present time, which is another thing that’s a problem. There’s no question it’s here to stay, but somehow we have to bring it back.

It’s of great interest, for example, if you have a morbidly obese patient who historically to have a hysterectomy or a procedure would require a very large incision, often with significant morbidity. You take that patient and treat them with minimally invasive surgery or robotics, that women can have a hysterectomy and be home the next day or the same day. That’s a huge difference in consequences.

PJ: You’ve obviously got the albatross view in terms of what’s going on across the world in terms of cancer surgery – you’ve been heavily involved in leadership both in the United States but also you’ve been a global figure in cancer surgery.

MB: You know the UN has just had a meeting in which they’ve committed to cancer in underdeveloped countries, much as they did with AIDS just ten years ago. Look what happened when they brought a focus on AIDS, what a difference it made. So now there is going to be – not as quickly as we’d hoped – a focus on cancer in developing countries.

It is the emerging problem. As we get rid of infectious disease, then cancer becomes [a big problem]. And cancer in younger people – as we look at some of the demographics (and we don’t even know those very well), in some developing countries the cancers are often advanced, they often occur ten or 15 years younger than we see here. That’s exciting for me because surgery really has a role to play there.

We aren’t going to immediately put PET scanners in the middle of Uganda, but we certainly could put clinicians there, and clinicians who could educate others – not necessarily medical professionals but people who could make a difference. So I think it is a global problem, and I think it’s going to be more and more of a global problem.

What about here in the UK? Well the UK is a little bit like the US – you probably have the best of cancer care and ten blocks away you might have the worst of cancer care, so it’s how we provide a standard of care that reaches all of the populace. And you – as we have done perhaps 30 or 40 years ago – have a strong ethnic mix. You have pockets of the population that are new immigrants, as we do, and we are often culturally insensitive to their needs, as they are to our professional behaviour.

So it’s an exciting time to look at that. It’s not all going to be solved very easily. We’re beset by the financial difficulties as I mentioned – I think it’s tragic. The analogy I usually use is that the US individual pays about $7,200 a year per person for medical care. In Cuba – though I’m not arguing for Cuba – they pay $700. For a ten-fold increase in expenditure, we have a lesser life expectancy. That’s a problem. It’s not just a medical problem, it’s also a societal problem, but it’s a problem. And so we have to come to grips with some of those issues.

PJ: One of our big challenges that’s come through a lot of the cancer registry data and cancer intelligence network data is that it’s the clinical access, getting patients seen quickly, making a diagnosis in a timely fashion seems to be where the biggest roadblock is, and also the thing that’s going to have the biggest impact.

So one of the challenges in the UK is to make patients – and indeed society – more aware of what they can be doing to think about cancer early, and of course our general practice and primary care physician community to be thinking about cancer in terms of the symptoms that patients have. So that’s one of the big thrusts that is currently ongoing right across the UK.

MB: That’s an important one, because we know that minorities – in our case the African Americans – have worse outcomes for almost all cancers. When you begin to dissect that one of the major factors is access to good care. So it’s not just that they have (quote) “bad genes”, it’s that they have limited access to care, which is a problem. And the only way to do that is to move cancer care into the community.

We had a number of outreach programmes, for instance, in screening mammography for breast cancer. We thought we were being very altruistic in providing free mammograms to people, and of course what we learnt was that we can get the patients to come and have the free mammogram, but if the person communicating the results didn’t speak their language, or even more were unaware that within 6 months 80 per cent of those people would have moved from the address they gave the first time, so we’ve failed.

PJ: We have very similar things here, particularly in groups in the inner cities. It’s even down to language and cultural perceptions within communities – for example if you’re seen going into a mobile screening unit you’re suddenly stigmatised. So it’s really simple things in our society that make people afraid to take the initiative in a sense.

MB: It seems a shame that you can get your driver’s licence for a taxi driver in New York city at last count in 13 or 14 different languages, but your opportunity to see a doctor that speaks your language is miniscule.

That was Professor Paddy Johnston speaking to Dr Murray Brennan at the NCRI Cancer Conference. You can read more about the conference on our Science Update blog – scienceblog.cancerresearchuk.org, and we’ll be back next month with all the latest cancer news.