APPENDIX 8
Memorandum submitted by Professor Terry
Hamblin, Professor of Immunohaematology, Southampton University
1. DEFINITION
1.1 It is sometimes forgotten that cancer research
comprises a wide array of activities carried out by a variety
of differently skilled individuals. Among these are epidemiologists
and statisticians (who may rely on environmental pressure groups
for hypothesis generation), cell biologists, immunologists, molecular
biologists, information technologists, chemists, phamacologists,
geneticists, x-ray crystallographers, pathologists, haemotologists,
virologists, microbiologists, biochemists, cytogenticists, physicians,
surgeons, gynaecologists, medical oncologists, clinical oncologists,
radiologists, radiographers, palliative care specialists, psychiatrists,
psychologists, nurses and industrialists
2. ORGANISATION
2.1 Much cancer research cannot be distinguished
from other basic biological research. It is not specifically cancer-directed.
Such enterprises as the human genome project will undoubtedly
have spin-offs for cancer, but they are not primarily so directed.
Monoclonal antibodies are a by-product of the investigation into
how antibody diversity is achieved.
2.2 The great pharmaceutical companies conduct
much cancer research. An example might be the development of tyrosine
kinase inhibitors that threaten to make bone marrow transplantation
for chronic myeloid leukaemia a thing of the past. The pharmaceutical
companies work closely with both basic researchers in universities
and with clinicians. Although a good proportion of this work is
done in the UK, it is important to recognise the international
nature of research. National barriers are irrelevant.
2.3 There are important cancer research
institutes in several localities. A national cancer institute
that downgraded these institutions would face fierce opposition.
Some types of cancer research benefit from a mass effect and the
ability of scientists from different backgrounds to exchange ideas.
In many American institutions the ability to walk into an adjacent
lab, to have a coffee or lunch together, to attend seminars in
an adjacent field all facilitate the generation of hypotheses
and the design of experiments. It is largely lacking in the UK.
2.4 Cancer research conducted in the absence
of clinicians is often aimless. Clinicians often make poor scientists,
but scientists make poorer clinicians. Close collaboration produces
the best results.
2.5 Recent news items threaten to produce
extra regulatory hurdles for researchers. What exactly is the
status of pathological material? Does specific permission need
to be sought for every possible use of every blood sample? Much
material has been stored for future use when more informative
tests become available. Is it all to be trashed? Regulation of
animal experimentation is becoming oppressive. Regulations are
applied differently by different animal inspectors. Recently,
experimenters had to move from Leicester to London because experiments
that were disallowed in the first were permitted in the second.
3. FUNDING
3.1 In contrast to the USA, in the UK research
into cancer is largely the province of the Cancer Charities and
not central government. By the late 1980s more than 90 per cent
of finance for cancer research was provided from charitable sources
(CRC, ICRF, LRF, Tenovus, Marie Curie etc).
3.2 MRC funding was artificially inflated
under the previous administration by transferring UGC money to
the MRC and then allowing Universities to claim 40 per cent on-costs
on MRC grants. The intended effect was to ensure that Universities
conducted high-quality, peer-reviewed research. In real life UGC
money was recycled but now with an imprimatur of quality.
3.3 Cancer charities are unwilling to fund
University on-costs.
3.4 The MRC is reticent about funding cancer-oriented
research, recognising that non-cancer areas are less well supported
by charities.
3.5 Universities do not welcome cancer research
grants in the same way that they welcome MRC funded grants, because
they do not bring with them on-costs.
3.6 Universities treat cancer researcher
less kindly than other scientists because they do not deliver
on the on-costs.
4. NOMENCLATURE
4.1 In the UK the organisation of cancer
treatment is different from other Western countries.
4.2 The difference is historical, deriving
from personal quarrels at St Bartholomew's Hospital in 1950s.
At that time, chemotherapy was in its infancy and almost exclusively
used for the treatment of leukaemia and lymphoma. Haematologists
and physicians quarrelled over who should treat these diseases.
Whereas in the rest of the country a new breed of Clinical Haematologists
developed, at Bart's the specialty of Medical Oncology was introduced.
When, in the 1970s, the CRC and ICRF funded chairs of Medical
Oncology in several provincial universities, graduates of the
Bart's tradition filled most of these posts.
4.3 In America and in most of Europe, this
artificial distinction is absent and the person who treats these
diseases is known as a haematologist/oncologist.
4.4 Cancer other than leukaemia and lymphoma
has traditionally been unresponsive to chemotherapy, although
it responds in part to radiotherapy. Its treatment has therefore
been the province of the radiotherapist. As these diseases have
begun to show better responses to drugs, the administration of
chemotherapy has become part of the training of radiotherapists,
and they have changed their name to clinical oncologist. There
remain many radiotherapists of the old school who are uncomfortable
with the administration of chemotherapy.
4.5 In the UK there are about 350 haematologists,
100 medical oncologists and 350 clinical oncologists. In the country
as a whole, by far the majority of patients with leukaemia and
lymphoma (which are the types of cancer most amenable to treatment)
are treated by haematologists. In addition, many surgeons and
chest physicians administer chemotherapy to individual groups
of patients (patients with bowel and lung cancer, respectively)
4.6 In all calculations that are designed
to demonstrate how short of cancer specialists is the UK, the
haematologists are not counted. This is either because there is
an ongoing turf war or because it is in the interest of those
who stress that cancer is underfunded to present their best case.
It is very important when making international comparisons to
compare like with like.
5. CLINICAL TRIALS
5.1 The randomised controlled clinical trial
is a device for discovering small differences between treatments.
It was pioneered by the MRC. Early successes include the treatment
of tuberculosis.
5.2 The MRC has been conducting clinical
trials in leukaemia since the 1960s. The success of this enterprise
can be adduced by comparing survival figures for the initial and
latest MRC trials. In 1966 the average survival for childhood
acute leukaemia was 10 weeks and for adult acute leukaemia was
six weeks. Currently, over 70 per cent of children with acute
leukaemia are cured and over 40 per cent of adults under 40 are
cured.
5.3 Over 90 per cent of children and over
60 per cent of adults under 60 with acute leukaemia are entered
into MRC organised clinical trials. No clinical trials for solid
tumours achieve that degree of commitment from medical or clinical
oncologists.
5.4 A startling observation from these trials
is that haematologists in district general hospitals achieve as
good or possibly slightly better outcomes in treating acute leukaemia
than do specialists in teaching hospitals. This is contrary to
the accepted wisdom that rare and difficult diseases should be
treated in specialist centres where large numbers of cases are
seen. Rather, the conclusion should be that patients should be
treated in centres where there are adequately trained staff and
national protocols are strictly adhered to.
5.5 Calman Cancer Centres are where they
are because of the huge cost of radiotherapy machines. Several
are centred in hospitals with inadequate clinical services (no
intensive care, no surgery, and no haemodialysis). Although some
are admirable in their ability to conduct clinical trials, many
have a service commitment so large and so poorly funded that they
have little time to organise clinical trials. Oncologists might
profitably apply the model developed by haematologists for the
conduct of leukaemia trials.
1 March 2000
| 
