Memorandum submitted by the Institute
of Cancer Research and The Royal Marsden NHS Trust
1. The Institute of Cancer Research and
the Royal Marsden NHS Trust together form Europe's largest centre
of cancer research excellence. We enjoy a wide range of funding
sources and relationships with many cancer charities. This ensures
diversity in our research and that the best possible treatments
reach the patients.
2. THE OVERALL
RESOURCE IN
CANCER RESEARCH
IN THE
UK
2.1 The cancer charities have made it possible
to be extremely strong in certain areas. Cancer charities provide
far more than research, particularly carer and patient care, support
and information. The smaller cancer charities may provide specialised
services to patients and scientists, which would not otherwise
be available, but such small charities can find it difficult to
obtain adequate peer review of the research proposals that they
receive. Mechanisms that helped to ensure that all charitable
funds are expended on high quality science would be welcome.
2.2 The overall level of funding for cancer
research in this country should be increased. When one considers
particular diseases, perhaps most notably prostate cancer, the
low levels of spending by all agencies lead to a failure to seize
clear research opportunities. The Institute is currently mounting
a major initiative in this disease and strongly advocates the
Government playing a much greater role in ensuring high standards
of treatment and in co-ordinating research (see Annex 1).
2.3 It is essential that the Government
reviews the opportunities for increasing support of cancer research,
for example by encouraging corporate sponsorship or considering
the possibility of matched funding. Such funds could be valuably
applied to Research Council budgets and also to NHS R&D programmes.
This would help to ensure that appropriate funding is applied
to areas that are currently undervalued.
3. ORGANISATION
AND CO-ORDINATION
OF UK CANCER
RESEARCH EFFORTS
3.1 A sensible diversity of research funding
sources is healthy for the advancement of scientific research
in the UK. We are in no doubt that the creation of a centralised
funding function for cancer research would work against the scientific
interest, impacting on patients in the UK and across the world.
3.2 We are aware of the argument that the
diversity of cancer charities may not be the most efficient form
of working but in our extensive experience there is no doubt that
this diversity allows for the co-existence of several complementary,
distinct strategies for taking forward research work. This maximises
the chances that innovative scientists and clinicians will find
appropriate support for their work and creates an environment
where many strands of research can be pursued and shared simultaneously.
3.3 Our own research strategy is firmly
based on the principle that, by bringing together work funded
by many bodies in one comprehensive cancer centre, we will maximise
the outcome for all. In this way we can provide leadership within
the sector. The success of this strategy is evidenced by:
— the recent discovery of the first
gene implicated in familial testicular cancer. This resulted from
a ten year international collaboration which in this country was
funded by the Institute, The Cancer Research Campaign and the
Imperial Cancer Research Fund;
— an ongoing programme in anti-cancer
drug development supported by the Institute, the Imperial Cancer
Research Fund, the Ludwig Institute for Cancer Research and industry.
4. BARRIERS TO
TAKING FORWARD
BASIC RESEARCH
INTO THE
CLINICAL ENVIRONMENT
4.1 Links between research and the clinic
are essential to developing skills, transferring science to the
clinical environment and encouraging complex research-led solutions
through tackling challenging cancer cases. We applaud the Government's
prioritisation of research and science in cancer care, which is
essential if the science is to get into the clinic. At present
taking basic research discoveries to the clinic is made difficult
by:
— the shortage of clinical academic
posts and the problems in funding both training posts and substantive
appointments in academic medicine, as assessed comprehensively
in the Richards Report;
— the lack of mechanisms for ascribing
responsibility for the costs of clinical research treatments.
4.2 Within the Health Service, it is difficult
to develop the clinical academic's role, as they often have a
lower clinical service load than NHS colleagues and therefore
do not contribute as much to patient care contracts. Within the
University Sector, they are seen as relatively expensive compared
to non-clinical scientists, again as they are able to contribute
only a proportion of their time to research since they often have
service commitments as a consequence of their NHS role. Clinicians
need to have "ring-fenced" research time, which is publicly
valued within the NHS and also opportunities to up-date their
skills; lifelong learning is as important for researchers as for
other professionals and benefits both scientific and health service
communities.
4.3 In additional, more resource must be
steered towards training. UK training levels are markedly lower
than those in Europe and other countries, in spite of the fact
that we have a world leading science base.
5. THE NUMBER
AND DISTRIBUTION
OF CENTRES
OF CANCER
RESEARCH EXCELLENCE
5.1 It is tempting for some to encourage
administrative neatness in the organisation of cancer research.
However, this does not necessarily provide good science or value
for money. Scientific freedom is enabled and encouraged by the
number of centres of cancer research excellence in the UK, leading
to world class standards of research. We believe that the UK should
exploit the advantages inherent in its diversified funding structure
and in the several centres of excellence that it possesses.
5.2 Mechanisms to aid further collaboration
between organisations and institutions could be valuable. It might
be sensible to consider the French, rather than the American,
model in which a Federation of regional Cancer Centres provides
an opportunity for national co-ordination and co-operation. These
Centres work together under a defined constitution, participate
jointly in clinical trials and follow commonly agreed, evidence-based
clinical practices.
5.3 A system by which government provided
funding to facilitate such interactions between regional Centres
might well provide increased value for money in some areas. We
therefore support the need for a review of the number and distribution
of centres of excellence in cancer research to ensure that the
appropriate infrastructure and critical mass are available.
6. A UK NATIONAL
CANCER INSTITUTE
6.1 The desirability or otherwise of a National
Cancer Institute (NCI) is difficult to evaluate without knowing
exactly what the advocates of such an Institute have in mind.
However, on the assumption that any such body would seek to centralise
cancer research funding and research projects, we would tend to
oppose such a proposal. We would, of course, be open to consultation
on any proposals and be happy to contribute to the debate.
6.2 The United States' NCI is often put
forward as a role model, but it seems to us to be unlikely that
sufficient funding will ever be available to construct an enterprise
of that sort in the UK. In addition, the lead time required to
establish such an Institute would be considerable, and the ensuing
paralysis of other initiatives would lead to many lost opportunities.
6.3 We fear that the creation of a UK NCI
would only serve to add another layer to the existing system of
regulation and administration and would not necessarily bring
any scientific benefits to the UK. We note that the Institute
has isolated more cancer genes than any other single research
organisation worldwide, and that it has brought two new drugs
to the clinic in the past decade, while the US NCI has brought
none despite its enormously greater resources.
6.4 It will be important to openly examine
all of the options in order to ascertain whether an NCI, or the
French model referred to above, or some other model would provide
the optimal environment for cancer research in this country.
7. DEVELOPMENT
AND CLINICAL
TRIALS: INDUSTRIAL
INVESTMENT AND
BARRIERS TO
TRIALS
7.1 An entirely new phase of anti-cancer
drug discovery will soon be with us. Through the forthcoming availability
of the sequence of the human genome, an unparalleled opportunity
for cancer research and treatment development will be created.
7.2 The Institute-led Cancer Genome Project
has attracted extremely generous funding from The Wellcome Trust,
and will be further supported by several cancer charities, including
the Institute and the Royal Marsden. This project will generate
a complete molecular pathology of cancer. We will know for the
first time exactly which genes are involved in many, perhaps most,
human tumours. This knowledge will identify the targets for therapeutic
intervention and will lead to an entirely new phase of anti-cancer
drug discovery.
7.3 It is of the utmost importance that
the UK is properly positioned to evaluate these new drugs in the
clinic. This will require the provision of infrastructures in
the NHS that support the drug development and clinical trials
processes from initial Phase I investigations through to large-scale
Phase III trials of efficacy and cost-effectiveness. Any reduction
in NHS R&D funding for centres like the Royal Marsden will
significantly impact on clinical trials and other cancer research.
7.4 The process for gaining approval for
clinical trials should be faster and more streamlined and the
funding of new high cost treatments must be addressed nationally
in the interests of equality and improved outcomes for patients.
7.5 Consideration should be given to the
automatic provision of extra resources to oncology centres entering
patients into clinical trials with the aim of markedly increasing
the percentage of adult cancer patients entered into randomised
trials. Last year some 70 per cent of children with cancer were
on national or international trials. It is noteworthy that this
remarkable achievement by the United Kingdom Childhood Cancer
Study Group was achieved almost entirely on the basis of charitable
funds. The Government should seek to ensure that a similar percentage
of adult patients participate in trials. This would lead to improved
patient care.
7.6 Industrial investment in the development
and trials of anti-cancer drugs should be encouraged. Clinical
trials prove very costly past the initial stages, and developers
need incentives to take the science through to the patient as
effectively and speedily as possible.
8. THE VALUE
AND STATUS
OF RESEARCH
AMONGST NHS CLINICAL
ONCOLOGISTS
8.1 The effective exploitation of the opportunity
to develop new therapies (presented by the availability of the
human genome) will require the training of a new cadre of clinician
scientists. They must be fully trained in both medicine and science
and posses the skills required to lead programmes of "translational"
research which convert discoveries made in the laboratory to tangible
patient benefit.
8.2 Much can be learned from the success
of the United States in this area. The introduction of formal
joint training schemes—M.D./Ph.D. Programmes in U.S. parlance—should
be considered. It would be highly cost and time effective if,
as in the U.S.A., clinicians could partition their clinical and
laboratory time in large blocks, weeks or months, rather than
half-day sessions. As the subject advances rapidly, it is also
important to provide opportunities for re-training in mid-career.
As stated above, the Government must enable this essential re-training
and research work to take place, or risk UK clinicians and scientists
being left behind their US and European colleagues.
9. THE APPLICATION
OF NHS R&D FUNDS
TO CLINICAL
ONCOLOGY RESEARCH
9.1 The Central NHS R&D Committee provides
funding for service support for clinical research undertaken within
the NHS. However, the cost of treatments within trials is a significant
marginal cost to an individual Trust. These costs are specifically
excluded from central support funding, when they should not be.
Government should ensure that full funds are available for prioritised,
peer-reviewed national Phase III trials.
9.2 At the same time, purchasers of health
care are reluctant to contribute to clinical research treatments,
since their value to the patient is unproven. This is a particular
problem in assessing the role and value of recently licensed anti-cancer
drugs and it is hoped that the National Institute for Clinical
Excellence will be able to take this on board.
10. CONCLUSION
The Institute and the Royal Marsden comprise
a world-class research and teaching institution, with a record
of achievement which has been enabled by a wide range of charities,
companies and government funds. We hope to maintain and improve
on that record of excellence, and trust that government policy
will support us in our endeavours.
10 March 2000
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