APPENDIX 53
Memorandum submitted by the Academy of
Medical Sciences
1. ADEQUACY
OF OVERALL
RESOURCE, PERCEPTIONS
OF THE
VALUE AND
STATUS OF
RESEARCH
1.1 The most critical component of resource in
cancer research in UK—and by far the most costly—is
the availability of high quality personnel. In particular, there
is need for medical scientists who both contribute directly to
patient care and also possess laboratory skills that enable them
to initiate and direct first-class research. It is on such individuals
that the translation of basic science into the clinic depends,
and from this constituency the future leaders in clinical cancer
research will be recruited. Experience—sadly mostly from
abroad—confirms that outstanding success in the understanding
and treatment of cancer begins to appear when clinical scientists
of this standing work together with first-rate biologists, physicists
and chemists in an environment in which the issues of the clinic
are not remote from fundamental laboratory science. Yet the evidence
is far from reassuring that we are investing efficiently in the
development of the young men and women who will deliver this resource.
1.2 Current provision for training in research
in cancer, pari passu with training in the appropriate
clinical service skills, rests on two elements. The first comprises
personal research training fellowships, some of which are offered
in nationwide competition by the Medical Research Council, ICRF
and the Cancer Research Campaign, at various levels of seniority,
to provide salary, research running costs and in some cases additional
staff. The second comprises established clinical lecturer posts,
providing salary only and funded in various ways from HEFCE and
NHS sources. As highlighted in the Richards Report, there has
been pressure (to which Clinical Schools have often yielded) to
reduce the number of clinical lectureships. This has been largely
because the short-term research productivity of these posts, when
filled by doctors in training for higher qualifications, is considered
less than can be delivered by full-time non-clinical scientists,
to whom the posts have been redirected. At the same time, the
candidates for cancer-related personal research fellowships have
often seemed disappointing in quality when compared both with
medically-qualified applicants for research fellowships outside
of cancer, and with non-clinical scientists seeking personal support
fellowships in basic cancer research.
1.3 The Academy has recently addressed the
problem of fostering clinical academic careers in general, but
it is worth considering briefly what factors may be responsible
for these disappointing trends in recruitment into clinical research
careers in cancer in particular. The Inquiry raises the question
whether one factor may be the value and status placed on cancer
research by NHC clinical oncologists. We do not think there is
a problem there. Rather, substantial understaffing places automatic
and inescapable priorities on immediate patient care and limits
capacity for research. This applies not only in clinical oncology,
but also in diagnostic specialities equally essential for cancer
care, such as pathology, haematology and medical imaging. Further,
when talented individuals do take up personal fellowships, usually
for periods of three years, postgraduate deans across the country
vary greatly in their readiness to generate a fresh specialist
registrar post and National Training Number (NTN) to sustain the
service interface. Without this, units with progressive attitudes
to research training are often penalised by attrition of their
specialist registrar workforce.
1.4 We suggest that one solution—perhaps
the single most important one—to the problems besetting
cancer research in UK lies in attention to enhanced recruitment
of high quality medical graduates into careers in which research
and clinical work can be combined in a realistic and mutually
supportive manner. This can only be done if there is adequate
staffing of the clinical service. We recognise that steps are
being taken to rectify the present oncology staffing situation
which is probably around 50 per cent the optimum. But we wish
to emphasise that similar understaffing also affects other specialities
(notably medical imaging, haematology and pathology) with major
roles to play in both research and service delivery related to
cancer. Training of the medical scientist leadership of the future
cannot be effected in an environment in which there is inadequate
basic provision on the NHS side.
1.5 Practically, several steps could be
taken in the immediate and medium term. First, the climate within
the relevant cancer-related specialties could be rapidly transformed
through increasing the NHS staff levels to provide an adequate
baseline of clinical care. Second, postgraduate deans should adopt
a nationwide policy of provision of extra specialist registrar
posts and NTNs to balance losses due to lateral movement of staff
into externally funded research training posts. Third, in view
of the current quality of recruitment into such posts it is probable
that the number and style of the present career development provision
offered by the cancer charities and the Medical Research Council
(MRC) needs little change in the meantime. This may need to be
reviewed upwards in the longer term. Similarly new schemes such
as Fellowships (or Return Fellowships) to attract both clinical
and non-clinical high flying senior cancer research workers from
abroad to strategic posts in UK should be considered. The MRC
has piloted such a scheme, and it may prove useful to earmark
a small number of awards of this type for cancer. It would be
vital, however, that such posts should be established in centres
in which a strong clinical service infrastructure is already in
place.
2. EFFECTIVENESS
OF ORGANISATION
OF CANCER
RESEARCH
2.1 The case has been made that the operations
of the major cancer charities in UK (ICRF and CRC) are sufficiently
complementary that there would be no advantage in fusion. Reference
is made to the extensive cross-participation between these organisations
in peer review. It has been argued that the charity income to
both, combined, would suffer relative to the present situation
in which the organisations compete for the public's generosity.
We consider this question to be finely balanced. There is still
an enormous degree of public confusion over the separate identities
of the two major charities: most donors are interested only in
the defeat of cancer. It is probable that this confusion is shared
by the majority of legators whose donations constitute some 70
per cent of the charities' income. There remains a case for exploring
increased interaction between the charities. Central bodies such
as UKCCCR and—perhaps—the new Cancer Research Funders'
Forum, demonstrate the feasibility of drawing the activities of
the MRC and cancer charities together in support of nationwide
activities.
2.2 It is essential, however, that cancer
susceptibility, diagnosis and treatment are monitored on a nationwide
basis: the move to establish a national MRC/NHS cancer database
is an important first step.
3. THE NUMBER
OF CENTRES,
NEED FOR
A UK NATIONAL
CANCER INSTITUTE,
ADEQUACY OF
NHS CENTRES FOR
TRIALS
3.1 We consider the number of cancer centres
of excellence in research to be about right. The important issue
is to work towards a situation in which these centres fully realise
their potential at the clinical interface, and this implies, as
discussed under (1) above, adequate infrastructural resource for
the clinical activities in terms of staff and equipment. Similarly
we do not see a clear role for a national cancer institution as
a physical and geographical entity. Good communications between
existing institutions would be enormously cheaper and as effective.
3.2 Clinical trials present a less straightforward
problem. Trial analysis is at its most powerful when numbers are
large and management internally consistent, a situation achieved
most easily through involvement of a small number of large units.
Recruitment to large trials is not a trivial exercise and tends
to be avoided by NHS units where staff are overstretched.
4. REGULATORY
SYSTEMS AND
COST BARRIERS
4.1 It is often said that substantial improvements
in cancer care could be made immediately if oncology units were
adequately resourced to implement treatments already approved
by regulatory bodies such as the National Institute for Clinical
Excellence (NICE), on the basis of knowledge that is already available.
We concur with this view, but point out that, again, the core
issue here is underfunding within the NHS sector rather than the
need to stimulate new research.
4.2 UK has often been successful in the
organisation of trials in cancer diagnosis and treatment, but
there are also tragic examples of initiatives lost through lack
of industrial interest at a critical early stage. Schemes such
as tax incentives for cooperation in clinical trials have been
suggested and are likely to be useful. ICRF, CRC and MRC all have
technology transfer companies, set up to facilitate uptake of
intellectual property by industry. This objective is of the utmost
importance, meriting the employment of talented and experienced
staff, but it is our impression that more could be done in supporting
the development of this activity.
4.3 While ethics approval for work with
patients has not been a problem, the licensing of animal experiments
has become labyrinthine in complexity. Cancer research often requires
analysis that can only be achieved through experiments on animals,
since many of the most serious aspects of cancer as a disease
relate to its growth within living tissues. In particular there
is need for a review of the Home Office requirements for licence
modification for animal experiments that differ only slightly
from one another.
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