NCRI Cancer Conference reports, communicating risks, and a lifetime of research
Kat: This is the Cancer Research UK podcast for November 2014. This month we’re reporting back from the tenth annual NCRI cancer conference, with a look at communicating cancer risks and a lifetime in research for scientist Ron Laskey. Plus our heroes and zeros.
Hello and welcome, I’m Kat Arney. This podcast comes to you fresh from the National Cancer Research Institute, or NCRI, Cancer Conference in Liverpool – a four-day gathering of hundreds of scientists, doctors, healthcare professionals, policymakers and patient groups, looking at some of the hottest topics in cancer.
To get a flavour of the meeting, I spoke to Richard Marais, director of our Manchester Institute and chair of the 2014 conference.
Richard: The conference is really to give a very broad view of cancer research. We go for breadth but we also go for depth. And so it's really multidisciplinarity. It's to give something for everybody – it's for clinicians, it's for scientist, it's for healthcare professionals, it's for patient advocates. So it's really to try and get an understanding of what's going on in cancer research for the UK market, but looking at the international scene.
Kat: And it's now the 10th NCRI conference. Happy birthday NCRI conferences! How has the conference been marking this? How have we been celebrating this 10 years?
Richard: We wanted to perhaps have a bit of the look back, and perhaps a bit of a look forwards. And so we had six celebrations lectures given by leaders in the field, who were really given free rein to look back and look forward and give us their thoughts – and these always turn out to be personal thoughts – on what we’ve achieved in the last 10 years. Some people went even further than that to what we've achieved in the last 30 years, and what we should expect over the next say 5 to 10 years. And I think that's been very helpful for at least framing particularly for the younger minds in the audience, and perhaps framing where they might like to see themselves in 10 years time.
Kat: And for you if it's possible to pick maybe one, two, a couple of talks for you that really stood out for you and need you think, wow that's great, or that's a problem, or that’s intriguing?
Richard: I prefer to not highlight one or two talks because all of the talks have been excellent quality. The plenary lectures have been superb, the celebration talks were superb, the symposia, the parallel sessions that I got to were all great, and of course the posters were really great. It was really busy down at the poster sessions, nice to see people discussing their data in a more informal setting. So trying to select one out of that makes it very difficult, because there were very many.
I mean, what we've seen is this meeting of minds from scientists all the way through to clinicians, healthcare professionals. And I think for me it's been that integration of thought from across the board. Having scientist listening to talk about behavioural sciences, and how patients might feel, and how they adapt to the news of the fact that they've got cancer. Perhaps having the people who think about patients more often understanding a little bit more about the science that goes on. I think that's where for me it's been a great conference.
Kat: Well, if very diplomatically you're not going to choose your favourite talk, perhaps if there were any key themes that seem to have emerged over the whole conference coming out of the research community?
Richard: Optimism. I think optimism is the key theme. I think people can see that were starting to win the battle. And having Mike Richards, for example, remind us where cancer treatment was in the UK 30 years ago gives you a sense of what we've achieved over 30 years and where we might go forward. Having a discussion about how we might implement personalised therapy and the logistics and the consequences, the costs, what that really means, what's the feasibility of doing that. People are starting to think about these things in a different way. How are we going to deliver the hope that we all have? How are we going to deliver the promise? I think that's what really strikes me about this conference.
Kat: It does feel like the tomorrow that we've been talking about for so long actually might be tomorrow, or someday very soon.
Richard: Hopefully. One always becomes a hostage to fortune when one makes these predictions, so I'm not going to. But I am optimistic, so I leave with optimism.
Kat: Richard Marais from the Cancer Research UK Manchester Institute. To get a more in-depth overview of some of the research presented at the conference, I caught up with Nick Peel who’s been helping to cover the conference for our Science Blog.
Nick: I thought the conference this year was really good, I really enjoyed being up in Liverpool. There was a huge amount of really interesting talks. A big thing that stuck out for me this year was about so-called liquid biopsies. Can we dig into what's inside the blood, whether it's tumour cells that have broken away and spread around the body or bits of DNA from those tumour cells – can we use those to diagnose the disease more effectively or just learn more about its evolutionary history?
Kat: There seemed to be a lot of talks about how cancers evolve and develop resistance to treatment, and about tracking them through time. I guess without invasive surgical biopsies, these liquid biopsies, these blood tests, would be a great way to do that.
Nick: Yeah definitely. And that did stand out from a number of the talks definitely that these liquid biopsies aren’t just a new way of doing something, they may actually a better way of doing biopsies. Something more friendly for the patient in the end, which is really important.
Kat: Any other key themes came from the talks that you want to?
Nick: I guess kind of picking back into that evolutionary idea, there was a whole section of the conference dedicated to this idea of tumour evolution and how genetic faults and tumours emerge over time and change, so that the tumour itself is actually a very different beast made up of all different types of cells. And we heard some theories about those origins of that evolutionary history, and how in some cases that may even be analogous to the theory of the Big Bang.
Kat: One of the things that I found really fascinating was more of the talks that are looking at using combinations of different drugs that almost head off the tumour's evolution before it gets going. You use one drug and then another drug and the tumour keeps on growing. You use them a different way round, the tumour keeps on growing. You use them both at the same time and it stops it dead. This is still early research but it does suggest that people are starting to identify the right combinations of drugs to get over this resistance that tumours evolve.
Nick: Yes, combinations really stood out this year of the conference as being a big thing for the future. The major challenge that comes from looking more at these combinations is how do we get – whether it's pharmaceutical partners, or different people in different areas of research - to work together collaboratively to make sure that ultimately those right combinations are made available for the patients with those different types of cancers who may benefit from having them.
Kat: Also there was a little bit of discussion about the price as well. Because some of these very targeted drugs are coming with extortionate price tags. There were some interesting debates about the pricing and access to treatments too.
Nick: Pricing is always going to come up when you're talking about cancer drugs, and this year was no exception. I think there was an interesting debate around the Cancer Drugs Fund, which is a hot topic in the media and will continue to be so. Getting those prices right, as you say, is really important.
Kat: But on the flip side we heard a lovely talk from Tim Maughan talking about targeted treatments in terms of radiotherapy and surgery, and how we can make those even better and more effective, and perhaps coming at less of a price tag than some of the drugs.
Nick: Definitely, and what stands out when you listen to Tim Maughan's talk was that he made the really important point that more cancers are cured through radiotherapy and surgery techniques then given drugs. So therefore finding new innovative radiotherapy techniques, or making surgery more precise so it's less harmful, that's a really exciting avenue for the future.
Kat: I loved some of the images he had of chemicals that can literally light up tumours, or light up cells in the body so the surgeon can see where they are.
Nick: There were a lot of really cool images knocking around at the conference this year, and you can imagine some sort of Google Glass type of tool where a surgeon is able to see the precise edges of the tumour so that it's really focused surgery to make sure that just the tumour gets removed and no other harm is made to the patient.
Kat: One thing that I noticed was almost missing from the conference was a big focus on immunotherapy. At the ASCO conference earlier this year it was all about the new immunotherapy drugs that reveal tumours to the immune system – things like PD-1 inhibitors, PD-L1 inhibitors that we covered on the podcast before - but there were only a few sessions focusing on that. But everyone seemed to be mentioning them in passing.
Nick: I think when we were all heading up there we have put our money on there being several sessions dedicated specifically to these new immunotherapy is, but it was difficult to ignore that the vast majority of talks that I went to at least have a mention of the immune system. And it's becoming such an important part of just understanding the basic nuts and bolts of how cancer interacts with the world around it. Because it's a tumour within a body, and that body has an immune system. And finding ways to switch the immune system back on to help aid cancer treatments, as we talked about, combinations is definitely something that's going to keep cropping up again and again.
Kat: And it wasn't just all about new treatments, we see drugs and all this kind of thing. There was still a big focus on prevention, early diagnosis, and issues from patients – reducing side effects from treatments and things like that. What did you notice from some of those kinds of sessions and talks?
Nick: I think that's one of the really good things about the NCRI conference is that the amount of stuff that is focused towards patients and improving things like early diagnosis. We had mentions of the Be Clear on Cancer campaigns which had such a big impact, at least early results showing a good impact for lung cancer. There was an entire session dedicated to prevention, the emerging challenges of dealing with obesity and an ever increasing waistline.
Kat: When I talked to Richard Marais who was the chair for this conference, he said that the key theme he took out of this year's conference was optimism. And I think that maybe this year, perhaps more of any of the other 10 years that we've been coming to this conference, it does really feel like there are some very exciting things very close.
Nick: Yes, definitely. I think I got a feel for that too, and it harks back to this idea of these collaborations and more people working together, these big groups of experts basically, whether it's different parts of the country or the world, now realising that they can't chip away on this problem on their own. And they’re starting to have meaningful conversations with each other that are actually going to, we hope in the future, really make a difference to people.
Kat: That was our media officer Nick Peel – and you can read our in-depth reports from every day of the conference on our blog – that’s scienceblog.cancerresearchuk.org
For me, one of the most enjoyable talks at the conference came from David Spiegelhalter, Winton Professor for the public understanding of risk at the University of Cambridge. His charismatic delivery – coupled with detailed breakdown of the health risks of watching TV costume drama – helped everyone understand a bit more about how we might better communicate cancer risks to the public. I spoke to him just before his presentation, to get a sneak preview.
David: I’m talking about the difficulty of communicating risk and uncertainty about these risks even to people, and the public like us - me and you - because we all find it difficult to understand numbers when they refer to the possibility of what might happen in the future. It's a bit like cancer which is associated with a lot of anxiety and concern and shock at a diagnosis, trying to explain to people what the options are what the consequences might be is really tricky. But I'm not just interested in the public either, you know actually explaining things to policymakers, to clinicians, to people working in the health sector is also not that straightforward at all. And we know that numbers can be used as sort of shock tactics to make people think oh no that's terrible
Kat: That sounds like loads!
David: That’s lots and it's used all the time of the newspapers. So I'll be looking at the classic newspaper headlines, if you do this your risk goes up by 20%, and all this kind of stuff. Which we know that the use of those kind of terms is manipulative, which is fine if you want to sell newspapers. But if you want to inform people, and in particular if you want people to make choices that are based on some understanding of what the consequences might be, and if you're really serious about shared care and informed choice, then it's our duty to try to use what's called transparent communication of risk.
Kat: So let's unpick this a little bit. I open my newspaper and I see the headline “Eating a bacon sandwich for breakfast increases your risk of bowel cancer by 50%”. Now to me that sounds terrifying, should I never eat bacon again? What's going on when the newspapers are reporting a story like that? What does a 50% increase in my risk mean?
David: Well that would be horrific, because it's actually about 20%. But it's still a lot. The crucial thing is to think 20% of what? How big is it? 20% on top of not very much is still not very much, and maybe you'd prefer to eat the bacon sandwich. So we have to consider, I'm going to show my talk, lots of different ways in which a risk like that – if we believe it, which actually I do about processed meats – lots of different ways in which you can tell that story. Because numbers do not exist on their own. There are always part of stories. How they are packaged, and how they’re packaged can be positive to make things look good, or negative to make things look bad. I can make a number look as big and worrying as you want, or I can make it look completely as if you wouldn't be concerned about. Tell me which one you want!
Kat: So for our bacon sandwich example, what do you think would be a better way of explaining the risks? Would it be how many bacon sandwiches I? Would it be how many people eat how many bacon sandwiches?
David: There are so many different ways. If you want to really frighten people you can say bacon sandwiches are responsible for thousands of deaths or bowel cancer cases every year. So that's a good metaphor. But it's actually irrelevant to your decision whether to eat a bacon sandwich or not. Because it's relevant to public health but not to an individual. And that's a good way to shock people. You can say it increases your risk of getting something by 20%, which is almost meaningless to people because you don't have a good idea of what the baseline risk is anyway. There's other ways you can do it. You can also say it decreases how long you're expected to live. You can say you might expect it to take one year off your life. And people quite like that.
Kat: Not per bacon sandwich?
David: Not per bacon sandwich, but I can tell you what per bacon sandwich it is. And if you're eating a bacon sandwich every day it may take two years off your life on average, people who eat a bacon sandwich every day that's 50 g of processed meat. And over an adult lifetime that adds up to about half an hour a day. So for that bacon sandwich another metaphor for it is that it's taken half an hour of your life – so you’d better eat it slowly! So different images capture different people. The one I like is that a bacon sandwich gives you an annual risk of death or getting cancer of someone who's a couple of years older than you, it's putting two years on your age. Your bowels are ageing two years, getting older faster than they need be. So that's another metaphor as well – premature ageing. Do we want to get older quicker?
Each of these might have different emotional responses from different people and there is no correct way to do it. They're all stories, they're all metaphors, they're all analogies – this is the same risk as if you were doing X, Y and Z. The same as a couple of cigarettes, that can be quite a shocking thing to tell people that eating that bacon sandwich is about three cigarettes for example, in terms of their overall health. So these different stories have got different emotional impacts, and we need to be aware of this and choose the one that's appropriate and choose what we want to do.
Kat: So next time you open your newspaper and see “80% increased risk from shower curtains!” or something, what do you think we can do about those kind of stories?
David: So when I talk to journalists and put them into the way that risks are generally considered it's best to communicate, they generally quite like it. And that's in terms of what you consider to happen to 100 people. This idea is called expected frequencies. So you don't use words like chance or probability, you don't need to use percentages, you certainly don't need to use decimals or anything like that, you just say out of a hundred people like you what do we expect to happen? And that's the way in which endless psychological research has been shown to be effective to enable people to grasp the magnitude and even to do calculations. I use that when I'm doing my own probability calculations. We’re teaching in schools now, it's on the GCSE syllabus as a way to teach probability, actually when I try to journalists they actually quite like it. But they tend not to get things in press releases in that form. The press releases are still full up with, oh this increases your risk by 30%, blah, blah, blah. And they don't have a clue what that means and I don't blame them.
Kat: And when it comes to risks, what risk would you like the public to take a bit more seriously than perhaps they do?
David: Oh it's the usual stuff. When I talk about this I just sound like a boring old public-health advertisement. Good diet, exercise, not drinking too much, not smoking. All the usual stuff. But the point is that it's true! It doesn't need any great big attention to should I eat blueberries are not, should I do this that or the other, it's not to do any precise thing. People get very obsessed by that, and endless magazines are sold on this basis, but actually it comes down to really basic ideas of trying to live in a healthy way. And that's what you need to get over.
Kat: David Spiegelhalter from the University of Cambridge. Another enjoyable presentation came from Ron Laskey, also from the University of Cambridge and winner of the Cancer Research UK lifetime achievement award at the conference. Incredibly, we’ve funded his work for around a third of a century, mostly focusing on DNA replication – that’s how DNA is copied by cells as they get ready to divide. Our reporter Alan Worsley met up with him to look back on his lifetime in research.
Ron: Many advances the translation for patient benefit come from the most unexpected directions. The most classic example of this would be the worst of Cesar Milstein on developing monoclonal antibodies, where the question he was asking at the time wasn't could we make an agent that would be good for diagnosis and therapy, it was something completely different. And as a byproduct he found these incredibly valuable reagents that are now used to treat many types of cancer.
Alan: It's always these insights that you didn't realise you were looking for when you find them.
Ron: I think that's right, but there's also a general lesson here which I sometimes illustrate by using a painting by John Constable, which is of a watermill in Essex. I think that a watermill is a very good analogy the scientific research the patient benefit, because if you regard the wheel as the machinery for translating the patient benefit, you need the constant stream of novel ideas coming in as the water that drives the wheel. And that constant stream of ideas from basic science needs to be in the same place as the machinery that is translating for the patient benefit. And then you get synergy to everyone's advantage.
Alan: So you always need more questions as you go along?
Ron: I think the new questions, the new information stimulates ideas of how to exploit it. Otherwise you get one turn of the wheel as it stops. And you really need new information coming in to stimulate the translation for the patient.
Alan: So as your career progressed what were those new questions and the new ideas that generated your research? Where did it go from the early days of DNA replication?
Ron: This feels slightly embarrassing to answer, because I would love to tell you that I had a clearly charted path and that would be totally false. In practice, many of the decisions of what I should do next and what questions interested me next arose from experiments that produced crazy answers. Experiments that produced an answer that we weren't expecting. The sort that I devote a lot of effort into persuading students to look out for those types of answers, because they're the ones that really tell you what's happening. The ones that if you ask is it A or is it B, and it says A or B tells you much, much less then if it tells you A or B and its G. They're the ones that open your mind to what's really going on, and extend your horizons in thinking of how to analyse them.
And I have to admit that many of the things we've done have arisen because of the result that makes us think, and think maybe we could do something else by following up that unanticipated result. So the pathway of my research career has been one of thinking, “oh that looks interesting, let's see if we can pursue it”, rather than the more commendable plugging away at a problem until you've cracked it. It may be that my boredom threshold is too low, but I've always found it interesting to follow new challenges when they arise rather than to stay locked onto the same question. It's rather like mining. If you find a seam, you pursue the seam rather than just keep drilling through the rock.
Alan: I've also heard it said that the best discoveries are not made at Eureka moment, but that's weird.
Ron: That's exactly the kind of point I was trying to make about saying that it's the result that says the answer is not A or B, it’s G, they're the ones, the “that's weird” result, that really make you think. Some of our best discoveries come from a result where we finished up saying “that's weird”.
Alan: You're also describing in your talk about how part of the work you've done has really been challenging the established paradigm for how the nucleus works, which is where the cells store their DNA. How does mRNA, which is used to help proteins get out, and other things come in, I think you describe yourself as the Victor Meldrew of the nucleus.
Ron: This is an image I hadn't thought of before preparing the talk and I was rather horrified when I realised that what I described in my abstract did make me look rather like the Victor Meldrew of the cell nucleus, mainly saying “I do not believe it”. But many of the things we've done have been triggered by being puzzled by the models that we all thought we knew of how the nucleus worked, and finding those models were not good enough. And in fact some cases were simply plain wrong.
So I've probably taken a rather contrary view frequently, I hope it hasn't upset my colleagues too much over the years, but it's been an interesting alternative position to try and sort out things like how proteins really enter the nucleus – it's not the way that everyone said it was during the 1970s. And we were able to overturn that in the early 1980s and established that it was completely different from the early literature.
Alan: So looking ahead to the next 30 years, what sort of advice would you have wanted to give Prof Ron Laskey from the 70s and 80s?
Ron: Oh that's a very tricky question. The one I would reiterate over and over again is look out for the misfit result. It's the misfit result. We tend to think down railway tracks, we think along the lines we think we know where the results are taking us, and we plod down them doggedly. And I think one danger in science is that we expect the result to be down that railway track, and it may not be. And we tend to go on trying to pursue the expected too often, when looking out for the unexpected result is often the most fruitful way to go. So expect the unexpected - it's a cliche but it's a very applicable one to many branches of science.
Kat: That was Professor Ron Laskey, from the Gurdon Institute at the University of Cambridge.
And finally, it’s time for our heroes and zeros. Our hero this month, of course, is the NCRI – the National Cancer Research Institute, a partnership of UK cancer research funders that have together funded more than £4.5bn of cancer research since 2002.
Not only does the NCRI organise the annual NCRI Cancer Conference, as you might expect, but they’re also busy throughout the year, running clinical studies groups focusing on different types of cancer and research topics and supporting research initiatives in area as diverse as prevention, early diagnosis, radiotherapy, surgery, imaging and many more.
And our zero this month is the misleading headlines claiming that sunbathing could be an ideal way to lose weight and cut the risk of diabetes. And, as usual, like everything that sounds too good to be true, it is. These stories were based on relatively artificial research involving mice – which are nocturnal – rather than humans, which aren’t. And there’s no evidence at the moment that the same mechanisms are at work in people.
The team’s main finding was that exposure to one of the types of UV radiation found in sunlight led mice fed a high-fat diet with no extra vitamin D to gain less weight and produce lower levels of certain diabetes-associated marker molecules compared to mice who didn’t receive UV. But the UV-exposed mice only gained less weight – they didn’t actually lose any. So headlines about weight loss are completely inappropriate.
The researchers who did the work call for more balance in the way the harms and benefits of sunlight are discussed, and we whole-heartedly agree. When it comes to sun, people need to find a balance between getting some sun for vitamin D while not putting themselves at risk of sunburn or skin cancer. You can find out more about this story on our science blog – just follow the link in the Soundcloud player – and more about staying safe in the sun from sunsmart.org.uk
That’s all for this month. My thanks to Alan Worsley and Greg Jones for production and reporting, and we’ll see you again next month with all the latest cancer news.
If you’ve got any questions or comments for us, drop me a line at firstname.lastname@example.org, post on our Facebook page, or tweet us – that’s @CR_UK. And if you’re listening to this on Soundcloud, do leave us a comment with your feedback. Thanks very much and bye for now.