New Cancer Research Priorities Needed to Correct Imbalance that Leaves Important Questions Neglected

Cancer research is too focused on new drug development, while not enough money and effort is being devoted to pursuing important advances in knowledge likely to have the biggest impact on combating the disease in the next few decades, a leading research policy expert says, adding that a major shift in research priorities will be crucial to the ability to cope with the coming wave of cancer cases.

Professor Richard Sullivan of the King’s Health Partners Integrated Cancer Centre in London told Europe’s largest cancer congress, ECCO 15 – ESMO 34, the joint 15th European CanCer Organisation (ECCO) and 34th European Society for Medical Oncology (ESMO) Multidisciplinary Congress, September 20 – 24 in Berlin, Germany, that studies aiming to improve surgery, pathology and diagnostic and staging imaging, as well as a radical rethink of the approach to prevention research, must become the focus of public- and federally-funded cancer research now. The global public sector spend on cancer research was about €14 billion a year in 2004/05, the latest year for which figures are available. Non-commercial funders in Europe spent just over €3 billion on cancer research in 2004/05.

“An analysis we have just completed shows that, on average, European public funders are spending 74% of their money on fundamental biology and drug development research and that well over 70% of the cancer research initiatives at the European level are aimed at the same areas,” noted Prof Sullivan, who is also chairman of the European Cancer Research Managers Forum, which studies cancer research and funding in Europe.

“In the United States, the imbalance is even greater. There is no shortage of cancer drugs coming through pipeline and the whole area of drug research is quite healthy. What we need is a reapportioning of budgets from the charitable sector and public funders to carve out space for these other areas of cancer research that are largely invisible to a lot of policymakers."

“This is a deeply unfashionable view and the easy way out is to say that we must just ask for more money, but the reality is that we’ve got to prioritise,” Prof Sullivan said. “Most of the new medicines are having a small impact on the big picture of cancer burden at the moment, extending life by a few months. Research in this area is already heavily funded and that will continue regardless, as will the investments in fundamental cancer biology.”

The World Health Organization predicts that the number of people worldwide living with cancer will rise from about 28 million today to about 75 million in 2030. Detecting cancer early enough to treat it successfully and improving our understanding of how to make primary prevention strategies work hold the potential for the greatest gains, he said.

“This demands an overhaul of prevention research. You can take the quite reasonable view that we know the risk factors now. What we don’t understand is how to take that research on prevention and apply it in populations because we don’t understand the behaviour of those groups or how that might change over the next 20 or 30 years. For instance, how do we address the fact that many men across Europe will put up with rectal bleeding for a year before going to see a doctor? This is very important because cancer is not just about genes, it is predominantly about culture.”

"Cancer researchers must now be more imaginative and collaborate across unusual disciplinary boundaries to embrace behavioural engineering, population psychology, evolutionary biology, novel sociological methods and ideas such as cultural transmission theory – the study of how behaviours are learned and transmitted between generations," Sullivan explained

“Research in these novel areas addresses questions that can never be answered with classical epidemiological studies or standard social science questionnaires – we’ve reached the limits of enquiry with many standard approaches. There are people doing fantastic work that could be extremely useful not only to cancer research, but to medicine in general and most medics and researchers are completely ignorant about their existence and what they can do for medicine. It is a huge untapped area with massive potential to make a difference,” Prof Sullivan said.

The growing scale of cancer in developing countries also presents an imminent challenge for cancer research, he said. More than half of all cancer diagnoses occur in developing countries, which will bear a large majority of the global burden before long. Keeping the research focus as it is in developed countries will not address the problem in the developing and transitional countries because drug development is not going to be the answer. Surgery and radiotherapy are the most important approaches for reducing the global cancer burden and financial support for programmes that bring those treatments to developing countries is still very poor.

“The argument is always made that there is enough to deal with in developing countries with the infectious disease challenges, but chronic disease is a major, often unrecognised problem and we can’t afford to wait any longer. Like it or not, developed countries have a responsibility to investigate which cancer control approaches are exportable and to support those institutions working in these areas,” he said.

Governments, research charities and European funders need to recognise the importance of shifting the focus to a new approach to prevention research and more investment in non-drug treatment research, but it will be largely up to cancer researchers to drive the change, Prof Sullivan said.

“There has already recently been a major shift in Europe toward hospital-university alliances driving the agenda. They need to start banging on the doors of the non-government organisations and the federal funders, lobbying hard and proving that it’s important to give attention to these neglected areas of cancer research.”

For more information:

• European Partnership for Action Against Cancer

What is the practical impact of quality cancer research?

How does biomedical and clinical research impact daily practice in cancer care? This question has been asked with increasing frequency over the last decade. Results of a study published earlier this year in the British Journal of Cancer, give the answer. The results shows how research in the United Kingdom is helping to deliver significant clinical improvements for cancer patients in the United Kingdom and around the world.

To date, there are 43 oncology guidelines and associated Health Technology Assessments (HTA) published (up to October 2006) in the United Kingdom. Each guideline and associate HTA has a clear evidence base in the form of references, many of which are papers in peer-reviewed journals. Researchers analyzed these guidelines for cancer care from the National Institute of Health and Clinical Excellence (NICE) and the Scottish Medicines Consortium (SMC), and found that papers from UK-based cancer researchers are cited nearly three times more often than would be expected.

These guidelines form the basis of the clinical care given to cancer patients and are devised from an evidence base which includes peer-reviewed research.

In contrast to held idea that the pharmaceutical industry is the biggest sponsor of biomedical research, the study reveals that Cancer Research UK supported over one-third of the clinical trials which were cited as evidence in these guidelines. The number of studies is more than the pharmaceutical industry as a whole, or the UK government. This outcome seems to confirm that altough the private sector will have an important role in identifying and implementing research priorities in cancer research and offer substantial and welcome funding, it does not set the overall research priority end execution. The main reason is that industry by its very nature is partisan and concerned only with commercially viable areas. On the other hand, government agencies, charitable organizations and universities have wider concerns for all cancer research.

Lead author Professor Richard Sullivan, who conducted this study when he was director of clinical programs at Cancer Research UK, and is now at the London School of Economics and the European Cancer Research Managers Foundation, said: "Our study demonstrates the real practical impact of research funding in the UK and shows that cancer research in the UK is punching above its weight.”

International impact
Previous studies have shown a strong sociological tendency for clinical guidelines to focus on domestic research rather than the best international research. The impact of UK research in this study was compared with a standard set by previous studies measuring how far individual countries are expected to deviate from the international standard.

Professor Sullivan continued: "Even taking into account the fact that UK clinical guidelines are inevitably going to be skewed in favor of UK-based research because of the make-up of our healthcare services, we still found that the impact of UK cancer research on clinical practice was disproportionately higher than would be expected - which is a credit to the exceptionally strong research base that we have in this country. We also found indirect evidence that UK cancer research has as impact internationally - particularly in Western Europe."

In numbers
Cancer research conducted in the UK contributes to approximately 6.5 per cent of the world's oncology research output, but almost 20 per cent of cancer research emanating from the UK contributed to the 43 NICE clinical guidelines which were devised before 2006.

The research team analyzed just over 3000 references which were cited across almost 800 research papers over a period of 25 years. The peak years of guideline references were between 1999 and 2001. They looked at the geographical breakdown of the research as well as the type of research conducted and the impact factors of the journals it appeared in. The researchers noted that studies from universities, hospitals and institutes based in Oxford, Cambridge, Edinburgh and Glasgow were the most frequently cited.

Professor Sullivan noted: "This is an interesting finding...[and] this may be because SMC guidelines tend to pay close attention to research coming out of Scotland - but it was still a significant contribution from the two cities."

Kate Law, director of clinical trials at Cancer Research UK, said: "This research highlights the importance of clinical trials carried out in this country and it's great to see that studies funded by Cancer Research UK played a major contribution towards these guidelines. This demonstrates that our research has a significant impact on the clinical management of cancer patients. NICE is seen to be a world leader in the development of quality, evidence based guidelines for cancer care, so it's crucial that the Government and NHS work together to ensure that these guidelines are being uniformly implemented across the country so that all cancer patients can benefit from them."

Although the impact of studies conducted in the United Kingdom is considerable, British researchers in general are concerned about the increased bureaucracy. One researcher noted that patients with cancer are dying because bureaucracy is stifling research. In general, it takes now takes five times longer than in the early 1990s to get a breast or bowel cancer drug into trials.

Professor Sullivan agreed that: "We absolutely agree that research should be carried out in a proper regulatory framework, but because of complex, contradictory, and opaque regulations patients aren’t being protected, they are being failed." The result is a 'culture of fear' in which many now playing it ultra-safe and avoiding sensitive but potentially important areas of research.

Researchers find it incredibly frustrating the added burden of bureaucratic rules slow down the development of new drugs. They agree that this kind of delay is undoubtedly costing lives. They also feel that the added (European) regulations do not provide greater patient safety.

Even though the increase in guidelines may be a concern, most researchers feel that the NICE recommendations are truly based on systematic reviews of the best available evidence. And even when minimal evidence is available, recommendations are based on the opinion of what constitutes good practice.

Also read:
Lewison G, Sullivan, R. The impact of cancer research: how publications influence UK cancer clinical guidelines, British Journal of Cancer (2008) 98, 1944–1950. Click here for the PubMed abstract.