European Multidisciplinary Cancer Congress (EMCC) 2011, 23-27 September, Stockholm
What drives improvements in cancer care?
John Clare
Professor Kurt Miller – Charité University of Medicine, Berlin, Germany
Professor Gordon McVie - European Institute of Oncology and ecancer
Dr Karim Fizazi – Institut Gustave Roussy, Paris, France
Peter Hazenberg – European Association of Urology, The Netherlands
Jane Griffiths – Head of Pharmaceutical Business, Janssen
JC: Welcome to the prostate cancer debate. My name is John Clare, I’m a medical journalist from London in the UK, and it’s a great pleasure to me to be the host of this first part of what I hope will be two great days, today and tomorrow. Now tomorrow we’re going to focus on prostate cancer, particularly metastatic disease, that’s tomorrow, but tonight we thought we would start the proceedings by widening the scope and talking about cancer in general, in particular the development of cancer drugs. Now that’s obviously a vitally important topic to the millions of people who have cancer and their families, it’s also important to all the people in the auditorium tonight, oncologists and urologists; it’s also a very important topic to the public because I think the public like to know that if they’re unfortunate enough to get cancer there is something there that can be done for them. Now, as I said, I am a medical journalist and cancer drugs are also a very important topic for journalists and I’ve written, like many journalists, many stories myself about cancer drugs. Just to do that, to illustrate how newsworthy the topic is, I looked at Google this afternoon, I did a little search and I put in ‘cancer drug’ into Google. Would anybody like to speculate how many hits there are on Google if you put in ‘cancer drug’? Anybody have an idea? Nine million? Higher. Keep going. OK, ‘cancer drug’ has 244 million hits on Google. I then tried ‘cancer breakthrough’, journalists’ favourite word, it gave me 18 million and ‘cancer drug breakthrough’, putting them together, still gave me over 2 million, so it’s a huge topic. Now, the fact is a lot of those stories, of course, are hype and some of them are hope but the question for tonight is this: where do those drugs come from? Now they don’t grow on trees, well most of them.
GM: Well Taxol does. [Laughter] Taxol, Taxotere…
JC: Now that’s what we’re going to discuss. We’re going to talk about whose responsibility is it to find them, to invent them, discover them, develop them and then deliver them to patients. Whose job is it to pay for it and what is the role of the medical societies, for example, in the communication and the training of people like yourselves who are going to administer them? So to do that we have a short discussion tonight and, I’m delighted to say, have a fantastically experienced panel here to discuss it with me. So they are, in order, order of right to left as you look at it. We have Professor Kurt Miller who is the Chair of the Prostate Cancer Debate tomorrow. Now Professor Miller is a urologist from Benjamin Franklin Medical Centre here in Berlin. Then next to him we have Professor Karim Fizazi who is an oncologist from Paris. In the middle we have Professor Gordon McVie who, some of you may know, used to head Cancer Research in the UK and during his time in charge there sixty, six zero, drugs went from the lab actually into trials. Then we have Peter Hazenberg from the European Association of Urology, EAU, and then finally on the end we have Jane. Jane Griffiths is the Head of Pharmaceutical Business for Janssen Pharma for Europe, the Middle East and Africa. So we have a very experienced panel and I would like to kick off by asking all of them one particular question, if I may. So let’s start with Kurt Miller, now my question is this, first of all: can each of you, please, give me a brief summary, thirty or forty seconds, on what is it that drives cancer drug development from your point of view? Kurt Miller, you go first.
KM: Well the general remark on that is chance, serendipity, curiosity, as always if you look at innovation. To be a little bit more specific, I think about fifteen to ten years ago we went from chemistry to biology and through the progress in translational research we identified targets in cancer. Let me make the example of angiogenesis – we thought we would have a very general target in oncology which can be used for any tumour and, as often, it has turned out no it’s not true, it may only work in a number of tumours or in specific tumours. Then again ten or fifteen years ago we thought hormone therapy is dead and we went on to look at EGFR receptors or PDGF receptors and so on and thought is the future. Now, all of a sudden, after it turned out that this is again not the magic bullet, we’re back to hormone therapy. So this is what I call serendipity.
JC: Serendipity, OK. We’ll come back to serendipity in a moment. Karim, from your point of view, from an oncologist’s perspective what’s driving it?
KF: Well, yes, obviously it’s now the biology and this is because we’ve been trying drugs in the past that we don’t really know what they would do against the tumour, this is old history of chemotherapy etc. And now all the drugs, basically, that we are testing we basically designed them to target something or target different things; sometimes it actually doesn’t do exactly what we thought it would but anyway this is how we develop drugs now. More and more we’re trying to incorporate biomarkers in drug development so it’s back and forth from the patients through to the benchmark. And hopefully for prostate cancer in the near future we’ll be able to do a more what I would call personalised treatment based not only on the general prostate cancer biology but rather based on the individual patient’s prostate cancer biology and this really is the future.
JC: OK, thank you. Gordon McVie, what’s your view?
GM: Thirty seconds, four Cs – compassion, we have to care for our patients, it has to make us drive to find new drugs and quickly. Secondly, curiosity; curiosity drives scientists and chemists to make new molecules and, in the case of abiraterone, Mike Jarman was the chemist who did this out of pure curiosity. My third C is coalition because you don’t get anywhere as a scientist without taking your medicine to pharma and if you don’t combine with pharma as early as possible you’re never going to get your drug to help those patients for whom you feel compassionate about. Then the last thing I think you need is communication, you need to be able to tell people what your new medicine does, how fast it’s got there and then to encourage people, not only the doctors but the patients, to understand the biology of what it’s all about. So four Cs – compassion, curiosity, coalition between academia and pharma and then communicate it.
JC: Thank you, thank you. Peter, from the EAU perspective, or from your own perspective, what’s driving it?
PH: Well I would like to share Gordon’s opinion when it comes to drive and passion and I think, representing the European Association of Urology, it should enable us and we’re obligated to do that, to anticipate more quickly these new develops and sharing these scientific and educational possibilities and opportunities. I think in the future it’s not only about, and not everyone will agree with me saying this, but I think that it’s not only about educating doctors, in this case urologists, I think that patients should be educated as well to anticipate fully in this quite serious process when it comes to cancer and prostate cancer specifically.
JC: OK, thank you. Jane Griffiths, from the pharma industry point of view what’s driving it for you?
JG: Well to get down to the practicalities, I think Gordon talked about needing compounds to treat cancer as well as all of the other care that the other panellists have talked about so I think what the industry brings is discovery, for a start, whether it’s in-house or partnering with smaller companies and academic institutions; to bring forward meaningful drugs, these days much, much emphasis on well-differentiated drugs in areas of high unmet need. Once the molecules have been identified then us as an industry contribute to the development, so development expertise, regulatory expertise, so the practicalities of getting the drug from an idea over the line and to patients with the appropriate education and partnership with everyone else on this panel really.
JC: OK, well partnership and collaboration is obviously quite a theme there. Partnership itself, I think, works at many different levels and one is from the pharma company to academia and we’ll talk about that in a minute. We have a urologist and two oncologists on the panel, can I ask how many people here are oncologists? Can I ask for a show of hands? OK. How many are urologists, putting both my hands up because I’m neither. OK. Right, OK, quite a mix. It’s quite a mix. How much collaboration is there between oncologists and urologists at the patient level, Kurt?
KM: Well that’s hard to measure. What do you mean with the patient level? I think there might be still problems in it’s country specific, crossing the border for a patient to get referred from the urologist to the oncologist. This depends on a number of factors which are rational, irrational, assessment of the drug, of the efficacy of the drug and so on. So in an ideal world, yes, there is a good collaboration and it’s to the benefit of the patient but I think in the real world there is still room for improvement.
JC: Gordon, what’s your view? Collaboration on the ground between oncologists and urologists?
GM: I think in heaven the collaboration is pretty good, OK? Up there at the level of the EUA and ESMO and ESTRO and they all talk to each other with the angels and that’s good.
KM: You mean when they’re dead or what?
GM: But I work in the European Institute of Oncology in Milan and we’ve got people wielding CyberKnives and we’ve got two da Vincis which are coring away and the idea that these guys really believe in what the other one is doing, well I’m just a medical oncologist and I don’t really hear the real multidisciplinary and the listening of the two disciplines.
JC: From the EAU perspective, your guidelines, the EAU guidelines say every patient should be treated by a multidisciplinary team. That, obviously from what we’ve heard now, is not realistic, Peter, is it?
PH: Well at least we try to contribute to this ideal world and maybe a place in heaven in co-operating with the other societies when it comes to education and even organise meetings together. I think a good example of a multidisciplinary meeting we are organising, I think for the third year already, is the European Multidisciplinary Urological Cancer meeting in Barcelona in which we try to unite the urologists and the oncologists to one world and share knowledge and share designs. And in the end, I think, that was part of your question, when it comes to the patient level I think it should be clear that, even with struggles in co-operating together, the patients should be treated as best as possible. They should not suffer internal discussions.
JC: OK. Karim, what happens in France, in Paris?
KF: Well I have to say that probably an important progress in collaboration because all what we’ve said here is and was true in France, of course. But one important progress was really when the state, the Minister, approximately ten years ago asked us by law to have this multidisciplinary meeting for each cancer patient that we would treat and now it’s written in the law. And for ten years now we’ve been sitting all together with a radiation oncologist, a medical oncologist and a urologist and, of course, it’s helped a lot the two or the three different roles to really more understand each other. I think this really is helpful, it’s not perfect for finding perfection, of course there are discrepancies everywhere but at least people can understand what the other is doing.
JC: OK. Gordon McVie, can I ask you, when you were running Cancer Research in the UK, I said in my introduction sixty compounds, six zero, went, I believe, from the labs to trials.
GM: Yes.
JC: What were you doing that was so successful and have people learned from that?
GM: OK, we trusted the chemists; we gave grants to small chemists in universities because chemists work in universities, they don’t work in cancer institutes or anywhere else; we trusted them, as soon as they got a compound that looked interesting we patented it with them so that they would share in the royalties and then when we put it through the charity’s own phase I phase II programme, which is completely academic and has no pharma money in it at all, anything that looked interesting we went off and found our coalition partner with pharma. And that’s how we sped drugs like carboplatin and temozolomide and abiraterone was a BTG drug but we were involved in the co-development and there’s another couple. Pharma does a great job once something is past the high risk phase. Somebody has got to do the high risk curiosity-driven research and that’s academia for me.
JC: So are you saying that pharma doesn’t take risks?
GM: But then when you have something interesting, and usually pharma who I have met want some clinical data and will see some clinical data and it’s safe and you’re doing the hypothesis testing and it works, then pharma, in my view, are not risk adverse anymore and they’ll pick it up and go with it.
JC: But are you saying that pharma will not take risks early on?
GM: Early on I don’t know too many pharmas who will take risks.
JC: Jane, you don’t take risks.
JG: I don’t agree with that comment, I think industry takes huge risk. It invests a huge amount of money in R&D, you’ll know that to bring a drug to market now anything between $1.4 - 1.8 billion, and some of that is invested in products that you’ve risked because it includes some of the products that don’t come to market and that is a huge risk. The licensing we do with small companies, there’s a product that we licensed from an American company five years ago that’s coming to the market soon, we made our decision on five patients and we paid a lot of money, it was a huge risk at the time. So I think to say the industry doesn’t take risks in its own research and the products that it licenses in is not true.
JC: Kurt Miller, what’s your view? Do drug companies take risks?
KM: Well, yes, I disagree slightly with Gordon because what is taking a risk? Being in a lab, getting a grant and playing around with molecules, is that taking a risk?
GM: Yes. [Laughs]
KM: Oh come on, that’s not real risk taking!
GM: Some of them cause cancer, you know. Some of them are carcinogenic, these molecules.
KM: Oh come on, come on. That doesn’t give you a nightmare if you lose because you’ll still have your job, you’ll still have your company, you’ll still have academia. So, as you said, if you’re compassionate, if you’re curious, you do that and that’s not about risk taking. It’s about risk taking, I would say, if you have just a pre-clinical model or a small phase I or II study and then say OK, I’ll throw $100 million on a drug, that’s risk taking in my mind.
JC: OK, let me move on if I may because another important part of the development of cancer treatments is the communication of the development and the education of the people who are going to prescribe them. Whose role is that, who should be doing it? There’s criticism that pharmaceutical companies do it, that’s criticised, who else would do it? Karim, can I ask you, who should be in charge of that education and communication?
KF: Well, again in a perfect world, I really believe it’s academia and not…
JC: Sorry, you would…?
KF: It’s academia.
JC: Academy? Academia should do it?
KF: Yes. I really think so because with a company you really play the risk of having a biased message which really is something we don’t want to see for treating cancer patients. But again this is not an ideal world so we need to have collaboration with the industry to make sure that all our colleagues can have some fair information and can have access to this information repeatedly because in oncology everything is changing so fast. So again you need to make sure that all oncologists and urologists and basically all doctors can have access to new data and quite often. I have to say that without the pharmas we just can’t do it because EAU, ESMO, ECCO blah blah O [laughter] just can’t do these big meetings, can’t do the smaller meetings, without the help of the pharmas.
JC: That’s the point, isn’t it? That you say in an ideal world pharma would have nothing to do with it but who would pay for it?
KF: I fully agree with you but we probably need to be smarter and to find new systems. Maybe we should have these kind of meetings, maybe in the future, in five, ten years or so, with several pharma funding that and probably the more balanced so that yes, we can deliver the message and yes, we can make sure the message is as balanced as we want it to be.
JC: OK, as balanced as we want it to be. Now Peter, from the EAU’s perspective, is there a role for a body like that in communication and education?
PH: Well, not specifically for the EAU exclusively but I think for all medical societies, referring to what you said about the academia and connecting it with the urologists or the doctors in general, I think the societies and, of course, they should improve still, should be the platform where these exchanges can take place under, let’s say, between brackets, neutral ground. I think even being here it is, with all respect because I know Janssen’s philosophy, but for outside, as it would be, a company hosting doctors to do this debate. So I think societies can fulfil a very important role in exchanging and providing this platform.
JC: Jane, what’s your view? Obviously you’re sponsoring meetings like this.
JG: Well I think that the notion that we can’t be trusted is a huge source of frustration to me, really. I’ve been in the industry a long time, maybe twenty years ago we were a different industry from where we are today. And events like this, for example, the faculty and the topics that are chosen to discuss are done by a third party group, maybe they wouldn’t be ten or fifteen years ago but now they are. We have very strict codes of conduct around healthcare compliance, we’ve got our healthcare compliance officer here this evening. The amount of paperwork that there is to set up a meeting like this is enormous, the oversight these days is enormous. So I think my, obviously, preference would be that we partner on the education. And I think the other thing is that a pharmaceutical company who has been developing a product for many years is likely to know a lot about that product and to concede all of the education around it to someone else seems a huge waste of knowledge and intelligence. So if we can partner and can win the trust of people we work with that we will be transparent and unbiased then it will be good.
PH: I fully agree and I would like to add something to what you said. There is no such as a pharmaceutical company in general. We have and see and speak to a lot of pharmaceutical companies and I think even the doctors here present do that as well. There is a difference between one company and the other and this difference can be distinguished, looking at the programmes and the way companies support the delegates. And this is what I wanted to remark about, there’s no pharmaceutical company in general, doctors really have to look into what companies do and especially research and development of what they contribute to science.
JC: OK. Let me go back to our opening statements and two words I’d like to pick on – serendipity from Kurt and curiosity from Gordon. Let me switch them about, curiosity, is there any role any more for the scientifically curious and will that scientifically curious person actually lead to new treatments for patients? Kurt, what do you think?
KM: Well yes, if serendipity comes into equations then yes because, as we’ve seen, it may be that for thirty years nothing happens and I’m sure that it was not the probable lack of curious persons during that thirty years; they’ve been looking for molecules, they’ve been looking for other ways to treat cancer, prostate cancer, whatever, but nothing happened and then all of a sudden a lot of things do happen. So it’s not a linear process and you always have to combine, as I said, curiosity with whatever comes – chance, serendipity, however we may call it, and then something happens. That’s it.
JC: Is that your view Gordon?
GM: Yes, I’m a strong believer in serendipity, things happen by chance. You know, I make all my best contacts in the pub, OK? That’s not serendipitous because I drink a lot but who I meet in the pub is often chance.
JC: Isn’t there a problem, though, that if you leave scientists to just get on and do what they fancy in their lab, you then get to this question, don’t you, what’s the difference between innovation and progress?
GM: Right, I’ll tell you who I take my hat off to for sheer perseverance and that’s the immunologists. I have lived through forty years of immunological disaster, I’ve heard immunotherapies which were going to be curing the world and every single one failed, every one of them. And they kept going because they were convinced that the body could be taught to reject their own cancers, and suddenly we’ve got a breakthrough. Instead of making anti-cancer antibodies, we made anti-T-cell suppressor antibodies and one of them, the first one in a series, I can tell you, is called ipilimumab. And suddenly we’ve not just got a new way of treating cancer but we’ve got a new set of side effects and a whole lot of new problems, but that’s fine and that’s progress and it came from persistence and also a fair bit of serendipity in finding that molecule.
JC: So that one was progress, but isn’t there a case that… Kurt, you want to come in?
KM: That’s a small streak between stubbornness and what you call it, you know.
GM: Obsession.
KM: Yes, and so after forty or thirty years, thirty or forty years, you start to think about it – am I stubborn or am I persistent?
GM: Yes.
KM: And this is sometimes difficult to say, actually.
GM: Yes, but I’ve got a bus pass.
KM: That’s good.
GM: I’ve got a bus pass so I’m more stubborn than you are.
KM: Yes.
JC: Karim, is there a French view on stubborn versus persistent?
KF: I don’t know if it’s a French view but what I see here is that if you take a team, for example, you probably need to have some people who will design the programme one step at a time, very progressively etc, and within the team you probably need to have one or two people who think different, who are very curious, who will try something very bizarre. Maybe it will fail forever, maybe immunotherapy is an example, I don’t know, and maybe sometimes it will be very successful and very innovative. And I think you will need to have the two models within your team and within research in general.
JC: OK. Gordon, can I ask you before we wrap up, you mentioned earlier that if you’re in a lab, you’re in an academic lab, you need to patent your compounds early.
GM: Yes.
JC: Otherwise pharmaceutical companies will not be interested.
GM: Correct.
JC: But you said it in a way that suggests people get that wrong, they don’t always do that.
GM: In Europe we get it wrong, in the United States every scientist knows that he’s only going to make any money and send his kids to college if he has a start-up company and the start-up company needs some intellectual property, the intellectual property needs a patent. So that’s the way it goes. In Europe we’re still a little bit naïve, a little bit blue skies up there with the ESMOs and ESTROs and the EUA and so on and we really have to bring a discipline into science. If you find things that are interesting, protect them.
PH: But aren’t there already some good examples? I mean I know some examples in the Netherlands where these processes take place within university clinics and that even universities realise very well when there’s an interesting compound they should license it out, they keep the patent.
GM: I think the universities have cottoned on to it because they’ve no money and they see this as a way of making money.
PH: Exactly.
GM: They don’t realise that they won’t make any money for fifteen years but the scientists themselves are slow to have picked up the message and I think it’s coming but we’re not as competitive in Europe. We make a lot of discoveries, we do not develop our discoveries as well as the Americans.
JC: OK, thank you. Right, the final question, if I may, to each of the panel, I’m going to ask each of them to indulge in some crystal ball gazing. So I’m going to start with Kurt Miller, the Chairman. Look into your crystal ball, you see 2025, fifteen years from now, a lot of people here will still be practising in fifteen years, what will cancer therapy look like in that time, how will it be different from today?
KM: So I mean I will not treat cancer patients in fifteen years so it’s easy for me to speculate. [Laughter] So yes, we have all those… Karim mentioned it already, we have all those markers and gene panels and things around where we can personalise medicine on a very specific level and we get much more drugs and we get much more targeted and defined. I think we can much better tailor the specific treatment to the patient and that’s going to be true for many tumours, that’s about it.
JC: OK, more tailored, more targeted. Karim?
KM: More personalised, yes, that’s it.
JC: More personalised, OK. Karim, will you be practising in fifteen years?
KF: Yes, I think so… I don’t know.
KM: Unless he gets a patent.
KF: That’s right. [Laughter] I’ll talk about it to Gordon.
GM: Ten per cent.
KF: That’s a deal, that’s a deal.
JG: Stop it, stop it! [Laughter]
KF: Come on, it’s important.
JC: This is the part to talk about patents, OK?
KF: OK, that’s good.
JC: Karim, fifteen years, what will be happening?
KF: Really I have to agree with Kurt, we were pleased but I don’t know what will be the future obviously. But really what I hope, for example for prostate cancer, is that we won’t be talking about prostate cancer anymore but about ten different diseases or a hundred different diseases that we will treat very differently one patient versus another one. Of course this will be then the patient’s advantage in terms of outcome, it may be in terms of toxicity, in terms of cost for society. I really believe in that.
JC: OK, thank you. Gordon.
GM: Well I’ll be eighty in 2025 and I first of all hope I’m going to be here, OK? Secondly I hope I’m still working. I hope that we have got rid of tobacco by 2025, we’ve got an antidote or some other way of making money for developing countries instead of growing tobacco plants, genetically engineered to make medicines. I’d like to see more vaccines and I think HPV is phenomenal, but that’s another forty years’ worth of dogged persistent obsessional work. I wouldn’t be surprised if breast cancer turns out to be due to a virus in which case we’ll have a vaccine by that time. I’d like to see a cancer test and I’d like to see it not a blood test but something you can get out of sputum or an X-Ray or an MRI scan, and I’d like all interventions to be no touch, everything to be no touch.
JC: OK, thank you. Peter?
PH: Well I think that within fifteen years the Y-generation will be in charge and in those positions where you are right now, the Z-generation, Einstein generation, is coming up. I think when it comes to education, when it comes to exchanging science, it will be much more efficient, it will be much more personalised as well to the person who needs and who wants to learn and it will be on-line in a cloud.
JC: OK, thank you. Jane?
JG: So a lot has been said already so I think we’ll all have mapped our genes, we’ll all have logged on to 23andMe, sent off a sputum sample, my son has already done it so I’ll know what I’m destined to or may get, so I’ll be monitoring myself more closely in some way with some technology. We’ll have biomarkers for all of the drugs that we bring to market, they’ll be much more targeted, as you said. I think I might have a little monitor implanted in me, actually, that’s just checking out for circulating tumour cells, or whatever it will be, under the skin. To your point there will be no touch, there will be a lot more treatment at home and there will be cures for many more cancers.
JC: Well a very exciting time ahead of us then for the next fifteen years. So thank you very much everybody for coming. I would like to thank the panel before we wrap up.
