GM: Gentlemen, thank you for giving ECCO and ecancer just five minutes of your wisdom. The three of you represent three trade unions: you’re the boss, Valentini, of ESTRO, the radiation therapists, and Naredi is a surgical oncologist and Casali is a medical oncologist, he’s the one who is supposed to be doing all the thinking for all three of you but don’t believe it, you all think, I know. 140 definitions of personalised medicine for sure and goodness knows what the patient makes of it. So let’s start with your definition of personalised medicine from the radiation point.
VV: Personalised medicine for radiation oncologists, I may say that is a very long established practice in our day to day work. Because every day radiation oncologists ask to tailor to those according to where is the tumour, according to the shape of the tumour, to save the surrounding organs. Nowadays with having more and more diagnostic tools in our treatment machines we can monitor how the shape of the tumour goes and to adapt our treatment. So we start to practise personalised medicine more and more in every day. On top of that we integrate this information with all the biologic information that we have and then we can start to work with the predicting models also to tailor the dose, the fractionation, our performance, according to this practice. So personalised medicine is our daily life.
GM: It’s already in there.
VV: Yes.
GM: You’ve got 160 hypoxia genes, do you use them yet?
VV: Oh this is a…
GM: In terms of planning the radiation?
VV: We are going in a research field. But we have a lot of research that using imaging, that monitoring hypoxia to tailor the dose according, it is hypoxia here to give more dose there. So we are in the track.
GM: OK. Peter, the surgeons, I suppose the first use of targeted therapy was Sir George Beatson in Glasgow in 1896 and the paper to The Lancet that oophorectomy produced responses in breast cancer; a very observant surgeon. Where is your definition of personalised medicine?
PN: Firstly I would agree with what Vincenzo has said, I think you can just move that into a surgical perspective. But I would actually like to focus more on the patient’s view. If you talk about personalised medicine, patients think of themselves – how will I, as a surgeon, because I very often diagnose and I treat the cancer patient, how will I do and how will my team do the best treatment for that patient? So that is to me personalised medicine, that they should feel that we as a team, if it’s multidisciplinary, if it’s the surgical team, whatever, we do the best for the patient. So it’s a much stronger emphasis on the word personalised, individual. Then, of course, I have respect for how we are using the term today on a more genetic aspect.
GM: Well, of course, you’ve got BRCA1 and 2 mutations to think about and to worry about and to manage and not just the patients with proven cancers but the families who are sitting with the mutation.
PN: That is included.
GM: So you’ve had to think a lot of the issues, maybe before your colleagues.
PN: Exactly, but it’s included that you have to know everything about the patient, or as much as possible, about the patient and the tumour when you then advise them what direction we should go. But I think it’s very complicated to talk to patients about only the genetic part of treatment, there are so many other aspects.
GM: Sure. Paolo, you’re the medical oncology guy, you’re a world authority in rare cancers, what’s your definition or ESMO’s definition of personalised medicine?
PC: I agree that everyone may have his own definition but I agree in principle that personalised medicine goes beyond precision medicine. So precision medicine has to do with genomics, so with prediction and prognosis through genomics. Clearly medical oncology has witnessed these new targeted drugs so of course this is personalised medicine in our perception today. But, for example in GIST, in gastro-intestinal stomach tumours, mutations predict but they may also be prognostic factors. So our use of surgery in GIST may well depend on mutational analysis as well as the use of medical therapy. So I think that really precision medicine is all about medical therapy but also the other treatment modalities and I agree in principle that if we talk about personalised medicine we should think of persons, so clearly the person goes beyond the tumour.
GM: So I can envisage you three as a multidisciplinary team talking about Mrs Somebody. How does the multidisciplinary team go in your experience? What’s the best way to run it? If you’re writing an ECCO policy on how to establish and set up and maintain multidisciplinary teams, given the bombardment of the science which is sometimes at risk of drowning us, how do you go about visibly doing that? You start off usually because you’re doing the diagnosis.
PN: I think we can continue with your example of the GIST tumours. Surgeons fully agree that we now have precision medicine in our arsenal, the question is then when should we give them – before surgery, after surgery, is surgery at all necessary? So the multidisciplinarity is that it’s so natural that we actually don’t treat a patient only by the speciality we come from, surgery or medical oncology, but that we meet in a multidisciplinary board. The same for rectal cancer when we always discuss the cases in the board where also the radiotherapists are present. Multidisicplinarity to me is that it’s not one person who knows anything better than the other one. Another aspect of this, it’s that when we sit together suddenly we realise that we don’t have the competence, the knowledge, that is enough and that’s the way we now bring in biologists, genetics, because we feel that we need added knowledge. That is, to me, true multidisciplinarity – we use people in our group that we really need.
GM: So the multidisciplinary team will sometimes be about choice of modality, inferring that one modality won’t be used at all? Or is it to do with timing most of the time – first we go with the radiation and the 5-fluorouricil in the rectum and then we do this surgery which spares the function of the rectum and then we give maintenance. Is that what you see as the multidisciplinary team approach to the personal?
VV: I think that it’s now very clear that managing patients by a multidisciplinary team saves lives; there ae consistent data that show this benefit. I have very practical rules to set what has to characterise a multidisciplinary team. First of all, the team has to define guidelines so they formalise what should be the best behaviour. It could be behaviour, the best treatment modalities, diagnostic tools to use. Then they have to meet weekly at least because if you don’t meet in person in a very timely schedule you will not have a multidisciplinary team. Third, that is very important, you share a database. So the data are to be for all people available there and it’s possible also to know what is happening for your patient, even they will be followed by one of the specialists for 3-4 months. Finally you need audit, so you need to establish what is your benchmark and to monitor if you have a benchmark. If you follow these four rules a multidisciplinary team is the place where you can take risks because you have to decline personalised medicine with what you have available in terms of knowledge, resources and frailty of the patients. This is the real place where you not only implement outcome and survival but you promote the best quality of life for our patients.
GM: Those are very good rules and we’ll write them down in the end of this video. Which other experts do you have in your multidisciplinary teams? Do you have the biomatics guy or the imaging people who do clever PET tracer stuff? Who do you think is involved in the medical side of the discussion that you need to lean on?
PC: I absolutely agree that today multidisciplinary tumour boards are not just the surgeon, the radiation therapist and the medical oncologist but we need radiologists and we need pathologists, we need molecular biologists, we need psychologists. This has to do with personalised medicine. I would say that multidisciplinarity allows you to actually personalise your treatment choices because if guidelines were enough we wouldn’t need tumour boards or at least we would need a tumour board every year, they share some guidelines and that’s it. Clearly if we need the tumour boards every week or even every day it’s because we need to tailor our everyday clinical decisions to the single patient. And then say that if you have a round of, say, medical oncologists, only medical oncologists, the best of them will not learn anything while if you have a multidisciplinary team the best people there will always learn something, this is the difference.
GM: That’s very clear and it’s unanimous I think. Thank you. ECCO has made policy, oncopolicy, a big priority. How do the organisations, the trade unions, the specialists in medical oncology and radiation, how do you fit into that? Does the same sort of collaboration on policy issues surrounding working together, does this happen in ECCO? Is this a good tool for you to use to get your ideas through?
VV: I think that ECCO is fundamental. I’m Italian, I love the small towns like in Tuscany and you know that these beautiful buildings, very old, very amazing have a meaning because they have a square where people can meet, can start to discuss what will be the perspective, what will be the rule to manage this small village, and the square is ECCO. The role of ECCO is mandatory in Europe, the role of ECCO is to offer the platform to put in place strategy, for making horizon scanning, what could be interesting that is happening nearby the village, and it’s a place where you can speak in front of the people to find what is the best for what your community and for people that come into your community, the patients.
GM: And the ESSO group, define their voice in ECCO?
PN: Yes, I think we can all agree on Vincenzo’s description of the village with the square where we all can participate. I also like that we are talking about ECCO with one voice because we have our problems and we need our priorities within the different societies that make up ECCO but we have to talk to the society, to policy makers, to patients, to communities. It will not make any sense if there are twenty different societies out there always talking about how important they are. This is the major role of one society, to really focus on the key things that can help cancer care to get better, it can provide better cancer care for the communities. So, for me, this one voice is very, very important and for that I’m prepared to give up some things for surgery so that cancer care really has a united governance.
GM: It’s interesting that I think each of your societies has got involved very seriously with patients and patient advocacy groups and so on and I see quite an impact, actually, at policy level within ECCO of the patient groups and a number of things that they have suggested have actually come to the surface of the agenda. ESMO is very committed to personalised medicine, you’ve even got a strategy within the organisation. How do you use ECCO as a funnel, as a voice or as a market square to talk shop?
PC: I think that ECCO should do something, of course, but should also be the place in which the societies co-ordinate themselves. So each society may well have its agenda, so ESMO has its agenda. So what we are asking ECCO is to be more and more a place in which we can also co-ordinate ourselves so that the ESMO’s agenda becomes the agenda also of the other societies, even if one society may work on something and another society on something else. I would add that we should realise that multidisciplinarity is still a challenge in our everyday professional life, so in our hospitals. So it’s a challenge but it’s a challenge everywhere. So I think that we should work on this.
GM: I think that a policy statement for ECCO coming out of this discussion is that you need to set up a training camp for multidisciplinarity and train how to do it because, as you say, it’s not easy, it’s discipline and people don’t always like to listen to other people; so maybe training and listening is a good discipline. Thank you so much all of you, I really appreciate your first class discussion.