The meeting covered a wide range of topics, from herbal medicines and how they interact with chemotherapy, to whether we should be encouraging the use of electronic cigarettes. Malcolm Qualie delivered an excellent lecture on the commissioning of cancer drugs and urged pharmacists to support positive changes in the Systemic Anti-Cancer Therapy (SACT) database reporting among other things.
Two extremely informative industry satellites, explored the potential of immunotherapy in cancer. Dr Andrew Walker explained how new drugs are assessed by the National Institute for Health and Care Excellence (NICE). A series of lively clinical streams were extremely popular with the delegates, and featured updates on key topics like metastatic breast cancer, pancreatic cancer and multiple myeloma, among others. Dr Chris Plummer, a cardiologist with a special interest in oncology, delivered an informative lecture on the long-term cardiac safety of SACT.
Dr Simon Grumett and Helen Flint discussed pharmacy-led clinics, while Andrea Crossfield, of Tobacco Free Futures, presented arguments for and against the use of electronic cigarettes. This year’s thoroughly engaging Succinct Lecture was delivered by Dr Kevin Fong, who concluded that progress in science and engineering continues to blur boundaries between science fiction and science fact but that only with teamwork can these rapid and sustained advances be achieved.
The conference offered three full days of educational content and lively discussions on the hot topics for oncology pharmacists; here, we have captured some of the highlights to whet your appetite and give you some idea of the wealth of enduring information available. The video footage and photos from the Gala Dinner can be found on the BOPA website under Annual Symposium. Presentation slides are also available in the members’ section of the website.
Click below to view a selection of images from the 17th Annual BOPA Symposium
Malcolm Qualie is the Pharmacy Lead, Specialised Services, NHS England. He delivered a measured and informative lecture on the challenges of cancer drug commissioning, summarising the state of play in today’s NHS and the role of different groups involved in the process.
According to the speaker, the current challenges include the following:
He explained that Principles of Medicines Optimisation was launched as a result of these and other challenges, to ensure effective drug use and to achieve optimal outcomes. Malcolm added that because of the climbing drug costs, more and more medicines are being rejected by NICE, putting pressure on the National Cancer Drugs Fund (CDF). As a result, a consultation was launched in October 2014 to look at reprioritisation of the CDF based on clinical benefit and cost effectiveness. An interactive session was held with the audience to gain views on the proposed changes.
Finally, Malcolm warned that as a result of the increasing importance of the SACT database, contract monitoring for SACT reporting would soon be implemented; no payment without data. He urged oncology pharmacists to help manage this change and offered it up as an opportunity to make a really positive contribution.
Dr Andrew Walker used to work for the Scottish Medicines Consortium; he is now a health economist at the University of Glasgow and also helps pharmaceutical companies with Health Technology Assessment submissions. Dr Walker talked about how new cancer medicines are evaluated, and whether there will be any changes to this system in the future. He provided a truly enlightening description of how clinical data are converted into cost per quality adjusted life year (QALY) to help decision makers calculate the ‘amount of health’ a drug offers.
He added that the number of claims based on these economic models is rising, but confounding factors in clinical trials limit the accuracy of these measurements. Dr Walker concluded by saying that QALYs are fundamental to reimbursement and are here to stay: a QALY is a basic metric that can be applied across disease areas, helping to level discussions.
Within cancer therapeutics, immunotherapy has recently emerged as a potentially effective option across numerous tumour types, including melanoma, non-small cell lung cancer, and haematological malignancies. The various mechanisms and targets, such as PD-1/PD-L1, interleukin, CD19 and TLR9 have been widely discussed at international conferences during 2014 and also at BOPA. As such, two industry satellites on the topic of immunotherapy were welcomed by delegates, eager to better understand the machinations of these future agents.
At the first, Professors Hardev Pandha and Aymen Al-Shamkhani presented a superb overview of cancer immunotherapy, educating the delegates on the scientific rationale for modulating the immune system in cancer. At the second satellite, Christian Ottensmeier, Professor of Experimental Cancer Medicine at the University of Southampton, discussed the so called ‘checkpoint inhibitors’ pembrolizumab and nivolumab for the treatment of melanoma and the benefits of potential combinations with vemurafenib and ipilimumab.
Professor Ottensmeier concluded that these agents demonstrate impressive and sustained responses, but only in some patients, and we are still some way off identifying which ones. Steve Williamson, Consultant Cancer Pharmacist at the North Cumbria NHS trust, clarified the pharmacist’s role in the management of these drugs and highlighted the need for education in this area.
The clinical update sessions were lively and extremely popular among the delegates. The key points from each of the lectures are summarised below, with links to the recorded sessions and speaker slides included where available.
Dr Daniel Rea is Deputy Clinical Director at the School of Cancer Sciences, University of Birmingham. He started his presentation by explaining that the management of metastatic breast cancer depends on several factors, including extent of disease, performance status and whether the cancer is hormone-responsive.
Dr Rea then talked about the various treatment approaches available, including oestrogen-receptor blockers, aromatase, mammalian target of rapamycin and mitotic inhibitors, and dual targeting of human epidermal growth factor receptor 2-positive tumours with pertuzumab and trastuzumab. He also spoke about the results of the EMILIA study, which indicate improved progression-free survival in patients receiving a trastuzumab-emtansine conjugate compared with a combination of lapatinib and capecitabine.
Dr Rea concluded by saying that new therapies can sometimes improve survival, but what we really need is more personalised treatment approaches, a greater understanding of the best sequence for the drugs available and sound clinical trial design looking at the whole treatment pathway.
Daniel Palmer is Professor of Molecular and Clinical Cancer Medicine at the University of Liverpool. He highlighted that, compared with other cancers; pancreatic cancer has seen the worst improvement in cure rates in the past 40 years, with gemcitabine, which was approved in the 1990s, remaining the standard treatment approach used in the UK.
That said, several new treatment options are now available for patients with pancreatic cancer, including the folinic acid, fluorouracil, irinotecan and oxaliplatin combination regimen and nab-paclitaxel, but Professor Palmer explained that it is challenging making decisions between these options because accurate cross-trial comparisons are difficult. Professor Palmer concluded by saying that prognosis remains poor for patients with pancreatic cancer, but some progress is being made with biomarkers (and hence accurate patient selection) and research into the importance of the stroma surrounding the tumour; immunotherapy is also showing some promise in this difficult-to-treat population.
Dr Mark Cook is a Consultant Haematologist at the University Hospital Birmingham. He explained that multiple myeloma is a disease of the elderly and often starts with monoclonal gammopathy of unknown significance.
He added that when the patient presents at the clinic, the first decision that has to be made is whether the patient is suitable for a transplant; if not, then the treatment pathway will depend on where they are treated — there is very little consensus. Bearing this in mind, it will be interesting to see how the new NHS England guideline currently in development will be received and adopted. Guidelines are also available from other sources including NICE, UK Myeloma Forum, the International Myeloma Working Group and the Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) from the Mayo Clinic. International collaboration certainly appears necessary to determine optimum sequencing and use of currently available and future treatments.
Dr Cook summarised the results of the key trials in the field, including VISTA, APEX and TEAMM, and highlighted that research in this area is moving rapidly; the key challenge now is getting products into phase III.
Dr David Peake is a Consultant Clinical Oncologist at the University Hospital Birmingham. He explained that sarcomas account for about 1% of all adult malignancies and 15% of all paediatric malignancies, with surgery being the standard treatment option; although evidence suggests that surgery combined with radiotherapy offers the best results.
Neoadjuvant, adjuvant and palliative chemotherapy may have a place in the treatment of osteosarcomas and soft tissue sarcomas, though the evidence is inconclusive. Dr Peake discussed some of the treatment options for advanced disease, including doxorubicin, ifosfamide, trabectedin, the combination of gemcitabine and docetaxel, and pazopanib.
Professor Charles Craddock is Director of the Blood and Marrow Transplant Unit at the Queen Elizabeth Hospital, Birmingham. He began his talk by explaining that MDS was a precursor of AML and that outcomes remain poor, even with novel therapies, because of the significant mutational complexity of the disease.
Novel treatment approaches include azacitidine and antibodies targeting CD33 and CD47 antigens, and lenalidomide in post-transplant patients. Professor Craddock concluded that epigenetic therapies show promise in MDS and AML, but increased antitumour activity is required. He explained that we need to understand the cellular basis for resistance, and combine grafting methods with adjunctive targeted therapies to decrease the chances of relapse. For these patients, the best course of action remains enrolment to clinical trials.
Dr Chris Plummer, a cardiologist with a special interest in the cardiovascular effects of cancer treatments, delivered a terrific lecture. He began his talk by highlighting that cardiac reserve naturally decreases with age because we each irreversibly lose 52 million cardiac cells every year and some cancer treatments effectively speed up this process.
Doxorubicin, for example, is used to treat breast cancer, and the clinical signs of heart failure only become evident >1 year after exposure, meaning that some women who have been cured of their cancer suddenly present with symptoms of heart failure. There are, however, convincing data that pretreatment with angiotensin converting enzyme inhibitors may protect cardiac cells, but for best results the treatment has to be given before or shortly after exposure to anthracyclines.
Dr Plummer concluded that the link between chemotherapy and cardiovascular toxicity is common, and the short-term benefits of cancer therapy must be considered versus life-time risks; furthermore, irreversible damage should be mitigated for where possible.
Dr Eleni Tsiompanou, a former medical oncologist, is convinced that the new revolution in cancer medicine will be nutrition.
She explained that diet can help the immune system combat cancer, and noted that there is evidence of oncogenes being switched off after intensive nutritional and lifestyle changes. Dr Tsiompanou acknowledged that nutrition is not a supplement for cancer therapies, but added that adopting a healthy lifestyle and diet can support survivorship in people with cancer.
Dr Richard Fitzgerald from the University of Liverpool talked about herbal medicines and whether combining these with SACT should be a cause for concern. He kicked off his talk with a ‘guess the herb’ exercise, which made the lecture both engaging and interactive. Studies show that between 30% and 70% of cancer patients self-medicate with herbal extracts in addition to taking prescribed therapies, and some of these herbal extracts may either reduce efficacy or increase toxicity of chemotherapy, depending on how they are metabolised.
Patients with chronic disease often start taking herbal medicines, believing that they are ‘going the extra mile’ with their treatment; use of alternative medicines also offers the patient a level of perceived control over his or her treatment. It is therefore important not to place a blanket ban on their use among cancer patients; however, evidence for the interactions of these herbal therapies with SACT is limited, so their combined use given the potential for harm is a cause for concern that warrants further investigation.
Dr Fitzgerald highlighted the need to educate patients and healthcare professionals on the subject to make sure this information is included in patient histories, and called for tighter regulation of herbal remedies.
OncoRX is an extremely useful onco-informatics database of anticancer drug interactions with complimentary and alternative medicines.
Dr Simon Grumett, Consultant Medical Oncologist at the New Cross Hospital, Wolverhampton, and Helen Flint, Clinical Services Manager at the Clatterbridge Cancer Centre, Merseyside and BOPA Chair, discussed the benefits of and challenges associated with pharmacy-led clinics. Dr Grumett was a great advocate for collaboration with his oncology pharmacist and their working relationship was inspirational and exemplary.
Both speakers concluded that benefits for patients include consistency, longer consultation times, exposure to different skill sets, and a more holistic and educational approach to care resulting in improved patient safety. The main advantages for the service are improved capacity and closer multidisciplinary team working.
The challenges that the speakers identified were as follows:
Dr Kevin Fong has degrees in astrophysics, medicine, and space engineering, and currently works as a consultant anaesthetist at University College London. He is the Anaesthetic Lead for both the Primary Emergency Response Team and Major Incident Planning. Dr Fong delivered a tremendously engaging lecture entitled ‘Extremes’ about exploration and the progress made in medicine that we have seen over the past years.
Dr Fong highlighted that progress in science, medicine and engineering continues to blur the boundaries between science fiction and science fact, and pointed out that anything is possible if we work as a team.
Andrea Crossfield, the CEO of Tobacco Free Futures, discussed whether electronic cigarettes should be viewed as a ‘problem or panacea’. She presented some fascinating statistics before concluding that, although long-term safety of nicotine ‘vaping’ is unknown, ‘vaping’ is probably safer than smoking and is therefore a better alternative to cigarettes for adults who currently smoke.
However, she also warned delegates about the potential for electronic cigarettes to become a gateway to smoking for currently non-smoking teenagers. As such, the key challenge is to limit the marketing of these devices to individuals who currently use tobacco products. There was unanimous agreement that ultimately the aim should be to encourage current smokers to quit completely and to protect young people from ever taking up the habit.
Carl Booth’s research into the use of thromboembolic prophylaxis was awarded this year’s prize for the best oral presentation, while Angela Kiernan’s impressive pre-registration pharmacy project on safety monitoring received this year’s prize for the best poster.
The BOPA Chair, Helen Flint, thanked all the participants for attending, being enthusiastic and contributing to the wonderful BOPA atmosphere. She also thanked the sponsors for their continuous support and the ICC and Succinct Medical Communications staff for making sure everything ran so smoothly.
The 18th Annual BOPA Symposium will take place on 23−25 October at the International Centre, Telford.