The potential of Precision Oncology
Medicine is personal, and physicians have always tried to put the patient first. More than 2,300 years ago Hippocrates, the ‘Father of Clinical Medicine’, said that “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” We know that everybody is different and reacts differently to diseases and drugs. Until recently however, it has been very difficult to get a detailed enough understanding of each individual to fulfil the aspiration of treating every patient individually. But now, for the first time in history, we have technologies that allow us to distinguish the molecular differences between humans and their conditions in health and disease. We can sequence genomes, but we can also map the expression of proteins and metabolites. In combination, these molecular profiles can provide us with an understanding of risk and resistance factors inherited with our genes, but also when and why potential risks become manifest during our life, and how we are affected by our environment, lifestyle, diet and therapies we may receive – information that is better reflected in our proteins and metabolites. Putting these data together is daunting. Written out the sequence of our genome is 9 kilometres long, and the proteome and metabolome are equally complex. Thus, we need computer models to integrate, analyse and interpret these data. Using these computer models we can generate personal molecular profiles for each patient, so that we can fully understand the disease a person has and treat this individual with the best possible therapies.
Now we face a new type of challenge. Personal medicine needs personal data. Developing personal molecular profiles and personalised computer models – how will individuals and society deal with that? The benefits are clear: better therapies, less side effects, better quality of life, and more lives saved. The dangers are less tangible, but there are safeguards. Molecular information can only effectively be used for the purpose we have collected it for, and that purpose and its transparency is
regulated by strict EU and national legislation. However, we recognize that the practical interpretation can sometimes be ambiguous. This is one of many reasons why POI works with all stakeholders so that we can plot a way forward that respects personal rights, promotes research and develops new cancer therapies that are badly needed. By 2020 cancer will have surpassed cardiovascular disease as the number one killer in Ireland, and every second Irish citizen will experience cancer in their lifetime. This future is bleak. Therefore, we have to gather all the tools, all the efforts and all the stakeholders we can to put a silver lining on the horizon.
voice will be heard with the aim to radically change cancer diagnosis and treatment for patients in Ireland and worldwide.
Perspectives on setting up a Research Consortium before and during a global pandemic
I joined the Precision Oncology Ireland (POI) team at the beginning of December 2019 and immediately started helping set up the consortium in my role as Senior Research Administrator. POI consists of five Irish universities, six Irish cancer research charities, and nine companies aiming to develop new diagnostics and therapeutics for the personalised treatment of cancer. It is based out of Systems Biology Ireland at UCD, and the combined SFI, charity, and industrial funding commitment to POI will total €11.9 million over the next five years. The Consortium was officially launched on the 26th of November 2019, and since then, huge progress has been made to establish the programme. Given the complexity of POI as a unique programme which receives funding from SFI, industry partners and Irish charities you can imagine that the process of setting up the programme has not always been completely straightforward, but we are getting there. The POI operations team have been recruited, along with some members of the research team. We have negotiated the majority of our partner agreements to secure our funding. And importantly, we have engaged with academic researchers, charity and industry partners, the patient advocate community, and the public, to communicate what POI is all about.
Back in February, we raised awareness of the consortium through POI being profiled on the RTE1 ‘Nationwide’ programme, which has an almost cult following across the country and is broadcast every weekday evening, reaching audiences in every corner of Ireland. POI Director Prof. Walter Kolch and Deputy Director Prof. Liam Gallagher were both interviewed and featured in the final broadcast programme. They spoke about the research that they and their teams do and shared the importance that precision oncology and cancer research have for patients and society.
POI Director Prof. Walter Kolch walking through SBI for Nationwide segment
Photo from Nationwide segment featuring a patient involvement session in collaboration with the Patient Voice in Cancer Research
POI has also held the ‘Choirs for Cancer’ event on 4th February 2020, to mark World Cancer Day. I helped organize this event, which had over 700 attendees, 10 choirs and 300 singers was hosted by RTE presenters Miriam O’Callaghan and Marty Morrissey and brought together cancer patients, advocates, survivors, and family members to share the story of their cancer journey with the cancer research community. These stories were interspersed with inspirational songs by choirs from across the Ireland including choirs whose members were from cancer support centers or had a link to cancer. Patient advocates shared their personal cancer stories, and cancer researchers spoke of their motivation and progress towards finding new ways to prevent, diagnose and treat this devastating disease. A huge amount of planning and preparation was involved in coordinating all of the speakers and choirs. In the run up to the event I liaised with all the participating choirs who were travelling from all across Ireland to ensure they had all the information they required, helped with any logistical arrangements including parking (which was a bit of a nightmare as UCD isn’t the easiest place to secure event parking) and answered any queries they had. On the day, all of our hard-work and preparation paid off and everything ran to plan with the exception of the Sing for Life Choir’s bus breaking down an hour into their journey from Belfast to Dublin! We didn’t know if they would make it on time to perform, but luckily, they eventually got the bus back on the road and arrived in UCD halfway through the event, just in time to give a beautiful rendition of the song ‘Falling Slowly’. The event was a resounding success, with huge traction on social media (84,000 mentions of #choirsforcancer2020), and photo/video content featured on outlets including the Irish Times and the World Cancer Day highlights video. Furthermore, the event was extremely moving and heartfelt and despite the huge amount of work that went into organizing it, everyone who worked tirelessly in the background felt that the experience was definitely worth the effort and agreed that memories from the day will stay with them for years to come.
February turned out to be a very busy month for POI. We headed west to Galway to hold our first team meeting with the researchers, charity partners and industry partners from all over the country and even further afield. It was lovely to meet everyone there in person for the first time after weeks of preparations to ensure everything would run smoothly on the day. However, unfortunately as I am learning, sometimes no matter how much you prepare there are always things out of your control (like a projector that does not want to cooperate and causes a 20 minute delay to the start of the meeting!).
We also hosted a table at the Patient Voice in Cancer Research ‘Dragon’s Den’ event in Galway on the 25th February 2020. This brought the POI management team members and those with a lived experience of cancer together, with the goal of co-designing a patient involvement plan for the POI programme, based on the insights and experiences of those around the table. On the following day, POI partnered with CÚRAM, the SFI Research Centre for Medical Devices at NUI Galway and Galway Film Centre, in this year’s Science on Screen programme, which will commission a short scientific documentary focused on cancer research. Members of the POI management team, together with patient advocates and researchers, shared their insights with an audience of filmmakers, with the focus of the proposed documentary film being on precision oncology. The pitches put forward by filmmakers are currently being shortlisted, and hopefully the successful candidates will be able to shoot the footage in early 2021. That same day, I manned the POI booth at the Irish Association for Cancer Research (IACR) Annual Conference, and I really enjoyed engaging with the researchers, discussing their current work and providing them with information on POI.
Manning the POI booth at the IACR with POI’s COO Jessica Ralston
So, the going was good and then everything changed. On the 12th of March we all headed home and have remained there since. What is the new reality of continuing to set up the programme remotely? To be honest, things have been running surprisingly smoothly thanks to modern technology and the virtual office environment is working well for us. On the operations side, our work is getting done, grant applications have been submitted and our meetings are still going ahead via Zoom in the comfort and safety of our homes.
An insight into our virtual POI management meetings
The clear negatives are that wet lab-based work has ground to a halt and it is unclear when this may fully resume. Recruitment of new hires to several projects has also been delayed due to Covid19 and this could mean that projects might be running behind before they can even start. Significant milestones have been set out for this programme and these delays could of course impact on the timeline for achieving these. The ban on holding events means that we unfortunately cannot plan any networking or team-building activities for newly hired researchers to meet the POI operations team or other researchers involved with the programme. These events are vital for building relationships and creating a sense of community within the programme so we will need to explore other ways of achieving this remotely.
However, on the positive side, in the overall scheme of a five-year project, any delays at the start of the research projects should not cause too many issues and we will still have plenty of time to get the work done down the line.
Now we must adapt to the current situation and continue to plan ahead. However, it is hard to know what future planned events will look like if social-distancing rules must apply. This is especially true for patient and public engagement activities where some attendees may belong to high-risk groups. Perhaps events such as these will need to be put on hold until a COVID-19 vaccine is available. As we can no longer host seminars in person, we have been forced to think creatively and explore innovative ways to engage our audiences remotely. We are currently planning a virtual tour of our industry partner’s labs and facilities, as well as a virtual seminar series. These are things that we probably would have never considered doing if it wasn’t for the new social-distancing restrictions and one clear benefit to working in this way is that the events are accessible to a wider audience as people can join in from home. So, keep an eye out for the invites to these virtual events as they are sure to be excellent.
So luckily, we are able to continue working and making progress in establishing the programme and we are very thankful for this. If we have any personal regrets though it would have to be that we didn’t take out shares in Zoom last year!
Promises of Tissue based imaging in Cancer research and Diagnostics
Transition to the Age of Digital Pathology
When a cancer patient first comes in contact with the clinician, a plethora of tasks sparks in their mind. These include proper diagnosis, selecting the best treatment option, monitoring treatment response, and lastly following up for recurrence of disease. To establish a diagnosis, biopsy tissue materials are often examined under the microscope by a histopathologist. In traditional practice, histopathologists examine glass slides of biopsy tissue under the microscope and characterise specific features relevant to the disease. Over recent years, cancer diagnosis has gone through a significant change due to a substantial improvement in computational power. Radical development of novel high-throughput imaging tools and image analysis algorithms has facilitated the gradual transition of manual histopathological analysis of traditional microscopy to digital pathology. Digital pathology involves digitising histopathological tissue slides into high-resolution images by scanning the slides with whole-slide scanners, and afterwards analysing the digital images with computer-aided image analysis software. After the slides are digitised to computer images, they can be viewed by a pathologist on a computer monitor, where the image can be magnified and navigated spatially in much the same way as standard microscopy. These scanned images represent the accurate depiction of the tissue slide, and in most cases, offer much more ease and flexibility in detecting complex morphological features of diagnostic or prognostic value. Image analysis software is then used to analyse those features of interest, and extract quantitative data from them that are generally much more accurate and reproducible. Figure 1 shows different steps in manual and digital pathology workflow.
Figure 1: Comparison between the workflow of traditional and digital pathology
For visual assessment of the otherwise transparent tissue samples, the tissue sections go through staining procedures. There are various staining methods used for staining histopathological slides. For example hematoxylin and eosin (H&E) staining, which is used as the routine staining for histological slides, and provides a general overview of tissue morphology. But when pathologists or researchers need to look into more specified features such as presence or absence of specific molecular biomarker (protein/RNA) in cells, other specialised staining techniques like Immunohistochemistry (IHC) and In Situ Hybridization (ISH) are used. IHC uses targeted antibodies to detect a specific protein antigen and ISH uses complementary DNA or RNA strand to localise a particular nucleic acid sequence in the tissue. These antibodies and nucleic acids are normally linked with enzymes or fluorescent dyes, which makes the target visible under the microscope upon binding. Examples of scanned images of some tissue sections with IHC staining can be seen in the figure.
Figure 2: A. Scanned images of IHC staining on different tissue sections showing different levels of expression of a specific biomarker. More intensity of the staining indicates higher levels of the biomarker expression. B. Mark-up image with stained cells detected and annotated by an automated image analysis tool. Different colors of annotation indicates different threshold of staining intensity, blue (+1) indicates weak staining, yellow (+2) indicates moderate staining, and red (+3) indicates strong staining.
Based on these molecules linked with antibodies, there are two different types of IHC techniques: Chromogenic and Fluorescent. Chromogenic IHC depends on the chemical reaction triggered by the linked enzyme molecule and for fluorescent IHC, it’s the linked fluorescent dye. Traditionally, chromogenic IHC detects a single antigen in a slide. This can be a major limitation as cancer is a very complex molecular disease, and to diagnose or predict a proper treatment outcome, multiple molecular events or biomarkers need to be assessed. To solve this issue, Multiplexed Immunofluorescence (mIF) platforms have emerged as a potent tool as they allows simultaneous detection of multiple protein biomarkers on a single tissue section while preserving tumour material. It allows the opportunity to study different components of the tumour microenvironment, providing a better understanding of the cross-talk between the host and the tumour. While not yet used routinely in the clinic, this technique has the potential to dramatically improve diagnosis. Figure 3 graphically represents how multiple targets can be visualised simultaneously in the same tissue with multiplexing.
Figure 3: Tissue section with simultaneous staining of four different markers by Multiplexed Immunofluorescence. The schematic is a simplified representation of a magnified portion of the tissue showing cells expressing varied combinations of the three markers and a special fluorescence dye to light up all nuclei in the tissue (DAPI).
Deciphering Tumour Immune Contexture with Multiplex techniques
In recent years, there has been huge interest in the scientific community on mapping the immune architecture of tumours, and tissue-based multiplexed techniques have become one of the most desired tools for executing that. A tumour microenvironment hosts a highly diverse network of immune cell populations which collectively plays a vital role in tumour progression. A lot of different Immune therapies have been developed over the years which attempt to stimulate these immune cells to trigger a desired anti-tumour response, contrary to conventional cancer therapies that target tumour cells directly. Lately a good number of those therapies have also found major clinical success, although in a lot of cases it is still not properly understood why many patients do not respond to these treatments and/or experience immune-related complications. Recent research data suggest that tumour’s response to these immunotherapeutic approaches depends on the presence of specific immune cells in the tumour. These Immune cells surrounding tumour cells commonly referred to as tumour infiltrating lymphocytes (TIL) reflect the host’s immune response against the tumour cells. Numerous research studies have established that the composition of these TILs has significant deterministic value in disease prognosis for various cancer types like Breast cancer, Lung cancer, and colorectal cancer. Along with the presence of different immune cells in the tumour, there are other distinct features of TILs that have potential clinical significance. That is why characterisation or profiling of immune contexture in tumours requires detailed information about the tumour microenvironment, density of different immune cell populations, and their spatial arrangement. Here, spatial arrangement refers to the co-localisation of different immune cells in relation to the tumour cells and among themselves (Figure 4). In a recent study with non–small cell lung cancer, all these spatial features of TILs are found to have predictive value in the likelihood of the recurrence of cancer after chemotherapy. As proper characterisation of TILs demands multiple spatial features to be assessed together, multiplexed staining platforms have emerged as an ideal tool for immune profiling in cancer research. In contrast to other tissue-based imaging tools, multiplexed platforms are the only platforms that allow studying the spatial distribution of multiple immune and non-immune biomarkers and the interactions among them.
Figure 4: Schematic representation of tumour microenvironment showing tumour infiltrating lymphocytes, epithelial cells, fibroblasts, blood vessels, other immune cells (macrophages, dendritic cells).
Incorporation of Artificial Intelligence in Digital Pathology
Along with the use of high-end imaging tools in clinical and research practice, the need for increasing translational outcome of these tissue-based biomarkers have continued the innovation of new and superior image analysis approaches. Over time in tissue-based biomarker analysis, more and more complex and sub visual features are being explored in clinical practice and academic research. Moreover, the enormous amount of data being generated from these advanced imaging tools has made management of diagnostic workflows increasingly tough. That is why there’s an increasing need to develop tools for pathologists to help them in achieving significant growth in clinical outcome. Artificial Intelligence (AI) comes right into play here. In simple terms, AI is machine-based approaches that emulate human intelligence; its purpose is to try making predictions like an intelligent human does. Integration of AI in image analysis of tissue-based biomarkers offers far more efficient and robust extraction of clinically relevant data from a large patient population and reduces human error to a large extent. It makes a subjective assessment of images quantifiable and extremely reproducible. In recent times, AI approaches for image analysis are shifting towards Deep Learning, which is based on artificial neural networks that imitate the learning process of the human brain. The way deep learning works in pathology is that pathologists feed the network with annotations of a feature in an image (e.g. – blood vessel), and then the neural network learns from those annotations like a human does and later tries to detect those features by itself in the tissue specimen. The more input data it gets, the more precise it gets at identifying the feature of interest and found to match or in many cases perform even better than humans.
There are still quite some challenges to integrating AI in regular clinical diagnostics exclusively. Nevertheless, the potential is boundless. We are in an age where treatment strategies are more and more being tailored to individual patients. Since advanced tissue-based imaging technologies offer ways of acquiring and assessing patient-specific clinical data with far more accuracy and precision than usual, these technologies are now growing immensely in popularity and demand in histology labs, hospitals, universities, and pharmaceutical companies worldwide. Many of them are leaning towards digitising their entire workflow. Over the next ten years, progress in this field will undoubtedly transform the field of oncology and related medical diagnostics. Ultimately, given the phenomenal rise of machine learning and AI, one can only imagine the sensational advancements that will be uncovered in the field of medicine in the next decade.
Author: Chowdhury Arif Jahangir, POI PhD student
After completing a Master's degree in Molecular Biotechnology under a joint program by Karolinska Insititute and University of Skövde (Sweden), Arif received a research assistantship at Karolinska institute. There Arif worked on investigating the molecular mechanism behind antioxidant induced lung cancer metastasis. After completing the project, Arif joined the Cancer Biology and Therapeutics Lab at UCD as a research assistant and worked under the OPTi-PREDICT project funded by SFI. Arif received his 1st class undergraduate degree (BSc) in Biotechnology from the University of Rajshahi (Bangladesh).
In May 2020, Arif started his Ph.D. with POI, under the supervision of Professor William Gallagher. His project aims to explore the interplay between master transcriptional regulators and immune cells within the tumor microenvironment of breast cancer. His project is co-funded by the Irish Cancer Society.
Doing a PhD during a global pandemic
The first mention of the virus was during lunchtime in the lab on a dull January afternoon. This was followed by a few concerned nods and a light debate before someone mentioned Netflix’s new show and the conversation moved along. Little did we know in a mere few months, a global pandemic would be announced and we would be shutting up shop. At this stage I was only six months into my PhD.
Rumours of lockdown started to circulate on a Wednesday morning amongst the research teams. Later that day, an official email was circulated confirming the closure of the lab until further notice. This was met with a wave of anxiety from my lab group. How would our work get done? What if one of us got seriously sick? A lab meeting was subsequently called and following some encouraging words from our supervisor, we hugged goodbye and parted ways not knowing when we would meet again. As I walked home my mind wandered to our charity partner NBCRI and how vital funds would be raised during this time. I also thought of those with BreastCheck appointments or those receiving treatment and how these people would be accommodated.
My mum, a natural worrier, wanted my sisters and I home once a nationwide lockdown was announced. I am part of a large family of six, the eldest of three sisters, mum, dad and of course our two dogs. It had been a good few years since we had all lived under the same roof so as you can imagine, adjusting to this was a challenge. There were arguments over the internet, noise during video calls and even who ate the last piece of cake put aside for someone else.
While initially I found it hard to be productive during such an uncertain time, developing a routine over the first few weeks helped me adapt to the change in my working day. Our weekly research meeting and journal club recommenced in a new virtual format bringing with it some normality. While I missed the physicality of lab work, this new way of working was a welcomed change. I began to do more in-depth reading around my project and worked on my scientific writing- even beginning a draft of my thesis introduction! I found I began to look forward to our group meetings on a Monday but mostly just to see that everyone was doing okay and to talk to someone other than my family! As the weeks went by and restrictions were slowly lifted, I began to wonder if we might actually get back to Galway. This was met with enthusiasm from our supervisor who mentioned a return to lab plan was in the works. Our research meetings became more intense but exciting as we all prepared plans and conducted order lists in preparation for our return.
On the 29th of June, following countless meetings, induction videos and forms, I finally stepped back into the lab after four months of working from home. The “new normal” took some time to get used to with most of us finding the first few weeks tough. Masks became mandatory making it hot and claustrophobic during work while glasses wearers had an additional challenge to face- fog! The lab days were short (due to rotating shifts) and lonely as we were capped at 25% capacity meaning little to no interaction. I think I found the lack of socialising like grabbing a coffee with a friend to rant or enjoying lunch together the hardest part to get used to.
As the weeks progressed, we were rewarded with longer working hours and increased capacity. This made the days easier, as we were able to meet (Two meters apart of course) and chat with each other. Finally, almost six months to the day since the closure of our lab, we had our first in person, socially distanced research meeting. This in itself brought a real sense of normality to my working day as we shared results and gave feedback to each other.
While there are of course still restrictions in place, I feel hopeful that my lab work will continue to be productive as the months go on. Doing my PhD during a global pandemic has been challenging but has given me a fresh perspective on what is important in life. I am grateful for my fantastic research group and supervisor who have been so helpful and understanding during these strange times. Despite the many arguments, I’ve learnt to appreciate my family more, as well as little things like a walk on the beach and brunch with a friends- something taken away from us all.
It is hard to believe that it has been almost a year since the launch of POI and the beginning of my PhD journey. While a difficult year, I look forward to the work to come, and in particular to being part of a large network of individuals striving to make a difference.
Author: Elan McCarthy, POI PhD student
In October 2019, Elan McCarthy started her PhD with POI, under the supervision of Dr Róisín Dwyer at NUIG. Previous work by this group demonstrated the potential of EVs for treatment of advanced breast cancer. Elan’s project is focused on understanding how these vesicles interact with the immune system, and will be critical to successful translation of this approach to the clinical setting. Her project is co-funded by the National Breast Cancer Research Institute.
Could bacteria function as tissue agnostic cofactors for checkpoint blockade immunotherapy?
Written by: Dr. Sidney Walker, POI Postdoctoral researcher
Immune checkpoint inhibitors (ICI) have provided a disruptive breakthrough treatment strategy for some tumours by reversing the immune privileged status that allows them to survive and grow. Unfortunately, objective response rate is low, not exceeding 30%. This low success rate has prompted the search for biomarkers indicative of an improved outcome. The key biomarker discovered to date is the correlation between high mutational burden, and effectiveness of the ICI therapy. Conversely, antibiotic treatment prior to ICI treatment is known to worsen clinical outcomes in patients receiving this therapy.
The human microbiome is considered a de facto organ with functions in digestion and metabolism, including drug metabolism and immune system regulation among many others. This makes it a logical starting point, especially given the effect of antibiotics.
A potential relationship between the microbiome and ICI treatment outcome was confirmed when it was showed that increased microbial diversity in the gastrointestinal tract corresponded with increased success of immune therapy treatment. These findings have been expanded upon again to show that responders and non-responders to ICI can be stratified based on their gut microbiome, with a panel of bacterial taxa associated with the specific outcome being identified in both groups. It must be said that the underlying mechanism for this remains unclear, and that there is yet to be a consensus on these panels of outcome associated bacteria between studies.
Relationships between bacteria and response to ICI targeting cytotoxic T lymphocyte associated antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1) have been identified in multiple tumours to date including:
- Non small cell lung carcinoma
- Renal Cell Carcinoma
- Urothelial Carcinoma
- Small Cell Carcinoma of the Head and Neck
Faecal Microbiota Transplants (FMT) from human responders into mouse models has been shown to improve response to ICIs, which confirms the key role played by the gut microbiome. As such, progress must be made to identify the underlying mechanisms modulating ICI efficacy before this information can be translated into a therapeutic strategy.
The current cutting-edge research into this potential therapeutic avenue shows that not only FMT (containing billions of diverse bacteria), but also specific bacterial taxa cultured and administered to mice have a significant impact on their response rate. The prime example is B. pseudolongum, a key metabolite of which is the nucleoside inosine, found to enhance the effect of anti-PD1 treatment through enhanced activation of anti tumour T-cells. This process is accelerated by the degradation of gut barrier function which is a side effect of immunotherapy. This was observed across a spectrum of tumour types such as colorectal cancer, bladder cancer and melanoma.
It is premature to state whether such effects could be repeated in humans, and considerable research is still required, but results in preclinical models raise the prospect for the following precision medicine treatment strategies:
- At a minimum, point of care sequencing using rapid turnaround tabletop sequencing technology to rapidly stratify patients into appropriate treatment group prior to therapeutic intervention.
- The ideal endpoint would be personalized treatment based on the results of (i) where targeted antibiotics are used to remove antagonists of ICI function, and create a niche if necessary, to be colonized by known agonists of ICI function.
About the Author: Sidney completed a PhD in Bioinformatics investigating the tumour microbiome in 2019, and now works as a post-doctoral researcher in the Dr Mark Tangney's lab in UCC. His project in POI is co-funded by Breakthrough Cancer Research.
Barrett's Biobanking and registry
Written by: Rebecca Anderson
Barrett’s oesophagus is a pre-cancerous condition which involves the development of abnormal cells in the lower oesophagus. This is understood to be caused by persistent acid reflux over a long period of time. The main symptoms of Barrett’s oesophagus are acid reflux and indigestion, and the condition is diagnosed by an endoscopy (a camera test) and histological examination of small biopsies (cell samples) taken during this test by a scientist in the laboratory. Thankfully, less than 1% of people who have Barrett’s oesophagus go on to develop cancer, but it remains important that we monitor patients with Barrett’s for progression of their symptoms, and work to understand better the connection between Barrett’s oesophagus and oesophageal cancer development.
A biobank is a large collection of biological samples and their accompanying medical information which can be used by scientists to do research. The Barrett’s biobank is a collection of tissue samples, blood samples and gastric juice samples from patients with Barrett’s oesophagus who have agreed to be involved in research into the condition. These samples are taken during the patient’s routine surveillance camera tests and are stored in the trinity translational medicine institute in St James’s hospital Dublin until they are needed for research. The Barrett’s biobank is an incredibly important resource for scientists interested in the condition, and allows them to ask questions about how Barrett’s oesophagus develops, and why some patients progress to cancer while others don’t. The power of a biobank is in its size. The more samples involved in asking a research question the more robust the results of experiments are, and we are very grateful to the patients who allow us use their samples.
As well as the Barrett’s Biobank, which allows scientists do laboratory research on the condition, we also maintain the Barrett’s registry, which contains the pertinent medical information of patients diagnosed with Barrett’s oesophagus. The registry is a national effort managed from St James’s hospital in Dublin, and involves hospitals from all over the country. We can use the registry to run audits, which allow us to ensure patients with diagnosed Barrett’s oesophagus are being monitored, and are having regular surveillance endoscopies. We can also use audits to track trends in the diagnosis of Barrett’s oesophagus in Ireland as well as in progression of the condition more generally.
The biobank and registry are powerful tools which allow us to better understand the condition of Barrett’s oesophagus and our patients. The overarching aim of the Barrett’s oesophagus biobank and registry is to improve patient care, whether through laboratory research using biobanked samples or careful monitoring of the condition through registry audit.
About the Author: Rebecca Anderson is the Barrett's Oesophagus Data and Biobank Manager in Beaumont Hospital. Her project in POI is co-funded by the Oesophageal Cancer Fund.
Making public and patient involvement in research a reality in Precision Oncology Ireland
Written by: Dr. Fiona Lanigan
Since the launch of Precision Oncology Ireland (POI) in November 2019, we have always strived to involve cancer patients and their families in our research as much as possible. During the patient forum held at the launch event, participants spoke of how they felt that being involved with cancer research gave them hope, a feeling of some power over their condition, and also the opportunity to give back to research, which in some cases had been instrumental in their treatment and recovery.
However, implementing public and patient involvement (PPI) in research at a practical level is not without its challenges. Depending on the research project, it can sometimes be difficult to understand how best to involve patients in the research in a meaningful and non-tokenistic way. This is particularly true for research projects at an early stage of their development, where the research may be focused on understanding how a particular process drives a tumour cell to grow, rather than developing a specific treatment for it, which would come at a later stage.
Another challenge we came across early on when developing plans for PPI was the fact that the research projects within POI had been defined when the funding proposal was submitted. Obtaining research funding can be a long drawn-out process, and the foundation of the POI research projects had been set out several years previously following extended discussions between academic researchers and partner organisations. Each of the research projects within POI, which are comprised of a mix of early-stage and later-stage research, are co-funded by Science Foundation Ireland plus an industry or charity partner. If the direction of this research was already defined, would it be fair for us to invite patients to be involved at this point, and give of their time, unless there was scope for us to implement the changes they might suggest?
It was with these questions, and more, in mind that we first heard about an initiative led by the Patient Voice in Cancer Research (PVCR). The PVCR was established in UCD in 2016 and aims to facilitate dialogue between patients and researchers so that the lived experience of cancer patients can enrich, inform and shape the research process.
They had planned an event in association with the UK-based National Cancer Research Institute, to be held in Galway in February 2020, called the ‘Dragon’s Den’. The idea behind this format was that researchers would apply to the PVCR to have their proposal or idea heard by a team of ‘Dragons’ – those with a lived experience of cancer who had applied to participate in the initiative.
Who better to advise us on how to involve patients in our research but the patients themselves? We drafted a PPI strategy as a starting point for our discussions, and set off for Galway to present it to the Dragons, hoping that they wouldn’t be too fearsome!
In those golden days pre-COVID, the PVCR events were a hugely social occasion, and we enjoyed the informal interaction with attendees and the buzz of the event, before sitting down with our team of eight Dragons.
We started our pitch by explaining why we as a research programme wanted to involve patients in our research: to improve the relevance of our research to patients, to define areas of unmet need for future research projects, and most of all, to make patients, who are ‘experts by experience’, our partners in research. We discussed the focus and scope of our research projects, and the spectrum of activities we hoped to participate in, from patient engagement (communicating to patients or imparting information) to patient involvement (actively partnering with patients in developing research). We outlined the questions and challenges that we had been grappling with in developing our PPI strategy, most of all the fact that we wanted our PPI activities to be achievable, worthwhile, and mutually beneficial. We then handed the floor to our 8 Dragons for their feedback.
The first key point made was that PPI is a two-way street. We as researchers may often feel that we are asking too much of patients, but they can say no if they do not want to be involved - we should not be afraid to ask. That said, our Dragons wanted this involvement to add value to the research process and not be tokenistic. One suggestion to ensure contributions were meaningful was to include patient representative(s) on the Governance Board, where they could bring not only their lived experience as a cancer patient to the table, but also their life skills and career experience. The difficulties in incorporating PPI into pre-existing projects was acknowledged, but this process is about developing partnerships in the longer term, so that future research programmes in the pipeline take patient input into account from the start. A suggested starting point was to hold a ‘POI research showcase’ where POI research projects were presented to a public and patient audience in an accessible way, allowing them to gain insight into the ongoing work and provide input from their perspective where possible. This may then lead to more in-depth partnerships over time.
The group also suggested practical ways that patients could be involved in promoting the importance of research to the wider public, such as partnering on community engagement events, and participating in the dissemination of research outputs. On a practical level, the importance of adequate compensation to ensure patients are not out of pocket due to participation in PPI activities, and acknowledgement of contributions in grant proposals, research publications or presentations, where appropriate, were highlighted. The point was also made that PPI participants were often a highly pro-active and self-selecting group, and more effort should be made to engage with seldom-heard groups and minority communities by attending or organising smaller local events targeted at these specific groups, or facilitating online events for those unable to travel.
We could not have foreseen that this would be the last time for a long while that we would meet other people to physically sit around a table, and we enjoyed the experience enormously, as well as gaining some insights into how best to map out our PPI strategy. Feedback from the Dragons to the organisers was also very positive, and in general this format of event has a lot to offer in terms of bringing patients and researchers together to facilitate PPI.
Based on the advice received, we have implemented some changes to our programme, outlined below. On top of this are the enforced changes to all our lives following the spread of COVID worldwide, which has brought some surprising benefits in terms of accessibility, as well as the obvious downsides.
- We are planning to hold a virtual ‘POI Showcase’ in 2021, which will be co-developed with patients. This aims to bring POI researchers and patients together to discuss and provide input on aspects of POI research, or proposed projects for the future. We hope that similar events in the future can be held in person!
- We have included patient representation on the POI Governance Board with the appointment of Jan Rynne, a hugely experienced patient advocate who will bring her unique insight to the Board.
- The Dragons suggested that POI should engage with the public by organising lay talks relating to POI research. Since February 2020, we have held 4 virtual public research talks in collaboration with various charity partners and patient advocacy groups.
- Based on the suggestion that more efforts be made to engage with under-represented groups, POI have worked together with the leaders of selected minority community groups to co-create a programme of engagement activities for Science Week 2020, funded by Science Foundation Ireland (For more info, see http://www.precisiononcology.ie/engagement/invisiblespectrum/) . We hope that this will be a starting point for further activities aimed at engaging minority groups in our research.
- We have also included in our publication policy that the contribution of PPI participants to research projects should be acknowledged in all research outputs going forward.
We would like to thank all of the PVCR Dragon's who contributed their insight and patient experience to help develop our PPI plan. If you are a patient or interested stakeholder (patient advocate, family member, carer, health care professional, policy maker) interested in sharing your experience and expertise and becoming involved in PPI in Precision Oncology Ireland, contact email@example.com, or contact firstname.lastname@example.org to find out more about the Patient Voice in Cancer Research.
About the Author: Dr. Fiona Lanigan is the Communications, Dissemination and Public Engagement Manager with Precision Oncology Ireland
The importance of nutrition in cancer care
Precision nutrition aims to tailor dietary advice to fit the specific needs of an individual1. This is particularly important for patients undergoing cancer treatment, in order to minimise weight loss and malnutrition. Malnutrition and weight loss, affects up to 56%2 and 70%3 of cancer patients respectively. Both factors actually lower cancer treatment tolerance, leading to reduced chemotherapeutic dose3. High-protein, high-energy diets are often required to circumvent this weight loss. This may seem at odds with current healthy eating guidelines, however, cancer is a unique scenario, wherein energy and nutrient requirements can be quite high, as cancer really affects metabolism, and appetite is often poor4.
Despite increasing awareness that specialist dietitians should be included as core members for many cancer types, inadequate resourcing means that most tumour MDTs have limited or ad-hoc dietetic service provision at best. It is estimated that between 1/3 to 2/3 of malnourished cancer patients receive no nutritional advice5. A study conducted in Irelands 9 specialist oncology centres by Lorton et al., which included 200 patients, the majority of which had gastric or hepatobiliary cancer, found that referrals to a dietician in both inpatient and outpatients were “reactive rather than proactive”, in response to weight loss. 45% of dietician referrals should have been made sooner according to the oncology dietitian while only 1/3 of patients received nutritional screening2. A survey of malnutrition in Ireland conducted by Sullivan E.S et al., in 1073 cancer survivors shows similar results with only 39% of those surveyed having been assessed by a dietician. This is despite 45% of this group having diet related problems and 89% of responders saying diet was ‘very/extremely’ important in cancer care, highlighting just how many of these patients need and want dietary guidance6 .
However, lack of referral is not the only hurdle cancer patients must overcome to receive sound nutritional advice. Currently, there is only 1 dietician per 4500 cancer patients in Ireland making access limited6. According to Professor John Reynolds of St James’ Hospital and Trinity College Dublin, a leading expert in Gastric Cancer, it would cost €1.6 million to hire the necessary oncology dieticians and provide services for the 10,000 cancer patients in need of nutritional screening each year. This cost, however, could be off-set by savings made in the cost of treatment, as malnourished cancer patients have longer hospital stays, suffer increased chemotherapy toxicity and dose reduction, frequent hospital readmission and reduced quality of life (QOL)7,6. Indeed, a landmark study in Australia determined that the cost benefit of screening for malnourished patients outweighed the cost of putting these screening systems in place8.
The main goal of cancer nutrition is improvement or indeed maintenance of nutritional status, with a particular focus on maintaining lean mass9. Lean mass refers to body weight excluding fat mass (concentrated in adipose tissue), wherein skeletal muscle mass is a large component. This will reduce treatment associated side effects, aid post-surgery recovery and improve patient’s QOL. Cancer patients are one of the most malnourished group in the hospital setting8. Many patients have nutrition ‘barriers’ that prevent them from eating normally such as anorexia, nausea, vomiting and difficulties in swallowing2. Cancers of the digestive tract cause the most severe weight loss, while some like breast cancer can cause weight gain or no changes in weight at all2. Work conducted by Dr Oonagh Griffin in St Vincent’s University Hospital Dublin demonstrated that unintentional weight loss and resultant malnutrition can be easily missed in patients who were obese prior to diagnosis10. When creating a nutrition plan for these patients, it is important to take their individual symptoms, cancer type and personal tastes into account. For those with difficulty swallowing, softer foods and things like soup which are easy to swallow are key for getting in calories and nutrients. Resources recommend eating smaller more frequent meals rather than 3 large meals which can lead to people feeling full quickly. A patient centred cookbook created by Dr Aoife Ryan and Eadaoin Ni Bhuachalla called ‘Good nutrition for cancer recovery’ is an amazing resource full of high protein, calorie rich recipe ideas (Figure 1). It also includes advice for patients at the beginning of the cookbook for each barrier they may face, for example ‘Avoid greasy, spicy and sugary foods with strong odours’ for those with nausea and vomiting11.
Figure 1: Good nutrition for cancer recovery
When your appetite is poor, achieving adequate energy and protein intake is challenging. Protein is essential for maintaining lean mass, tissue repair and also helps patients withstand the effects of chemotherapy and prevent further weight loss. Protein requirements for healthy individuals is 0.8g/Kg each day, this increases to 1.2-1.5g/Kg per day for cancer patients12. Therefore, a woman weighing 60kg would need around 90g of protein a day. Or a 90kg man would require 135g per day. To put that in perspective, Figure 2 presents food portions that deliver 30-40g of protein. A medium sized chicken breast (100 grams), for example, provides 31 grams of protein. However, many patients do not meet the protein requirements for healthy individuals, not to mind cancer recommendations, due to treatment and/or symptom related side effects. Protein is particularly important for those with cancer cachexia. Cancer cachexia refers to the rapid unintentional weight loss, particularly associated with significant loss of lean body mass, seen in many cancer patients. Patients with cachexia have an altered metabolism which shifts away from muscle building towards the breakdown of muscle13. A study conducted in UCC in foregut cancer patients found the prevalence of cachexia to be as high as 62%14. It is a complex response to malignancy and/or cancer treatments of which there are few treatment options. However, maximising protein and energy intake is paramount for these patients to minimise its affects.
Figure 2: What 30-40g of protein looks like in food. It is equivalent to ~ ¾ L skimmed milk, 5 boiled eggs, ¾ chicken breast or ~ 3-4 oz of cooked mince.
As well as ensuring adequate levels of fat and protein, vitamins and minerals are an important part of any diet but especially cancer patients. As cancer can adversely affect appetite and eating habits, many cancer patients may not get their recommended amount of essential vitamins and minerals15. It is estimated that 72% of cancer patients are vitamin D deficient16, compared to 20% of the general population17. Vitamin D is obtained through vegetables (vitamin D2), oily fish, fortified foods and the exposure of skin to sunlight (Vitamin D3). It is responsible for a healthy skeletal system and helps regulate calcium in the body15. The VITamin D and OmegA-3 TriaL (VITAL) was a large randomized clinical trial in 25,871 men and women that investigated whether dietary vitamin D3 or fish oil supplementation reduced the risk of developing cancer. While vitamin D supplementation did not significantly reduce cancer incidence, post-hoc analysis of the 5-year primary prevention study demonstrated a possible reduction in fatal cancer with vitamin D supplementation, depending on subject’s body weight18. Advanced cancers (metastatic or fatal) were significantly reduced following vitamin D supplementation if the subjects were not overweight or obese. However, it is important to note that evaluating Vitamin D status in the acute phase of inflammation or cancer is a challenge. C-reactive protein, a common marker of inflammation, is associated with lower serum 25(OH)D (vitamin D) levels and therefore may not be an accurate reflection of vitamin D status. In addition, 90% of vitamin D is bound to vitamin D binding proteins so measuring free serum levels may not give the most accurate result19,20. More work is needed in this area to improve our understanding of micronutrient status, including sensitive methods of measuring Vitamin D, in the presence of cancer.
Despite the importance of adequate vitamin and mineral intake, specialists do not advise exceeding the recommended daily dose. If a patient is struggling with food intake a multi-vitamin can be taken but it is imperative to consult with the oncologist before taking any new medication. As vitamins and other herbal supplements are not well regulated, it can be difficult to know what you are truly getting. Herbal remedies might seem harmless but some such as St John’s wort has been shown to decrease the efficacy of certain medications including chemotherapy21. As dietary advice for patients can be lacking, it is natural for those with cancer to seek information online. While there can be many great resources for patients, such as the cookbook I mentioned above as well as the Memorial Sloan Kettering integrative cancer centre, there is also a lot of false information out there. Extreme diets that cut out entire food groups and claim to cure cancer can do more harm than good. It is best to consult your doctor before making any drastic changes to your diet.
Receiving a cancer diagnosis can be a devastating time in a person’s life. Patients are often given lots of information at once and it can be difficult to take it all in. Diet may not even enter a patient’s mind until they start to experience symptoms that affect their eating and by then it may have already affected their weight. Conversely, adopting dietary changes may be at the forefront of some people’s minds as it may be the only component of treatment they feel can choose or control. Dietician referral should be integrated into first line cancer care, not just after surgery or when major weight loss has occurred. This could help save the lives of many patients, giving them the accurate information they need to make well informed decisions about their health. To make this possible, nutritional screening, well defined referral criteria and education and resourcing of relevant dietetic staff is necessary to bring about the necessary changes and improve the lives of cancer patients.
About the Author
Rianna started her PhD in January 2020 with Professor Helen Roche in UCD. Her project is focused on finding a biomarker for individuals with cancer cachexia and sarcopenia in the hopes of determining who will benefit from the drug Anamorelin by Helsinn.
Authors: Rianna McElroy (1), Oonagh Griffin(1)(2) & Helen M Roche (1)(3).
1. School of Public Health, Physiotherapy and Sports science. UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, 4 Dublin, Ireland.
2. National surgical centre for pancreatic Cancer, St Vincent’s University Hospital, Dublin 24, Ireland.
3. Nutrigenomics Research Group, UCD Institute of Food and Health, UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, 4 Dublin, Ireland.
- Juan de Toro-Martín BJA, Jean-Pierre Després,Marie-Claude Vohl. Precision Nutrition: A Review of Personalized Nutritional Approaches for the Prevention and Management of Metabolic syndrome. Nutrients; 2017. p. 913.
- Cliona LM, O G, K H, F R, G S, N G, et al. Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2020;28(5).
- Louise Daly, Ross Dolan, Derek Power, Éadaoin Ní Bhuachalla, Wei Sim, Marie Fallon, Samantha Cushen, Claribel Simmons, Donald C. McMillan, Barry J. Laird, Aoife Ryan. The relationship between the BMI‐adjusted weight loss grading system and quality of life in patients with incurable cancer. 2020;11(1):160-8.
- Maria Rohm AZ, Juliano Machado,Stephan Herzig. Energy metabolism in cachexia. EMBO reports: EMBO reports; 2019.
- Xavier Hébuterne EL, Mauricette Michallet,Claude Beauvillain de Montreuil,Stéphane Michel Schneider,François Goldwasser. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN Journal of parenteral and enteral nutrition. 2014;38(2).
- ES S, N R, E K, A K, JV R, J F, et al. A national survey of oncology survivors examining nutrition attitudes, problems and behaviours, and access to dietetic care throughout the cancer journey. Clinical nutrition ESPEN. 2021;41.
- Kim DH. Nutritional issues in patients with cancer. Intestinal research2019. p. 455-62.
- AG B, JM L, BL S. Using a public hospital funding model to strengthen a case for improved nutritional care in a cancer setting. Australian health review : a publication of the Australian Hospital Association. 2013;37(3).
- Norleena P. Gullett VM, Gautam Hebbar, Thomas R. Zieglerc. Nutritional Interventions for Cancer-induced Cachexia. Curr Probl Cancer.2012. p. 58-90.
- Neil B, Oonagh G. Nutritional considerations for the management of the older person with hepato-pancreatico-biliary malignancy. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2021;47(3 Pt A).
- Good Nutrition for Cancer Recovery – a nutritional resource for the treatment of cancer‐induced weight loss - Ní Bhuachalla - 2016 - Nutrition Bulletin - Wiley Online Library. Nutrition bulletin. 2021;41(2):151-4.
- P R. Nutrition in Cancer Patients. Journal of clinical medicine. 2019;8(8).
- T A, KP T, A R, H M, K T. Cancer cachexia, mechanism and treatment. World journal of gastrointestinal oncology. 2015;7(4).
- LE D, ÉB NB, DG P, SJ C, K J, AM R. Loss of skeletal muscle during systemic chemotherapy is prognostic of poor survival in patients with foregut cancer. Journal of cachexia, sarcopenia and muscle. 2018;9(2).
- Kurt A. Kennel MTD. Vitamin D in the cancer patient. Curr Opin Support Palliat Care.2013. p. 272-7.
- Ali A, Berna KE. Vitamin D deficiency in cancer patients and predictors for screening (D-ONC study). Current problems in cancer. 2019;43(5).
- Abigail Cowan RPMaAM. Treatment of Vitamin D Deficiency in Adults. Wirral University Texas; 2020.
- PD C, Division of Preventive Medicine BaWsH, Harvard Medical School, Boston, Massachusetts., WY C, Department of Medical Oncology DFCI, Harvard Medical School, Boston, Massachusetts., ON A, A H, et al. Effect of Vitamin D3 Supplements on Development of Advanced Cancer: A Secondary Analysis of the VITAL Randomized Clinical Trial. JAMA Network Open. 2020;3(11).
- MC S, TW F. Does serum 25-hydroxyvitamin D decrease during acute-phase response? A systematic review. Nutrition research (New York, NY). 2015;35(2).
- DANIEL D. BIKLE EG, BERNARD HALLORAN, MARY ANN KOWALSKI, ELIZABETH RYZEN, JOHN G. HADDAD. Assessment of the Free Fraction of 25-Hydroxyvitamin D in Serum and Its Regulation by Albumin and the Vitamin D-Binding Protein. The Journal of Clinical Endocrinology & Metabolism. 2021;63(4):954-9.
- Josefson D. St John's wort interferes with chemotherapy, study shows. BMJ. 2002;325:460.