We are in an amazing era of oncological development. Since the turn of the millennium, the management of cancer has changed significantly. However, rapid progress presents new challenges.
In 2000, radiotherapy was still largely an analogue two dimensional process. There were limited options for chemotherapy, and the first monoclonal antibody treatments for cancer were just coming into clinical use.
Cancer treatments, both radiation and systemic, are now more precise. New biological agents become available practically every month. While we are still using much of the same chemotherapy that we have used for the past 50 years, its importance is gradually decreasing. The results of cancer treatments, both for cure and for control, have generally improved. The prognosis for some cancers, such as malignant melanoma, and renal cell cancer, has transformed over the past 20 years. For other cancers, such as high-grade brain tumours, there is still a long way to go.
It can be easy to forget that improvements in cancer outcomes do not depend purely on new pharmaceuticals, equipment and infrastructure. The delivery of cancer treatments requires an expert multidisciplinary workforce, but this cannot simply be purchased – it has to be developed over many years, as new therapies require increasing specialisation in all areas of cancer care. More people with cancer are living longer, and there are more lines of complex treatment. There has also been a natural increase in cancer incidence due to factors such as population ageing. As a result, the amount of clinical work continues to grow.
Sustainability of the cancer workforce is a perpetual issue. Human resources teams are struggling to keep up with the demand. For example, in 2020 the UK was about 190 consultant clinical oncologists short, and 55% of consultant vacancies remained unfilled after one year, up from 29% in 2015. This deficit is expected to grow. The problem applies to a variable extent across all cancer-related specialties, both medical and non-medical. Scientific progress has outpaced clinical delivery. To keep up, we need to prioritise investment in training a specialist workforce.
Despite this shortfall in expertise, it is impressive how quickly new anti-cancer drugs come into clinical use after receiving approval and funding. Within reason, an oncology consultant can prescribe a new drug straight away, even if the infrastructure creaks just a bit more each time.
There is an added difficulty, however, with using therapeutic radiopharmaceuticals such as radioligand therapy. In the UK, for example, clinicians need a special licence from the Administration of Radioactive Substances Advisory Committee (ARSAC) for each type of therapy. Given the potential hazards of radioactive drugs, rigorous licensing is important. However, the process is not quick, and each new ARSAC license requires formal registration, mentoring and logged clinical experience.
Thus far, ARSAC’s licensing process for radioligand therapy has been manageable largely because current treatments are used for rare cancers, allowing expertise to be concentrated in a few tertiary delivery centres. There will be an immediate problem, however, if new radioligand therapies are approved for common cancers, where patient numbers potentially justify the provision of the treatment in many UK centres. There simply are not enough ARSAC licence holders to prescribe new radioligand therapies to people with common cancers at present, and the ARSAC licensing machinery will struggle to deliver in a timely fashion if there is a rapid increase in demand.
There are at least eight radiopharmaceutical therapies in phase 3 trials, and even more at an earlier stage of development. To successfully integrate these therapies into cancer care requires innovative planning and concerted efforts to expand the cancer workforce. Such planning needs to become a standard part of cancer service commissioning, with some urgency, to ensure the sustainability of our health services.
Dr Martin Rolles, Consultant Oncologist, South West Wales Cancer Centre; Radiotherapy Lead, Wales Cancer Network