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www.cancerworld.net Issue 90 Summer 2021
Scan to access
our website Shaping the future of cancer care
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‘Covid did not stop cancer research’
by Vito Manolo Roma
20
Contents
2 Editorial 40 Interview with the expert
Europe’s Beating Cancer Plan, Liquid biopsy can potentially
and returning to ‘normal’ after revolutionise lung cancer
the Covid-19 outbreak screening
Editor-in-chief 4 Cover Story 45 Covid-19
Adriana Albini Beating cancer is complex – our A silver lining: Could changes
Senior Associate Editor
Anna Wagstaff
messaging must be clear forced by the pandemic point
Core Contributing Writers to better ways to conduct our
Adriana Albini, Marc Beishon, Rachel 10 Team Talk clinical trials?
Brazil, Alberto Costa, Simon Crompton,
Janet Fricker, Sophie Fessl, Anna Wagstaff
Their fingers on the button: why
International Contributors
neglecting radiation therapists is 52 Spotlight
Valeria Hartt (Brazil), Esther Nakkazi no longer an option Who wouldn’t want to cure
(Africa), Alexandra Nistoroiu (Central
and Eastern Europe), Myriam Vidal 100% of childhood cancers?
Valero (South America), Swagata Yadavar 16 Biology Basics
(South Asia)
The sunshine hormone: the 58 Cutting Edge
Publishing Coordinator
Jacopo C. Buranelli
many wonders of vitamin D Natural killers: a new
Graphic Concept and Design tactical unit joins the cancer
Studio TheValentino, www.thevalentino.it 20 Profile immunotherapy brigade
Printed by Mike Morrissey: At your service
Grafiche Ambert, Verolengo
62 In the Hot Seat
Cover by 26 Cutting Edge
Vito Manolo Roma Manfred Weber:
Illustrations by
Oncolytic viruses – a new wave Chair of the European
Sara Corsi, Maddalena Carrai, of therapeutic possibilities Parliament EPP group
Vito Manolo Roma, Alessandra Superina
All enquiries to: 32 Policy
SPCC Sharing Progress in Cancer Care
Piazza Indipendenza 2 Could Covid-19 boost interest
6500 Bellinzona - Switzerland in drug repurposing in
info@cancerworld.net
editor@cancerworld.net oncology?
© 2021 European School of Oncology.
All rights reserved
Cancer World is an online-first magazine that publishes weekly
Published by
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Decreto n. 436 del 8.11.2004
Direttore Responsabile
Alberto Costa Subscribe at: http://bit.ly/CW_Subscribe
Summer 2021 1
Editorial
Europe’s Beating Cancer
Plan, and returning
to ‘normal’ after the
Covid-19 outbreak
Adriana Albini – Editor-in-chief
A
n ageing population, environmental factors, in- the entire disease pathway, from prevention and early
fectious agents, and lifestyle changes all add to detection, to diagnosis and treatment and quality of
the rising impact of cancer on our lives. survivorship. With several billion euros in funding, the
If nothing is done, cancer will soon become the lead- Plan identifies aims and initiatives to tackle every stage
ing cause of death in Europe. A comprehensive collab- (see Table).
oration across all sectors could reverse this rapidly On prevention, the Plan looks to achieve a tobacco-free
rising trend. Up to four in ten cases of cancer are pre- Europe, reduce alcohol consumption, and promote sus-
ventable, by immunisation, better diet, physical exer- tainable and affordable diet and physical activity. On
cise, and greater awareness of cancer risks. Yet, at the early detection, the Plan will put forward a scheme to
moment, only a tiny sliver of health budgets is spent on ensure access to breast, cervical and colorectal cancer
prevention. screening for the great majority of the respective target
In 2020, 2.7 million people in the EU were diag- populations. Screening for other cancers will also be
nosed with cancer, and 1.3 million people lost their considered. The Plan also looks to secure equal access
lives to the disease. On the positive side, 12.5 mil- to high quality, curative healthcare; to improve the
lion people who were diagnosed with cancer are now quality of life for cancer patients, survivors, and carers;
considered cured. This points to the effectiveness of to reduce cancer inequalities; and to put childhood can-
improved early detection and diagnosis, better and cer under the spotlight.
more tailored therapies, and a well-orchestrated sup- Dramatically, while Europe’s Beating Cancer Plan
port. It also raises new challenges, with many survivors was being designed and published, the Covid-19 pan-
struggling with quality of life, rehabilitation or family demic was wreaking havoc on our lives, uprooting
issues, and often finding it hard to keep working, or to our sense of normality, and propelling us into a new
find a job, or access insurance or a mortgage. All of and uncertain landscape. Early detection and timely
these can be tackled by increased support in research treatment of all forms of cancer took a hit from the
and innovation. combination of lockdowns, self-isolation, overstretched
On February 3rd 2021, the Europe’s Beating Can- health systems, and restrictions on family support.
cer Plan was presented ahead of World Cancer Day, as We know that a backlog of cases at higher grades
a political commitment to beat cancer by addressing will need to be tackled once we have contained the
2 Summer 2021
Editorial
virus and returned to ‘normal’. But what will ‘normal’ data, artificial intelligence, and genomics will con-
be? We can anticipate a period of economic, physical, tribute to a better understanding of this multi-faceted
and psychological repercussions that will need to be disease and fill some of the gaps in our knowledge,
dealt with (Dell’Osso L et al. J Psychopathol, 2020). ultimately allowing us to save costs as well as lives.
Will Europe’s response favour or undermine efforts to Technologies and machines may shape new ways of
implement the Beating Cancer Plan? If we could har- preventing, detecting, and treating cancer. Emerging
ness some of the knowledge and experience we have challenges must also be tackled, such as privacy con-
accumulated over the past year, this could help us prog- cerns and cross-border data exchange, speeding the
ress towards a healthier society. process of new technology uptake, and interpretation
At a policy level, the EU is investing billions in and sharing of data. Innovation could also worsen
its ‘NextGenerationEU’ recovery plan for Europe, inequality, at least in the short term. The Plan together
which is presented as “… a once in a lifetime chance with the Cancer Mission and Horizon Europe will
to emerge stronger from the pandemic, transform facilitate and encourage scientific research, leading
our economies, create opportunities and jobs for the to new discoveries, therapies, and affordable medi-
Europe where we want to live” (bit.ly/NextGenEurope). cines. The success of Europe’s Beating Cancer Plan
At a societal level, we humans see ourselves as inde- will rely on intercommunication, sharing and collab-
pendent thinkers, acting with free will, yet as social orating. To quote Manfred Weber, chair of the larg-
animals, we adopt behaviours and habits that make us est political group in the European Parliament, (see
fit in with our community (see, for instance, ‘Why we In the Hot Seat p 62): “The development of the Covid
are all creatures of habit’ New Scientist 2007). Such vaccine is one great example of how much Europe-
ingrained patterns of behaviour can be useful to main- ans can achieve when they work together. What this
tain continuity within the herd, which may be why it experience shows is that promoting collaboration and
can be so hard to use free will to change our habits. supporting research and innovation across Europe can
And yet lifestyles can change quickly when faced with make a tangible difference in people’s lives.”
a crisis, and can become the ‘new normal’ – that is,
become as ingrained as our previous behaviour (see, 12 Points for a high-impact Beating
for instance, J Biomed Informat 79:129–142). Cancer Plan
Some of the changes we have adopted during the
pandemic we might well want to keep. People are 1.Set Ambitious Goals to Inspire & Galvanise
showing much higher interest in health, and a desire 2.Ensure ALL Stakeholders are Involved
to search more solid sources of information, such as 3.Focus on the Quality of Cancer Care
reputable journalism and medical literature. We have 4.Take Action to Improve Survivorship and Quality of Life
rediscovered home cooking, with the added advantage 5.Achieve Better Integration of Primary Care into the Cancer
of looking more carefully at ingredients and quanti- Care Pathway
ties. Although outdoor activities and gyms have been 6.Address Inequalities
closed or less available, video fitness classes and home 7.Support Healthcare Professional Education & Mobility
workouts have increased (Front Psychol 12:664568), 8.Improve Data Use and the Evidence Environment in European
which also draws the attention to inner balance and Cancer Care
personal journeys. New technology, working remotely, 9.Be Courageous on Primary Prevention
travelling less, rediscovering the joys of family, can 10.Increase Health Literacy
all have a positive impact. And last, but not least, the 11. Assist Early Detection Including by Updating EU Screening
race to research Covid-19 has shown the world the Recommendations
outstanding results that are possible from collabora- 12.Improve Access to Outcome-Improving Innovation
tion and funding science.
Much has changed in the world of science, technol- Source: Adapted from the European Cancer Organisation ‘A checklist for
an ambitious, unifying and change-making Plan’, developed in discus-
ogy, communication, and social awareness since the sion and agreement with members of the European Cancer Organisation
Europe Against Cancer action plans of 1987–1994. and its Patient Advisory Committee, www.europeancancer.org/poli-
cy/1:the-europe-s-beating-cancer-plan.html
All of these advances have an important role. Big
Summer 2021 3
Cover Story
© Sara Corsi
Beating cancer is complex –
our messaging must be clear
With the launch of Europe’s Beating Cancer Plan, the Cancer Mission, and the EU4Health
programme, the European Commission has offered an ambitious vision, a road map and
momentum. Anna Wagstaff looks at how Europe’s cancer community can work together to
translate that into lasting change in every member state.
A
window of opportunity is policy must be a purely national respect borders, and the argument
opening up across Europe to competence has lost ground in the that Europe’s economic success can
reverse the ever-rising trend face of insistent demands, not least be separated from the health of its cit-
of new cancers and improve out- from cancer patient advocates, to end izens is no longer credible.
comes for patients everywhere. gross disparities in health outcomes, EU President Ursula von der
It’s been brought about in part together with evidence of the advan- Leyen, who took office after the
by a major shift in favour of Europe tages of collaborating to improve 2019 European elections, is a cham-
taking on a stronger policy making access to quality care. The Covid-19 pion of expanding the EU’s health
role in health and healthcare. The pandemic has also played a part in remit. Under her leadership, and
traditional argument that healthcare transforming attitudes: viruses don’t with strong backing from across the
4 Summer 2021
Cover Story
European Parliament, the EU4Health prehensive cancer networks, which Europa Donna – said she and her
programme has hugely expanded balance the need to pool specialist team had spent the past year “lis-
its budget, to more than €5 billion knowledge and experience with the tening, consulting… and learning”,
over seven years. Expanding areas of need to extend access to that spe- and that they had received more
action include strengthening health cialist care to people, regardless of than 2,500 contributions that helped
systems, digital transformation of their socio-economic means, and in shape the plan. She signalled that
health systems, access to healthcare, whatever corner of the country or the she wants to maintain this high level
and making medicines and medi- region they may live. of interaction with interested parties
cal devices available and affordable. While this is all music to the as the focus moves on to getting the
Cancer is a priority. ears of Europe’s cancer commu- plan implemented across Europe:
First we have the Cancer Mission, nity – and indeed the result of many “I will be asking them… to join
one of only five mission areas funded years lobbying to push cancer up the me on this journey, to walk this
within the Horizon Europe research political agenda – it has also put on path, and to help turn this concrete
framework, and the only one focused their shoulders a big responsibility. ambition into concrete action.”
directly on health. With budgets yet Europe’s politicians have lined up
to be finalised, this is the first time behind policies that are worth fight- “I will be asking them…
the EU has framed research fund- ing for – can the cancer community
ing in terms of defined goals relat- work together to deliver the pressure to join me on this journey,
ing to social impacts – lives saved, that will be required to ensure those
lives improved, cancers prevented, policies lead to action? to walk this path, and to
inequalities reduced. help turn this concrete
Then more recently, on 3 Feb- So many different voices
ruary 2021, came the launch of ambition into concrete
Europe’s Beating Cancer Plan. Led One of the big challenges to
by EU Health Commissioner Stella working together is the extraor- action”
Kyriakides, it sets out a wide range dinary diversity of roles that play
of “ambitious but achievable goals” their part in beating cancer – from The European Parliament, mean-
with specific targets and timelines the public health, environmental while, has set up its own Beating
and backed by €4 billion of funding. health, and lifestyle prevention roles Cancer Plan (BECA) committee.
These include actions in traditional to the GPs, imagers, pathologists Chaired by Bartosz Arłukowicz,
EU policy areas such as public and and molecular biologists involved a Polish MEP and paediatrician,
environmental health and research, in early diagnosis and diagnostics, the committee has been holding its
but there is also a focus on actions to all the disciplines and specialists own public panel hearings on topics
to level up access to high quality involved in planning and delivering including: ‘Empowering Patients and
diagnostics, screening and care that treatment and care and support for their Caregivers’ (patients’ rights,
show the new assertiveness in getting survivors, and of course the patient survivorship, quality of life), as well
involved in issues of healthcare struc- advocates who have expert knowl- as ‘Equal Access to Cancer Medi-
tures and delivery. edge about what matters along the cines and Treatments’.
On top of the longstanding EU entire patient pathway. Each of these Like Kyriakides, Arłukowicz also
role of developing quality guidelines contributing roles will have their stresses the need for those involved
for screening programmes comes own priorities regarding what has to in the fight against cancer to actively
a new emphasis on implementa- happen to improve the service they engage with the EU policy process.
tion, with a target of 90% uptake of are able to provide. His message to those attending the
screening for breast, cervical and Speaking at the press launch 2020 European Cancer Summit was
colorectal cancer. The goal of equal of the Beating Cancer Plan, Stella unequivocal: “I would like to ask
access to high quality diagnostics Kyriakides – herself a cancer sur- you all to treat the BECA special
and care is supported by actions to vivor and former president of the committee as a means of achiev-
concentrate cancer care within com- European Breast Cancer Coalition ing our common goals. To use the
Summer 2021 5
Cover Story
opportunity to create, to put forward dealing with related policy areas, they have the requisite knowledge
concrete proposals, for improving says Charalambous: “For example about cancer and cancer surgery.”
our systems of oncological care. research and employment, where we Patient advocates strongly support
BECA is a scene for politicians, but directly got in touch with them to such a measure, she says, but she
mostly it should be a scene for us. raise issues of concern to us.” worries that the surgical oncology
Doctors and patients.” Europe’s cancer surgeons, by community is finding it hard to
It’s a welcome invitation, but contrast, say they are struggling to compete with other disciplines and
some doctors and patients may find get their voice heard because, while specialisms to get that message
it easier than others to respond. they have a lot to say about how to across.
raise survival rates and quality of
Getting heard life for patients across Europe, they “There have been so
currently lack the public relations
A leading figure in the Euro- capacity to make that case at the many groups trying to get
pean Oncology Nursing Society, right time and in the right places.
Andreas Charalambous has repre- Isabel Rubio is President Elect their voice heard in the
sented EONS in discussions with of the European Society of Surgical European Commission. So
many policy makers on a range of Oncology, and heads up the breast
issues, and has encountered many surgical oncology unit at the Navarra unless you have an expert
challenges. “It is not an easy task to University hospital in Madrid. The
transfer the message from the disci- majority of cancer patients will need in public affairs…”
plines and the professions directly surgery at some point in their treat-
to the European Parliament, or any ment, and for most of them it offers “With the Europe’s Beating Can-
policy maker. The difficulty may the best hope of a cure, she says, cer plan, there have been so many
lie in the fact that we don’t speak “but when you talk about innova- consultations, there have been so
the same language in the sense that tion in cancer or treatment, most of many societies, institutions, groups
we tend to be more technical when stakeholders, policy makers, think trying to get their voice heard in
we speak to issues involved in can- about medication,” she says. “They the European Commission. So
cer. Our issue is that it is not always forget about the other parts of the unless you have someone who is
receptive on the policy makers’ side treatment.” an expert in public affairs… you
on the same issues that are of con- “Imagine in surgery how things are doing surgery, you are seeing
cern to us.” have changed in the last 10 years. patients you are doing clinics – you
But the consultations over the We are continuously trying to pre- need someone who is on the policy
Beating Cancer Plan were different, serve the organ. We are now doing level. That can send the message
he says. “The consultation was open surgery for hereditary syndromes to that we want to get through.”
and policy makers were seeking reduce the risk of getting cancer. We ESSO is now working with a con-
extensive and detailed input… We are doing surgery in early stage can- sultancy to upgrade the society’s
analysed to [Health Commissioner cer, in locally advanced cancer, and public affairs capacity. “Unless we
Stella Kyriakides] the vision of the in some metastatic cancers where have professional skills we are not
European Oncology Nursing Soci- surgery often benefits. We think going to get anything changed. We
ety as a whole, and also what the that those specialists doing cancer can be advocates, but our time is
society is expecting from the EU surgery don’t need to be trained in limited, our knowledge is limited,
Beating Cancer Plan, in order for the surgical oncology?” and if you want policy changes by
plan to be relevant and realistic in Europe’s cancer surgeons have a lawmakers done in Europe, by the
terms of the realities of the clinical simple and clear message she says: European Commission, you need
context in relation to cancer nurses.” “To improve outcomes, cancer to be there, you need to know how
The consultations around the patients should be operated in can- everything moves around, and for
Plan also helped open a direct path- cer units by surgeons who have been us as surgeons this is way out of
way to areas of the Commission trained as surgical oncologists, as our area of action.”
6 Summer 2021
Cover Story
European Cancer Organisation Focused Topic Networks
Nine networks bring together different coalitions of interest groups around specific topics to develop collective policy posi-
tions, which are published on their respective webpages (europeancancer.org/topic-networks).
Health Systems and Treatment Optimisation – Over 30 participating organisations, with EORTC (clinical researchers) and
ESTRO (radiation oncologists) in the chair
Quality Cancer Care – Over 30 organisations, with ESTRO and the Organisation of European Cancer Institutes in the chair
Inequalities – Over 30 organisations, with the European Association of Urology and SIOG, the geriatric oncologists, in the
chair
Survivorship and Quality of Life – Over 25 organisations, with MASCC, the supportive care in cancer specialists, and IPOS,
the psycho-oncologists, in the chair
Workforce – Over 20 organisations, with EONS, the cancer nurses, ESOP the oncology pharmacists, and ESSO, the cancer sur-
geons, in the chair
Digital Health – Over 25 organisations, with the European Association of Nuclear Medicine and the European Society of Ra-
diology in the chair
Prevention – Over 30 organisations, with the European Society of Breast Cancer Specialists and European Respiratory So-
ciety in the chair
HPV Action – Over 35 organisations, with the Association of European Cancer Leagues and EONS in the chair
Impact of Covid-19 on Cancer – Over 40 organisations, with European Cancer Organisation board members in the chair
Joining forces to policy issues around the cancer work done by the participating soci-
workforce. eties, but he agrees that teaming up
Rubio argues that every profes- The network – one of nine such on this topic with the cancer surgeons
sion that plays a role in cancer care ‘Focused Topic Networks – is chaired and professional groups makes good
has something to say about how to by representatives from European sense. The bare bones of a policy
improve the unique services they societies of cancer nursing, surgical position developed by the network –
provide and needs their own voice to oncology and oncology pharmacy, on access to multiprofessional care
be heard. She recognises, however, with radiotherapists, radiologists, and the need to proactively deploy
that the value of super-specialisation molecular imaging specialists, geri- the Professional Qualifications
applies across the field of cancer care, atric oncologists, psycho-oncologists, Directive “to support specialisms in
and that there are advantages in col- urologists, breast cancer specialists cancer care in harmonising education
laborating to get that message heard. among the participating groups. and training requirements” – was one
“At the end, many of our problems, Developing recognised education of a number of policy resolutions pre-
or many of our solutions, are mainly and qualification is an issue common sented to the European Cancer Sum-
the same. We just need special train- to many of these groups, not least the mit, last November, and endorsed by
ing and we need our specialty, or cancer nurses, who have been cam- a vote of all participants. The inten-
sub-specialty, officially recognised paigning on this issue for decades. tion is to use this evidence of broad
by member states. This is also the “The argument is much the same backing from across the cancer com-
case for other professions involved everywhere,” says Charalambous, munity as ammunition in discus-
in the multidisciplinary care, such as who was recently elected as President sions with policy makers at EU and
oncology nurses and so on. Because Elect of the European Cancer Organ- national levels.
cancer management has become so isation. “How is it possible for some-
complex.” body who has absolutely no speciali- A magnifying voice
ESSO is now collaborating with sation to treat a cancer patient?”
other professional oncology societ- Coordinating work in this area is “We do our best to be a magnify-
ies in a network set up by the Euro- quite a challenge, he says, because ing voice,” says Matti Aapro, Presi-
pean Cancer Organisation dedicated of the wide diversity in the type of dent of the European Cancer Organ-
Summer 2021 7
Cover Story
isation. “We are not seeking to speak challenge of the Covid-19 pandemic. to have a dialogue with the individual
on specific areas where our members The flexible format also makes it eas- members and of course they all have
have the expertise, but to pull it all ier for groups that are not primarily their vested interests and you have
together.” Organising coalitions of cancer societies to get involved, such divergence and it makes it politically
interest to work on developing policy as professional societies for sexual much more difficult to find the right
within the Focused Topic Networks, medicine, and study and manage- way forward, because then they have
he says, is a completely new way of ment of pain, and of obesity. to give preference to one over the
working. “It’s not meeting every now other. It is much better that we cre-
and then to say ‘hello’ for one hour. “The advantage is to ate consensus among ourselves.” It’s
It is hours and hours of collaborative a strategy that Aapro believes paid
work.” find common ground off when it came to the consultations
The first networks was launched around the Cancer Mission and the
in October 2019, as part of a tran- and come to a common Beating Cancer Plan – indeed some
sition away from the federal model European Commission DGs explic-
used by the European Cancer Organ-
resolution. By doing that itly asked them for “clear messages
isation in its previous incarnations as we create an authority at on what are the priorities,” he says.
the Federation of European Cancer
Societies, and later ECCO. The topics the policy level” Seize the moment
focus on different parts of the patient
pathway, from prevention through Patient advocacy groups cover- With the Cancer Mission and the
to survivorship. Policy development ing a full range of cancers played a Beating Cancer Plan now launched,
for each topic is done with explicit central role in developing the Euro- Europe’s cancer community now
reference to the list of 10 ‘patients’ pean Code of Cancer Practice, and faces the much bigger challenge of
rights’ defined in the European Code now spread their efforts across all the turning paper policies into reality in
of Cancer Practice – a ‘citizen and networks – with a particular inter- every country, every region, every
patient-centred manifesto’ of the core est in topics of quality care, quality health service. Nine in every ten
requirements for good clinical cancer of life and treatment optimisation. eligible cancer patients being cared
practice. Stefan Gijssels, a patient advocate for within the proposed networks
The initial plan was to develop the with Digestive Cancers Europe, of National Comprehensive Cancer
networks one at a time, says Aapro, who co-chaired the European Can- Centres; nine in ten of those eligible
“But there was so much enthusiasm cer Organisation’s Patient Advisory for cancer screening receiving invi-
right from the beginning from all the Committee for the past two years, tations to participate in programmes
members, we were able to get all the echoes what Aapro says about the that comply with EU quality guide-
networks started by the following value of collaboration in lobbying lines; improved care for survivors
Spring… Member organisations sud- policy makers to take a broad range and an end to unfair discrimination
denly realised that if you have a spe- of actions to improve cancer out- – these and other goals on preven-
cific area of interest in that specific comes. “The advantage, for all the tion, early detection and more are
area of interest you have also many identified topics, is to find common hugely ambitious, but all the more
other organisations that also have an ground among all these associations, worth fighting for. The cancer com-
interest.” bringing different perspectives, dif- munity has shown it can collaborate
The model seems to be working, ferent evidence and facts and stories, to magnify its voice at a European
judging by the number of organisa- and to come to a common resolution. level. Applying a similar strategy at
tions who are now contributing to By doing that we create an author- a national level may now be crucial
the various networks. The European ity at the policy level that very few to convincing governments in each
Hematology Association is the most organisations might have.” and every member state to do what
recent new member, joining forces It is easier for institutions working it takes to deliver on the ambitious
with other cancer organisations in on cancer policy to have a counter- goals of Europe’s Beating Cancer
developing an urgent response to the part, he says. “Otherwise they have Plan.
8 Summer 2021“Best practices/state-of-the-art in “Best practices/state-of-the-art in
precision testing in breast cancer” precision testing in lung cancer”
on demand - available at on demand - available at
https://www.oncocorner.net/webinars/27 https://www.oncocorner.net/webinars/180
Co-chairs: G. Pruneri, IT - M. Zambon, IT Co-chairs: A. M. Baird, IE - S. Novello, IT
Experts: A. Batistatou, GR - G. Curigliano, IT - Experts: K. Kerr, UK - N. Normanno, IT -
J. Gligorov, FR - N. Harbeck, DE - U. Pastorino, IT - J. Remon-Masip, ES -
F. Penault-Llorca, FR G. Scagliotti, IT
“Best practices/state-of-the-art in NEXT WEBINARS - COMING SOON
precision testing in colorectal cancer”
“New precision testing methodologies
on demand - available at
(NGS, CGP, circulating tumor cells)”
https://www.oncocorner.net/webinars/189
Co-chairs: S. Gijssels, BE - E. Van Cutsem, BE “Improving accessibility to precision
Experts: K. Dahan, BE - J. Galon, FR -
testing”
P. Laurent-Puig, FR - J. Taieb, FR “Best practices/state-of-the-art in
precision testing in other cancers”
The webinars are made possible thanks to unrestricted educational grants and/or unrestricted sponsorships from
Supporting companies have no control over the webinars content or speakersTeam Talk
© Alessandra Superina
Their fingers on the button
Why neglecting radiation
therapists is no longer an option
Can you be sure that the person who positions you on the radiotherapy table and delivers
your prescribed dose has received the necessary training and education? Europe’s radiation
therapist profession are working hard to ensure you can, but they need support from policy
makers and the wider cancer community. Sophie Fessl reports.
T
he job of a radiation thera- Moreover, by doing each task the patient. Given this responsi-
pist may sound straightfor- correctly, the risks to patients can bility, it might seem reasonable
ward: deliver the right dose be minimised so they derive the to assume that radiation thera-
of radiation to the right location. greatest benefit from treatment pists receive extensive training.
But it’s not. These are complex (Box). At every step of the way, But across the world, including in
tasks that involve working with data, an error may occur, with poten- Europe, the education and further
high-tech equipment and patients. tially disastrous consequences for training of radiation therapists
10 Summer 2021Team Talk
Delivering radiation therapy: what’s involved
The job of a radiation therapist involves many tasks, each of which have to be done right to ensure the patient gets the
greatest benefit with the least risk.
Data transfer
Transferring beam arrangement and dose data from treatment plan to treatment machine:
• Wrong information concerning treatment/dose/location/field size/beam energy
• Wrong monitor units
Checking treatment plans
Simulation, imaging and volume determination
Determining region of the body to be treated using typically a dedicated CT scanner for virtual simulation.
Positioning and immobilisation
Setting up the patient in a reproducible position for accurate daily treatment:
• Incorrect patient positioning
• Incorrect immobilisation position
• Wrongly applied immobilisation device
Patient setup
Placing patient in treatment position for each treatment
• Incorrect patient identification
• Inappropriate alignment with external reference system (e.g. lasers)
• Incorrect application of shifts from reference points to isocentre
Treatment delivery
Physical delivery of radiation dose
• Incorrect radiation dose (overdose or underdose)
• Incorrect beam energy
• Incorrect field size and orientation
• Undetected equipment failure
Treatment verification
Confirmation of treatment delivery using image guided radiation therapy (IGRT); monitoring of the daily setup; monitoring of
side effects by regular patient review and support.
(RTTs) are on shaky ground, says radiotherapy content, says Coffey machine and deliver the radiation
Mary Coffey, Adjunct Associate – coupled with a certain indif- dose that’s prescribed.” Added
Professor in Radiation Therapy ference towards the profession. to that, radiation therapists are
at Trinity College Dublin. “The “There is a feeling that the med- involved in treatment preparation
public, and even people within ics are very well qualified, so that and patient care. “This is a key
the discipline itself, have no idea treatment prescriptions are very point in the treatment chain that
that the people who are actual- well done. And medical physi- people don’t appreciate.”
ly giving the treatment in many cists make sure the equipment is
instances have no or very little functioning really well. So noth- No title, no recognition
knowledge of what they do.” ing can go wrong! But they forget
The core problem lies in vari- that it’s actually the RTT who has Currently, across Europe, no
ations in the quality and extent to put the patient on the bed, in unified educational programme
of education covering specific the right position, and turn on the exists to prepare radiation therapy
Summer 2021 11Team Talk
professionals. Indeed, the prob- tumour, but greater risk to normal ally treating a patient on a linear
lem starts at an even more basic tissue. No specialist education was accelerator is a very different pro-
level: a lack of a unified title. required, because radiation thera- cess than taking an X-ray. Being
“Radiation therapists, first of pists were drawn from a range of competent to take X-rays doesn’t
all, are not recognised as a pro- backgrounds and minimal radio- make you competent to treat a
fession,” says Michelle Leech, therapy content was included in patient,” explains Coffey. “By the
Associate Professor and Head educational programmes, explains same token, if the background is
of Radiation Therapy at Trinity Coffey. In the past decades, how- nursing, which is a requirement in
College Dublin. “Even in Europe, ever, radiation therapy has devel- some countries, that is very posi-
we have 28 different titles for the oped into a highly complex dis- tive from the patient care perspec-
profession, which makes it hard to cipline. With current approaches, tive. But a nurse has no education
compare curricula, training and small precise areas conforming and technical understanding of
competences across the continent. more to the tumour are targeted. what happens when you turn on
This lack of a unifying title is the This limits the dose delivered to a treatment unit and the potential
first step. Radiation therapists not normal tissue, improving outcome for harm to your patient.”
being a recognised profession is and quality of life for patients. In
really the main stumbling block this setting, however, the need for
for any education.” accuracy is critical and the risk of
“Being competent to
Europe’s radiology and oncol- errors can be greater if position- take X-rays doesn’t make
ogy society (ESTRO) and the ing is incorrect.
International Atomic Energy In 2011, ESTRO carried out a you competent to treat a
Agency (IAEA) are working on survey on how educational pro-
defining an internationally com- grammes prepare RTTs for this patient”
parable, recognised title for the complex role. With responses
profession. The acronym RTT is from 28 European countries – Currently, the therapeutic rela-
recognised by both bodies, stand- though possibly somewhat dated tionship acknowledged in the
ing for Radiation TherapisTs. This now – this showed that frequently term ‘radiation therapists’ is also
title could then be used on the RTT education is a component of rarely emphasised in educational
international stage, in addition to a broader programme, in nursing, programmes. Radiation thera-
national titles for the profession. diagnostic imaging or a technical pists usually see a patient for the
discipline. Although the educa- entire period of treatment, often
“They forget that it’s the tion programme is, in some cases, over several weeks, during which
at degree level, the academic con- they monitor side effects, dis-
radiation therapists who tent relating to radiotherapy is cuss psychosocial conditions and
often limited, and relevant clini- provide support, explains Leech.
put the patient on the bed, cal education may be confined to “We very much see ourselves as
in the right position, and just a few weeks of learning. therapists. We are here to sup-
As Coffey points out, without port and educate the patients
deliver the prescribed recognition as a profession, it is about their treatments, make sure
difficult to insist on a standard they’re involved, listen to them,
radiation dose” of competences and a standard support them in managing their
of education that achieves these side effects. It’s a profession that,
The current problems may competences. “Historically, radi- when the person is educated, con-
arise, in part, from the history ation therapists have not been rec- tributes to the holistic way of pro-
of radiation therapy. Historically, ognised as a profession within its viding cancer treatments.”
radiation therapy was delivered own right. You find it lumped with The therapeutic aspect also
through large radiology fields something else, as part of radi- affects the education required to
with less potential for missing the ography, for instance. But actu- carry out the job, adds Coffey.
12 Summer 2021Team Talk
“That’s why we want to move ern Europe at all,” says Coffey. lum for radiation therapists, which
away from radiography. Radiation “Countries like Australia and New was first published in 1995, with
therapy is a therapy discipline, in Zealand, the UK, and Ireland have the third and latest revision pub-
the same way as a physiothera- strong, dedicated programmes. But lished in 2011. This core curricu-
pist or an occupational therapist, for example in Portugal, an excel- lum sets standards for education of
because you treat a patient. This lent course in radiotherapy was radiation therapists and links these
is key, because you need to incor- closed down and replaced with a to core competencies. Courses
porate psychology, communica- joint radiography programme.” designed to fit this core curricu-
tion and patient care in the teach- lum should equip graduates with
ing environment.” “Unlike many other the defined competencies.
How the limitations in edu- Additionally, ESTRO and
cation and training of radiation disparities in cancer IAEA have collaborated in a
therapists affects patient care is Train the Trainers programme,
known only anecdotally. A 2008 care, this is not a divide which started in 2008. This seeks
review of radiotherapy inci- between the ‘old West’ to empower radiation therapists to
dents by the WHO showed that, address educational needs within
although a significant proportion and the ‘old East” their own countries. After a week-
of incidents could be traced to long training, given to three par-
incorrect equipment use or setup, What is added in eastern Europe ticipants from each participating
contributing factors included is that many countries are quickly country, the participants organise
“incorrect treatment decisions, catching up in their radiotherapy three courses on RTT-specific
mistaken treatment delivery and standards, says Siret Kivistik, radi- topics for other radiation thera-
inadequate verification of treat- ation therapist at Tartu University pists in their own countries. Five
ment, due to inexperience and Hospital and radiotherapy lecturer rounds of this ‘Train the Trainers’
insufficient knowledge of the staff at Tartu Healthcare College, in programme have been completed
involved.” Estonia. “The development in our so far.
“There is currently no equality country has been huge… in the One consequence of this proj-
of care in radiation therapy across 12 years that I have been actively ect has been increased network-
Europe, and it’s not just about working in this environment. So ing among RTTs. In the Balkans,
access, it’s in the actual delivery the need for trained people really this has led to the establishment
of treatment, which is nowhere grows day by day.” of an international platform for
near equitable,” explains Leech. cooperation to exchange knowl-
Velimir Karadža, Head of the Train the Trainers edge, experiences and solutions.
Radiotherapy/Technology Unit at Four meetings have been held so
the Clinic of Oncology, University Efforts have been made to far in the Balkan region, under
Hospital Center Zagreb, in Croa- improve RTT education across the title South East Europe Tech-
tia, echoes this feeling. “I’m sure Europe. “Radiation therapists on nology in Radiation Oncology
there have been more mistakes the ground are dissatisfied,” says (SEETRO) congress. The project
happening than we actually detect. Leech. “They know that their stan- is also helping radiation therapists
But people need to have the aware- dard of care could be better… and to push for increased recognition
ness. If people are not educated want to change it from the ground of their profession. “A lot of coun-
well enough, they will not care, up.” tries have actually set up their
they will not see, and they will not Helping drive this change is own RTT society, and in several
detect the error.” ESTRO’s RTT Committee, which countries they’re working in that
Unlike many other disparities was established in 1993 to rep- direction,” says Coffey.
in cancer care, this is not a divide resent radiation therapists at the One aim of the Train the
between the ‘old West’ and the European level. ESTRO supported Trainers project was to influence
‘old East’. “It’s not specific to east- the development of a core curricu- national education, so that the
Summer 2021 13Team Talk
radiotherapy component of pro- need to just cut off some subjects programme, however, teaches a lot
grammes is increased. Karadža is and bring in new learning.” of the skills and knowledge that
one of the driving forces behind Coffey, set up a degree pro- graduates should know already,
the SEETRO Congress and RTT gramme for radiation therapists at entering a Master’s level pro-
training programmes in Croatia. Trinity College Dublin, which has gramme. But we get great backing
“Our workshops and symposia been further expanded by Michelle from the clinical departments, and
raised awareness about the prob- Leech. In countries with limited we are in a good situation, having
lems. But to make this something resources, Coffey argues that is such a programme established.” In
permanent, the only way is to important to use a ‘pick and mix’ a next step, Kivistik wants to safe-
change the official educational approach to design a course con- guard proper education for every-
programme,” he says. That is taining the most relevant existing one in the radiotherapy depart-
not always easy to achieve, says educational content, tailored to ments as part of Estonia’s next
Leech. “There must be an internal future radiation therapists, rather cancer strategy.
recognition in various countries than trying to establish a more
that there’s actually a problem. costly full degree programme. “If
“They work really hard
And there must be a recogni- constrained by time and resources,
tion by the educational institutes education should be tailored and and care deeply for
themselves that the programmes focus on teaching key areas of
they are running are not fit for radiotherapy,” she says. their patients, but it’s
purpose, that they do not teach the In Estonia, Siret Kivistik has
fundamental science, that is nec- been instrumental in setting up difficult without proper
essary to understand your actions a two-year MSc course for radi-
understanding of what
on a radiation therapy unit.” ation therapists, for which she is
now the course coordinator. Esto- happens when they treat
New models for education in nia faces an additional problem:
Croatia and Estonia as the country is small, only two a patient”
clinical departments in Estonia
In trying to change education in offer radiotherapy services, with a Lack of traction at a policy
Croatia, Karadža and colleagues total of only six linear accelerators level is one hurdle radiation ther-
started out by drawing up the com- available in the country. “We’d apists are facing. “We did try to
petences that RTTs would need. need to have 15 students per year have events inviting the minis-
“Even the educational bodies to set up a dedicated programme try of health and education from
participated in that, but when we at BSc level. But with just two various countries to attend, but
tried to make the actual changes clinical departments, we do not we had to abandon this because
to education itself, we encountered have enough positions to offer to there was no interest in us. It’s
problems.” Nevertheless, in 2019, 15 graduates each year.” A joint very difficult, we never reach the
radiation therapists were, for the programme by the Baltic States top level of government,” says
first time, appointed as lecturers at to provide radiotherapy education Leech. There are also challenges
the University of Applied Health was envisaged and developed, but at the level of professional soci-
Sciences in Zagreb, Croatia. “We failed for political reasons. An eties, because radiation therapists
think this is absolutely mandatory, international MSc programme are frequently members of organ-
that people from the profession are focusing on radiotherapy is now in isations where other professions,
teaching students about profes- its second year at Tartu Healthcare such as nursing or radiography,
sional issues.” College in Estonia. The course is are in the majority. This can make
Now, Karadža seeks to change intended both for already practis- it hard to ensure attention is paid
the curriculum further. “But it ing radiotherapists, as well as for to their specific interests and
takes time to convince the Dean of graduates of related disciplines needs. “One head of a national
the Faculty and everyone that they without prior experience. “This radiography society told me that
14 Summer 2021Team Talk
radiographers might get bored Coffey insists that, currently, rific to listen to the students actually
with diagnostics and want to do a radiation therapists in all settings are discussing with the rest of the team
bit of therapy. So therapy is still doing as good a job as they can do, from a point of absolute understand-
being seen as an add-on to diag- given the circumstances. “I’m not ing, and it becomes an equal discus-
nostics,” says Coffey, who also taking away from the people on the sion. It just enables everybody to do
encounters the fear of RTTs tak- ground, they work really hard and a better job.”
ing away the responsibilities from care deeply for their patients, but Leech points out what is at stake.
other professions. “We are not it’s difficult without proper under- “Who would you like to be treating
about educating people to take standing of what happens when they your child? The person who is spe-
over someone else’s job, which is treat a patient.” She points to her cialised in this area or someone who
another big fear… it’s not about own graduate students participating maybe sees this case once or twice?
that, it’s about educating radiation in discussions in multidisciplinary I think citizens know the answer to
therapists to do their own job.” teams on an equal footing. “It’s ter- that question.”
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Summer 2021 15Biology Basics
© Alessandra Superina
The sunshine hormone
The many wonders of vitamin D
Vitamin D has drawn much scientific interest and media coverage in recent years, and
increasingly so in 2020, when a link was found between vitamin D deficiency and Covid-19,
writes Adriana Albini. This is a very unusual vitamin, in that it behaves both as a hormone and a
vitamin – our skin produces it through exposure to sunlight − but it is also supplemented by diet,
one of its primary sources being oily fish. In cancer, vitamin D levels are inversely correlated to
risk; it has neoplasia-suppressive effects, as recent trials confirm.
A
mong the most interest- There is a discussion about severity of the disease. (Lancet
ing findings from the huge whether, along with obesity, dia- Diabetes Endocrinol 2020, 8:570;
volume of research relat- betes and high blood pressure, JAMA Netw Open 2020, 3(9):
ing to the Covid-19 outbreak is vitamin D deficiency is associ- e2019722-e2019722).
the emergence of Vitamin D as a ated with vulnerability to coro- As oncologists and cancer
possible biomarker. navirus infection and with the researchers, we know that low
16 Summer 2021Biology Basics
levels of vitamin D increasingly sive elements and modulating gene seen in individuals with normal
appear to be correlated with can- expression. weight (i.e. not obese) (JAMA
cer risk and worse prognosis, as Netw Open 2020, 3(11):e2025850).
well as with response to chemo- The link with cancer A Giovannucci paper in a mono-
therapy. In trials, vitamin D sup- graph dedicated to vitamin D and
plementation appears promising Vitamin D levels are inversely cancer ‘Sunlight, Vitamin D and
for cancer control, as recent news correlated to cancer risk. The Skin Cancer’ summarised that
has also suggested. vitamin has suppressive effects “the results from meta-analyses
It is one of many potential bio- on neoplasia, and various mech- support that achieving circulating
markers of sars-2-cov suscepti- anisms of action mediating can- levels of 25(OH)D around 54–135
bility and infection that are being cer cell inhibition have been nmol/l may contribute to reduc-
studied by disciplines other than described. One of the major inves- ing cancer mortality. Although
virology, mostly oncology and tigators into the vitamin D and the optimal 25 (OH)D level for
rheumatology. Interleukin 6 and cancer liaison is Edward Giovan- prevention is not established, it is
interleukin 1 are other examples. nucci, Professor of Nutrition and likely to be higher than 50 nmol/l,
Epidemiology at Harvard Medi- and currently, a substantial por-
What it is and how it works cal School, Boston, who received tion of the world’s population is
the 2019 AACR-ACS Award for below even this threshold.” (Adv
Vitamin D is a steroid hor- Research Excellence in Cancer Exp Med Biol 2020, 1268:39-52).
mone; the major molecular moi- Epidemiology and Prevention, To have the right levels in our
eties in this group are vitamin D3 and in 2020 co-authored a JAMA system, without the intake of
(cholecalciferol) and vitamin D2 paper on the ‘Effect of Vitamin man-made supplements, is no
(ergocalciferol). Various modified D3 Supplements on Development easy task. To synthesise enough
forms exist, including calcifediol of Advanced Cancer’ (JAMA Netw vitamin D through sunlight expo-
(25-hydroxyvitamin D or 25(OH) Open 2020, 3(11):e2025850). sure we should ideally live in
D), an indicator of vitamin D lev- To follow up on the hypothesis sunny countries, but also lead a
els in the blood, and calcitriol of reductions in cancer deaths, the lifestyle that involves a lot of time
(1,25-dihydroxyvitamin D or team evaluated whether vitamin D outdoors, wearing skimpy clothes
1,25(OH)2D), an active hormonal reduces the incidence of advanced (short sleeves, no gloves), and no
form. (metastatic or incurable) can- sunscreen products filtering UVB.
Cholecalciferol is synthesised in cer and examined possible effect As for diet, the only way to
skin epidermis, and the reaction is modification by body mass index, compensate for lack of sun expo-
catalysed by sun exposure (mostly in the VITAL trial (VItamin D sure would be to follow the tradi-
UVB). With less efficiency, chole- and omega-3 TriAL). VITAL is a tional diets of populations in cold
calciferol and ergocalciferol can randomised, double-blind, place- climates, which are heavily based
also be absorbed from the diet, and bo-controlled, 2×2-factorial clin- on fatty fish. Both hypotheses are
vitamin D can be provided as a ical trial of vitamin D3 (chole- non-viable for obvious reasons,
supplement. calciferol, 2000 IU/d) and marine from health risks related to high-
The hormone exerts its actions omega-3 fatty acids (1 g/d). The fat diets and prolonged exposure
through the vitamin D receptor, trial was designed to test the inde- to UV rays, to economic, reli-
which is part of the nuclear recep- pendent effects of vitamin D and gious, ethnic, and social factors
tor family (as is, for example, the omega-2 supplements, and test for that influence our diets, our life-
oestrogen receptor, NdA). The synergy between the two. It con- styles, and also our constitutions.
vitamin D receptor mediates vita- cluded that supplementation with The Endocrine Society recom-
min-D-stimulated calcium metab- vitamin D reduced the incidence mends at least 1500–2000 IU/day
olism, but it also exerts other cel- of advanced (metastatic or incur- intake of vitamin D to maintain the
lular effects by translocating to the able) cancer in the overall cohort, levels of 25(OH)D above 75 nmol/l.
nucleus, binding to DNA-respon- with the strongest risk reduction
Summer 2021 17Biology Basics
A historical perspective common was it in that part of the Covid-19, and even depression. It
world that it was nicknamed ‘the has become almost a panacea in
Vitamin D was discovered in English disease’, although other the eyes of doctors and consum-
the first half of the twentieth cen- countries, particularly the United ers alike, with clinics carrying out
tury, but, from time immemorial, States, were also ravaged by it. vitamin D tests for a wide variety
people have empirically under- The need to find a solution of conditions. Needless to say, the
stood the benefits of both sun prompted research for a chem- sale of vitamin D supplements has
exposure and intake of oily fish ical factor that would make the skyrocketed during the pandemic
to prevent or cure a number of empirical remedies of exposure of 2020.
ailments, mainly affecting bones to sunlight and ingestion of cod The cure of sunlight and cod
and lungs. liver oil, successful in alleviating liver oil for conditions other than
In the third book of his Histo- or curing the condition. Leading skeletal is also well rooted in
ries, the Ancient Greek historian researchers, such as McCollum, history. People with tuberculosis
Herodotus (c. 484 – c. 425 BC) Mellanby, Windaus, and others, were usually treated with both.
recounts his visit to the site at identified this factor with a vita- In Victorian times, those patients
Pelusium, where, almost a cen- min that, as the fourth discovered, who could afford it went to the
tury earlier, an important battle was named D. Italian or French Riviera in win-
had taken place between Persians The introduction of vitamin ter to benefit from sunlight and
and Egyptians. The bones of the D-fortified milk and margarine, clean air. Menton, on the French
dead were still scattered on the alongside sun exposure and cod Italian border, became one of the
battlefield, Egyptians on one side, liver oil, brought about an almost most popular health destinations
Persians on the other. complete eradication of rickets – thanks to the publicity given it
Herodotus noted that the skulls after which, chemical research on by James Henry Bennett, a Lon-
of the Persians were so brittle they this vitamin, its components and don physician, who, having con-
would be pierced by simply throw- action, stagnated. There were a tracted tuberculosis, “…departed
ing a pebble at them, while those few interesting discoveries relat- southward in the autumn of the
of the Egyptians were so strong ing to the mobilisation of cal- year 1859 to die in a quiet cor-
that they would not even crack cium in the 1950s and again in ner…” But die he did not. Instead,
upon receiving a much stronger the 1970s, but it is only in the past staying in Menton, he made a full
blow. Puzzled, he was told by the couple of decades that interest in recovery… His book Winter and
locals that the Egyptians shaved the sunshine vitamin has been Spring on the Shores of the Med-
their heads from childhood and rekindled. iterranean became a sought-after
their skull thickened by exposure Aside from the need to tackle read.
to the sun. a global resurgence of rickets, it The same Bennett is also
This was also the reason why was the identification of the vita- author of the treatise On the treat-
there was no known case of bald- min D receptor that excited the ment of pulmonary consumption:
ness among them. On the other curiosity of the scientific commu- by hygiene, climate, and medi-
hand, Herodotus continues in his nity, as it is also found in tissues cine. In the chapter entitled ‘The
aetiology, Persians always cov- with no involvement in calcium medicinal treatment of phthisis’,
ered their heads with felt hats. He homeostasis, such as skin, breast, he acknowledges the benefits of
therefore deduced it must be lack pancreas, T cells, and so on. cod liver oil, but only in conjunc-
of exposure to the sun that made In other words, it appears that tion with other remedies such as
their skulls brittle. vitamin D plays a role that goes exercise and sunlight. He is also
Jumping forward from antiq- well beyond the skeletal muscle, puzzled as to what substance con-
uity to the beginning of the last into many areas of immune func- tained in the fishy oil produces
century, one in four children in tion and disease prevention. It the curative effect.
Britain were affected by the bone affects heart, lungs, cancer devel- Interestingly, in the 1800s
disease known as rickets. So opment and progression, obesity, there was already an awareness
18 Summer 2021You can also read
