Winner: National Essay Competition 2023

We are really excited to announce the winner for the National Essay Competition this year. Thanks to all medical students and junior doctors around the country for submitting their essays, we have really enjoyed reading and found them interesting.

Our winner for the National Essay Competition is:

Dr Thomas Quarrell
Foundation Doctor at Addenbrooke's Hospital, Cambridge

Which area of cancer research should receive more funding in the next 5 years and why?

Medical funding is complex. Governments, non-profits, and pharmaceutical/biotech companies all provide funding which is essential for research and development, but is allocated according to the ethos and goals of each organisation. There are over 4000 such organisations(1). As an example of differing focuses, bibliographic analysis shows the US government tends to fund breast cancer research at the ‘cell’ level, whilst private organisations tend to fund at the ‘patient’ level(2). If we take a moment to remove ourselves from this complex ecosystem, and imagine a world where funding is allocated by essay-writing foundation doctors, which area would we increase funding to?

SECTION 1 - THE TUMOUR

We can define an ‘area’ of research in many ways: a particular tumour, a research domain (e.g. pharmaceuticals, prevention), or a specific technology. We will start with the first of these. There is a broad appreciation that cancer funding is unequal relative to disease burden; breast cancer, prostate cancer and leukaemia research is consistently well funded, whilst pancreatic, oesophageal and lung cancer is consistently underfunded(3–9).

Unequal does not mean inequitable, and there are potentially justifiable reasons for unequal funding, including the outcome per unit investment and opportunities for ‘spin-off’ research related to other fields(10). The “quids to QALYs” argument of outcome per unit investment is not applicable to these underfunded cancers, which typically have poor outcomes and are in need of further research. Given the serendipitous nature of ‘spin-off’ research, this would seem a poor basis for funding decisions. Some arguments for unequal funding which may be more justifiable apply to blood cancer, CNS cancer and sarcoma: serious cancers which often affect young people who have not had a “fair-innings”[1], with unique biology owing to their non-epithelial origin which means pre-existing research from other cancer types is less relevant. However, there is a limited pool of cancers to which these arguments are applicable.

It would be remiss not to realise that many of the cancers which receive more funding, including breast and prostate cancer, are those which are more prevalent in patients of higher socioeconomic status(12). Cancers which receive less funding, including oesophageal cancer and lung cancer, tend to be diseases of poverty(12), in keeping with their strong association with risk factors like smoking(13,14). Given the relative underfunding of these tumours, which may be in-part related to societal inequality, these would be good areas in which to increase funding.

SECTION 2 - THE DOMAIN

Next we turn our attention to the research domain. The majority of cancer research is pharmaceutical research or discovery science(5,6,15,16), as has been appreciated by the Lancet Oncology’s ‘Groundshot’(17), the European counterpoint to the American ‘Moonshot’. An increasing focus on expensive, targeted pharmaceuticals at the exclusion of other areas of research is not likely to be of benefit to the population as a whole(17,18).

Both oesophageal and lung cancer often present late in the disease course, with consequently poor outcomes(14,19). Early stage disease is amenable to intervention and is associated with significantly reduced healthcare costs(20). Given this, and that both cancers have recognised high risk populations(13,14,19), targeted screening could be an effective measure to improve outcomes on a relatively short timescale.

SECTION 3 - THE TECHNOLOGY

There is now good, randomised trial evidence that low-dose CT screening of high risk groups for lung cancer can detect disease at an earlier stage and reduce mortality(21). More work is needed to confirm large scale feasibility, which groups should be eligible, and what the optimum screening frequency would be. The evidence for oesophageal cancer screening, outside of specific circumstances such as tylosis or head and neck tumour patients(22,23), is less clear.

Even for patients with Barrett’s oesophagus, the results for endoscopic surveillance are mixed and derived from non-randomised studies, which are prone to biases including lead- and length-time bias(24–26). Stronger evidence for endoscopic screening comes from the South Korean gastric cancer screening programme, with screened individuals having reduced oesophageal cancer mortality(27). Naturally, there could be issues with selection bias here. A randomised controlled trial of endoscopic screening is taking place in China, but it is still some years away from reporting(28).

One issue with endoscopic screening is the required expertise, both of endoscopists and histopathologists, with other barriers including expensive equipment and sedation. Whilst some techniques have sought to remove some of these barriers, like ultrathin endoscopy which can be performed in a primary care setting without sedation(29), endoscopy remains a poor screening technique. Non-endoscopic screening using a ‘cytosponge’ passed down the oesophagus has shown promise, and is able to diagnose Barrett’s oesophagus based on the presence of the marker trefoil factor 3 with good sensitivity and specificity(30–32). This technique has also been reasonably well tolerated by participants(33,34), an essential part of any screening test. As most patients with Barrett’s oesophagus will not progress to adenocarcinoma(29), and on a global scale squamous cell carcinoma is the predominant cause of oesophageal cancer(14), further biomarkers will need to be identified for the use of this technique in global cancer screening. Nonetheless, this is proof-of-concept, and a step towards widely available oesophageal cancer screening.

CONCLUSION

Perhaps one day, sophisticated technology like immune checkpoint inhibitors or CAR-T cells will melt away even advanced cancer, preferably without risks of iatrogenic thyrotoxicosis or cytokine-release syndrome. Perhaps they will even be affordable and accessible for a global populace, as cancer becomes an increasingly global problem(35). Till then, it is important that we fund research into diverse areas like screening, primary prevention and palliation to create a robust, multicomponent health system. It is important that we fund this in an equitable way, and increase funding into the less researched cancers associated with lower socioeconomic status. We should also recognise the importance of racial and gender diversity when supplying this funding(36,37), and should recognise that funding is only part of the issue - we must also encourage innovation and collaboration. We have explored one technology: oesophageal cancer screening using a cytosponge technique. This would be a good option for increased funding over the next 5 years.

Footnote:

[1] Although note that this argument is debated in ethical fields(11).

References:

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