Good start Sally, have another go!

I am a great admirer of Professor Sally Davies, our Chief Medical officer. She is an innovative and determined leader, who listens and sets direction after due consideration of the issues involved. Her enthusiasm for genetics and its potential is to be admired but the recent Generation Genome publication, which gained wide press coverage earlier in July because of its implications for cancer, is a flawed document. It is a great shame, its an opportunity missed

The 256 page report also has some sloppiness which betokens haste. Chapter 3 is followed by Chapter 9 which has been transposed into Chapter 4. Chapter 9 really is Chapter 9 and not to be mistaken for the earlier Chapter 9 which is now Chapter 4. Confused – so was I until I worked it out. However this is a trivial slip.

The report is a fascinating overview of genetic medicine covering a lot more than cancer. I learned a lot from it – indeed I have not finished reading it yet. I am only competent to comment on the cancer chapter and not about the science.

It presents a one-eyed view of cancer treatment. The assumption that genetic science will be the only treatment that is needed for cancer comes across strongly. The word ‘surgery’ is only mentioned once yet surgery (plus adjuvant therapy) currently cures more than 50% of cancer patients and if we diagnosed them earlier it could be many more. No mention of these important self-evident truths. There is a real-life context for genetic cancer medicine.

A lot is made of ‘big data’ and its potential to impact on clinical decision-making. This is true regardless of genetic information, although such information will undoubtedly add immensely to the potential. The paper alludes to being able to select patients for treatment but does not consider the moral and ethical issues of empowering computers to make individualised assumptions which are used to deny treatment.

If the intention was to create the idea that surgery and radiotherapy (plus all the other modes of treatment) will be redundant in the future and that cancer treatment will solely rely on costly designer drugs, the chapter succeeds. It talks about personalised medicine as if that is the exclusive characteristic of new generation drugs. In my experience surgery is the most personalised medicine there is. Someone needs to cut out the hype and wake-up to the real life context – Dame Sally please take note. Case Study 1 describes a colon cancer patient with inoperable liver metastases and how cetuximab reduced them to become operable. There is no mention that the patient would have had surgery for his primary tumour and that without that intervention treating the metastases was inappropriate. Surgery to remove the residual metastases is mentioned – the only use of the word surgery in the whole chapter. Even Case Study 1 seems to have been distorted to support the idea! And there isn’t a Case Study 2.

This over enthusiasm and lack of context does a dis-service to what would otherwise be a useful paper. It has some relevance to what is happening today and clearly points to a lot of tremendous scientific and clinical advances. It will have an impact for surgery and radiotherapy, no mention of that. The tremendous advances in imaging and the relationship with that work is ignored. It focuses on drugs alone and then makes no mention of the fact that today there are more known mutations than there are drugs to treat them.

Genetics will undoubtedly create change. There will be new and valued diagnostic information although the ability to act on it will develop over time. Curative surgery plus radiotherapy, curing most patients, will change slowly as evidence to support change appears. There will be new adjuvant therapies and maintenance therapies. The precision medicine impact will be largely to the way advanced disease is treated, when successive metastatic events introduce new mutations which can be identified though techniques such as liquid biopsy. This will deliver patient benefit. Patients currently on a path to end-of-life care will have that pathway extended, although at largely unknown cost.

We need to have a balanced and inclusive view rooted in our multidisciplinary world. Patients need a range of skills and knowledge to support their survival, or their pathway to dying, that must be reflected.

Good start Sally, have another go.

Download Generation Genome (Government website)