How Close Are We to a Cure for Cancer? (Your Radical Questions with Professor Sir John Bell)

0:08Hello and welcome to Your Radical Questions, where I put your questions to one of our radical guests. This is your chance to engage directly with the brilliant minds that we have on this podcast and ask them about their ideas for the future. My name's John Burn-Murdoch, standing in for a mole this week. I'm a columnist and chief data reporter for the Financial Times. I've just finished up a brilliant conversation with Sir John Bell, who is Emeritus Regis Professor of Medicine at Oxford University. And if you haven't heard that conversation yet, I'd encourage you to go and listen. Professor Sir John has advised the UK government on life sciences, pharmaceutical strategy and COVID testing and played a pivotal role in the development of the AstraZeneca COVID-19 vaccine during the pandemic.

0:49He's currently a partner at Population Health Partners, a firm focused on investing in and advising life science companies, and he previously served on the board of pharmaceutical company Roche. And he joins me now. Welcome back, Professor Sir John Bell. Yeah, it's a pleasure to be here. Well, we've got a really interesting question to start off with, which I think gets into the nitty gritty of some of this stuff. So when we're talking about personalized medicine, the listener Ruxandra asks, one of the big questions for her is, how do these truly personalized therapies fit alongside our current regulatory framework around clinical trials?

1:23So she's spoken in her work in this space, She's spoken to very wealthy people who have the financial means to pursue these avenues for themselves or their own families. So really high net worth individuals. But even among this group, regulatory requirements mean some therapies are effectively unaffordable. So surely unless we change how the clinical trial part of this works, we're only going to see the very richest people able to really benefit from the revolutionary treatments. Yeah, so great question. So one of the things we haven't talked about was this revolution in therapies for rare disease and ultra rare disease and ultra ultra rare disease where only one person on the planet has the problem.

2:03but because of genetics and the commoditization of genetics, we can now identify the exact mutations that cause those things. And there are now ways to correct many of those using short strands of DNA that you called oligonucleotides that you can put in, which will actually change the way the gene operates. So if you only have one person with a disease, it's hard to do a clinical trial. You know, that's the problem that she's quite rightly identified. I have to say that the MHRA, who are the regulator for drugs and devices in the UK, has been very, very proactive and very innovative in thinking about ways that you can make this possible, because it simply won't happen unless they make it possible.

2:45And the same, interestingly, applies to the cancer vaccines that we talked about, because everybody's cancer vaccine is different than everybody else's cancer vaccine. So you're not going to be able to trial these in the way you have before. So setting these things up as platforms and getting a structure whereby you know the product is safe, so it's made in a completely safe way. You've got a certain amount of safety data about the target, but then you let people get on. And this is being used to treat people with pretty bad diseases. So you do always have to balance what's the risk, but what's the reward?

3:17And this gets back to my point, you know, sometimes you just have to push the boat out a bit and do stuff when you look at that balance. And I think the MHRA have been terrific in thinking about this in the UK. One thing that strikes me on that one is, how do we think about side effects with a truly N equals one personalized treatment? So the answer is that a lot of this is going to require very careful observation of patients. And to be clear, some of these drugs have had side effects. Some of them have had bad side effects when they've been tested in an experimental setting. And it's been from that that we've learned how to modify them so we get rid of those side effects.

3:55I think, again, this has got to do with how big is the problem you're trying to treat. And if you've got a small child who's got a major intellectual disability, who's having epileptic fits 20 times a day, who has no quality of life, you might be prepared to do some stuff that is an N1 experiment just to see whether you can get around the corner all the time thinking about whether there might be side effects. And again, it feels like these things, even with all those caveats, are still very, very expensive at the moment. But would the hope be, again, that when they become platforms, they become commoditized and that the prices drop rapidly?

4:32Yeah. So interestingly, they are expensive. And the kids being treated at the moment tend to be the kids of very wealthy families who can afford just to pay the million dollars it takes to get it done. And I think that there's a system. And to be clear, the NHS has been very good at these. So for example, bone marrow transplantation, they run as a system, not done as a private thing. It's done as a system. And the cost, it could be very small. It just needs to be done in the same way, robustly. So you just need a system whereby you do it routinely and the price will come down quite dramatically.

5:06So I would be optimistic that this would be available widely across the NHS if we can go about it the right way. Some of the more sophisticated gene therapies involving vectors and this and that, they do tend to get more expensive. But again, there's no real reason why they have to be expensive if you're doing it across the whole country. That brings us on to the topic of money here, right? I obviously understand that there is a certain inevitability to things getting cheaper as you scale them up. But is there an issue here around the incentives on the firms involved to bring the prices down? We've got a little punchy question here from a listener called Adrian, who says, given the impact that this all has on equitable distribution of medicines, can we rely on Sir John to be fully impartial on the subject of intellectual property and the bias in favour of richer nations and their pharmaceutical giants.

5:58Is there a fundamental conflict of interest here around getting these treatments out as cheaply and as broadly as possible? Or are there incentives that will at least encourage companies to go slower on the cost reduction? Yeah, so there is an ecosystem, which is the life sciences ecosystem, which has delivered us all 12 years of additional life expectancy. So that's not a bad result. Now, have people made money in that? They absolutely have. And as you know, the pharmaceutical sector has an annualized growth rate, which is really pretty substantial as a result of delivering a whole range of different innovations.

6:38they tend to be accessible to people in rich countries in the first instance and they're pretty costly so it's not going to work if you don't have a society that's got quite a lot of money but don't forget there is a patent life these things they do get into the wider population and there has also been in parallel with that the technologies that have been used in that high value system have also been used to actually deliver some really impressive inputs into diseases of the developing world. And I will point to malaria as a good example. So the development of novel therapies for malaria, the development of malaria vaccines, these things have all fed off the ecosystem which is driving the high value bit.

7:24So the two things are hooked up. If you say, we're not going to let anybody make any money out of this because we should just do what's right for everybody, then that well will go dry. And consequences of that is the speed at which we get innovations, which will help the global population, will be slow. And the pharma industry has also taken a responsible view as to how can we help with some of these issues, particularly vaccines for developing country problems. So for example, we've got an outbreak of Ebola at the moment. We're going to need a new vaccine for that strain. Where's it going to come from?

8:01It's going to come from the technology that was used to develop many of the other vaccines. So am I a completely independent view on this? Probably not, because as you know, I've been involved in the biotech and the pharmaceutical sector. I make no bones about that. And I currently work with a company that's trying to develop therapies for common disease. But I do think there is a system wide effect. And do we want to be part of that in the UK? I think we do, because we will get the benefits on multiple levels. Thank you for those first two questions to Roxandra and Adrian. This next question is from Christopher, who asks, how far away does Sir John realistically think a cure for cancer is, and what makes you think that?

8:40Well, I think within a decade, we'll be detecting cancers at stage one and stage two, and we'll be intervening with some of the new immunotherapies that will cure those cancers. So I think we're within a decade of getting a cure. Maybe not to all cancers, but to many of those cancers. The speed and progress has been pretty fast, And now that we recognize the steps that you need to take to intervene early, I think we'll be able to go all in on that. And it will save a lot of money because, you know, at the moment, a lot of the therapies we use, we use in very late stage cancers where you really have no chance of curing them.

9:17The sooner you get further up, the better this is going to be. That's fascinating. So this would be both a lifespan gain and a financial gain. A huge financial gain. And that, as you say, the key there is the early detection means that it's a more routine treatment. That could be done without surgeons and all that stuff, because in theory that the drug should be able to do it. Yeah. And are we still talking there about personalized drugs? No, I think you'd be talking about general drugs that you could just give to people because it activates your immune system. And you just really want to do is just give it a bit of a boost so it deals with the cancers on site.

9:51And the other thing that strikes me as really interesting here is that there's been this tradeoff discussed about if we get too good at detecting cancers, you end up with a lot of people having these quite nasty invasive therapies. Whereas presumably what we're saying is if you detect them at that earlier stage, there is no tradeoff. The treatments there are not invasive. Yeah, exactly. And I think the other thing which is interesting is that I think you can tune the dose of those treatments down because what we now recognize is that there's what we call a sort of tumor microenvironment that builds up around tumors that makes it really hard for these drugs to work.

10:25If you get in early, that hasn't developed and it is very likely to have a really powerful and beneficial effect without causing a lot of side effects. I mean, you've been in this space for decades. Would this be the most dramatic, advanced breakthrough that you've seen? Yeah, this would change the entire paradigm of cancer, which would be wonderful. Because we have too many people rocking up in casualty departments with big lumps in their tummy with stage four cancer, and then treating them with very expensive drugs to give them an extra six to eight weeks of life. This is not a good model. Remarkable.

10:58Well, let's hope we do get there in that time frame. So thank you to Christopher for that question. and one from Sam. What impact will the Trump administration have on the advance of medical science and what should the UK and perhaps we could extend that to Europe be doing in response? Well, we've already discussed the impact on the biomedical research agenda. Similarly, the FDA under RFK is a disaster and, you know, their inability to make sensible science-based decisions has been a real drag on the ability of the life sciences industry to progress in a variety of different ways. So I think that those are all really problematic issues.

11:36I think it gets back to what we said earlier, and that is, you know, the UK shouldn't be embarrassed about the capabilities of our biomedical research community. There's a really good group of people, but we need to make sure they get funded properly. We need to make sure that they operate independently of either China or the US. We need to develop our own capabilities. And we talked about UK Biobank. UK Biobank is absolutely unique. Nobody else on the planet has been able to do that. Our future health is absolutely unique. We do stuff in the UK that nobody else on the planet can do. So we should be quite proud of that.

12:11But it does mean that if we want to stay at the front edge of this field, it needs to get resourced properly and managed much more effectively. Yeah, and I should just add there as well the comments you made about the Trump administration. Of course, again, they're not in the room with us. RFK is not here and they may have other things to say. But there is a follow up question on a related point, which comes in from Patrick Leary, who asks about the role of wealthy supporters of Trump and their prominence in the medical business. There's a name here that you'll be familiar with. You formerly were at the Ellison Institute run by U.S.

12:48tech giant Larry Ellison, which is doing a lot of interesting work in health care. Are there risks when politics and medical research seem to develop this close reliance? Yeah, I'm not entirely sure that those two things are as connected as people think they are. And certainly not in the biomedical space. So it may be true in the tech space, but it's not. I don't think in the biomedical space. There is the possibility of all political decisions having an impact on biomedical science. So, for example, if you cut the budget of the Medical Research Council in this country, you will have a catastrophic effect.

13:30And governments could do that for a whole variety of different reasons. That's why I've warned against that. And basically, that's what's happened in America, is that they've decided to turn the tap off on that sort of stuff. I would view that as not being the right decision. There are others who would argue that it is the right decision because they want the money to be spent in different ways. So I don't think I can get too heavily into that stuff, actually. Right. But I guess the broader question maybe is that when you have people like Alison, who has a close relationship with Trump, you're exposing yourself to vulnerabilities.

14:02Those kind of decisions, those whiplashes from one to the other are more likely when there's that proximity between key figures in the two. Yeah. Well, I don't really want to comment on that. I mean, that's up to Larry and Donald Trump to decide what they're going to do. We now have another question from Pratesh, who asks, what are the short, medium and long term scaling challenges here? And how can the NHS itself mitigate them and get the best outcomes from this space? So in a sense, one of my frustrations, and you can tell I'm a bit frustrated with the NHS, is that it is a fantastic engine to actually help explore, develop and implement innovation at a kind of scale that most healthcare systems simply couldn't even think about.

14:48because it is big as a nationalized healthcare system. It's about the biggest anywhere. And I think the NHS probably needs to be a bit bolder about how it goes about adopting innovation. And it's been constrained a bit by its cost-effectiveness wrapper, which has been applied to all these things. 90 % of the stuff we do in the NHS never gets put under the microscope for cost-effectiveness. but you can do it for drugs and devices and diagnostics because you know how much you paid for it and you can work out what you get. So I do think this has got to do with changing some of the fundamentals about the way we run a healthcare system to be much more technology coherent and adopt technology at a much more effective level because I think that will reduce the major cost of the healthcare system, of course, is people.

15:44And one of the things that technology can help you do is eliminate the need for so many people standing around. And that's, I know people like to think that the health service is entirely made up of nice people who go around and look after you. But the truth is, the big advances have all been driven by technology advances. They haven't been driven by bedside manner. And of course, when we're talking, I mean, anytime I think the words eliminate people come up, you're going to get a lot of pushback. and certainly you know there are different parts of the NHS that function at different productivity levels and that kind of thing would we not expect here not so much a elimination of people but just those same people doing far more yeah so the great thing about AI is it does allow you to do more and more effectively so I don't I don't think over time you're going to see a major reduction in the number of people in the NHS but what they do will be actually I think greatly enabled by some of the tools and technologies.

16:41So for example, we have been really slow to adopt the kind of diagnostic technology you need at scale. And what does that do? Well, it shortens the time that you need to take to diagnose people. It makes the whole thing work a lot more efficiently. And we've got a big capital gap in our hospitals. We don't have enough operating theaters. We don't use them properly. You know, those are the kind of things that you can actually make work. And AI will enable all that stuff so we get into a lot of this in in the main episode and people can refer back to that but i guess what we're specifically talking about here or a good example is ai's impact on imaging so the ability to quickly spot concerning patterns what you're essentially saying is the capital that you already have to literally take those images acts as a constraint on how much ai can then benefit yeah so if you've got loads of scanners and loads of scans ai scales that up massively if you're a country like the UK that is quite scan and scanner and broader capital constrained, we will benefit less from what AI is doing.

17:43Yeah. So let me give you a good example. So pathology, tissue pathology, when people look down a microscope at the tissue to diagnose cancer or not diagnose cancer, as the case may be, it sits really right at the heart of the diagnostic paradigm. And you've got to have that in order to decide whether to turn right or turn left. It's not as robust as people think it is, because of course there's quite a lot of human error in trying to decide, is it a cancer? Is it a good cancer? Is it a bad cancer? But it's all digitized images, and it's absolutely perfect for turning that into algorithms that will tell you what the diagnosis is on the back of an AI algorithm.

18:21The problem is that the NHS has not moved in the right direction in terms of digitized imaging capability. We started down that road in 2018 with the life sciences strategy, where we brought in all the companies that made digitized imaging and they shared that those cameras with lots of hospitals we set in to process a whole system for taking digitized images that should be nationwide it shouldn't be optional because it's a lot cheaper you store the images it's a lot more robust the quality of the outputs are higher but it's just been so slow to get the system to actually adopt it but that could save dramatic amounts of money and would also be a great driver for the generation of the algorithms, which you could sell to everybody on the planet because they're hugely powerful.

19:08Same with radiology, x-rays, CT scans, all that stuff. These are all really amenable to AI interventions. And also when we talked about eliminating people, I guess the key thing to note here is that we've not seen a collapse in the number of radiologists, the number of people who read these scans. It's more that they are now able to do far more of the other valuable parts of their job. They're processing more scans, as it were. Yeah, no, So look, we're not going to get rid of radiologists or pathologists in the near future. It's just going to be there a lot more efficient at what they do. I suspect the accuracy of what they generate at the end of the diagnostic tunnel is going to be better.

19:46And they'll be able to do more and do it more effectively. So it's just a question of making a system which is kind of ground to a halt now, needs to move faster and more efficiently if we're going to get on top of these problems. Well look, Professor Sir John Bell, thank you so much for answering all of our questions and thank you to the listeners for sending those in. There will be another episode of Radical coming your way very soon. Thank you to everyone and goodbye.