What does the future hold for gynaecological cancers and sarcoma?

On Tuesday 8 October, we held the latest in our series of patient and public engagement events, showcasing the research being carried out at The Royal Marsden and The Institute of Cancer Research, London (ICR) into gynaecological cancers and sarcoma.

What does the future hold for gynaecological cancers and sarcoma?

Over 90 people, including patients, carers and healthcare professionals, attended the evening, to find out about the latest research taking place in key areas such as genetics, targeted drugs and radiotherapy, in addition to getting advice from our research nurses and dieticians.

Gynaecological cancers - the value of research

The Gynaecology Unit at The Royal Marsden aim to develop new and more effective treatments and improve outcomes for women with gynaecological cancers.

One in six ovarian cancer patients have a mutation to key DNA repair genes, known as the BRCA genes. Research led by the ICR has resulted in the development of a group of drugs called PARP inhibitors, which specifically target cancer cells with these BRCA mutations. Consultant Medical Oncologist Dr Susana Banerjee discussed the practice-changing SOLO-1 trial demonstrated that the PARP inhibitor olaparib can significantly delay the time until cancer returns and progresses in patients with advanced ovarian cancer. As a result of this trial, olaparib was made available on the NHS for women with newly diagnosed advanced ovarian cancer who carry the BRCA mutation in July 2019.

Research into immunotherapies, which harness the immune system to kill cancer cells, is a rapidly developing field; however these treatments are not always successful in all cancer types. Clinical trials investigating the use of immunotherapies in ovarian cancer have so far been disappointing, but are showing promise for cervical and endometrial cancers. The immunotherapy drug pembrolizumab was approved by the US Food and Federal Drugs Administration (FDA) for use in recurrent and metastatic cervical cancer in 2018 and trials are on-going in to the use of immunotherapies in combination with other treatments such as PARP inhibitors.

Download Dr Banerjee's presentation slides 'The Value of Research - gynaecological cancers'

Sarcoma – the value of research

Sarcomas are a rare group of tumours, accounting for just 1% of adult cancers and 15% of paediatric cancers. There are over 100 different types of sarcoma, which can make diagnosis incredibly challenging.

The Sarcoma Unit and Paediatric and Young People’s Unit at The Royal Marsden have a strong track record in delivering clinical trials and collaborating with international research groups.

Dr Spyros Gennatas discussed the DOREMY study is investigating whether patients with myxoid liposarcoma, a rare subtype which is highly sensitive to radiotherapy, can be effectively treated with a lower dose of radiation in order to reduce the immediate and long-term side effects.

PASART2 has also been investigating whether treatment with radiotherapy and the chemotherapy drug pazopanib before surgery can improve outcomes for patients with non-metastatic sarcoma patients. This trial ended in March 2019 and results are pending.

Figure 1: Attendee feedback from gynaecological cancers and sarcoma patient engagement event

Cancer genetics

Our genes can provide invaluable information about a tumour, which can be used to predict factors such as how the cancer will grow, where it could spread to and the response to chemotherapy, and allow the most appropriate targeted treatments to be selected.

The majority of cancers are caused by genetic mutations which occur spontaneously, however around 120 genes can inherit mutations linked to an increased risk of cancer. In ovarian cancer, around 15% of patients have inherited genetic risk genes, such as BRCA, whereas only 7% of sarcomas are linked to an inherited genetic defect.

Dr Angela George, Consultant in Oncogenetics at The Royal Marsden, discussed how patients with a form of ovarian cancer classed as non-mucinous (which includes serous, endometrioid and clear cell), are considered for inherited gene testing, in addition to those with a strong family history of other cancers such as womb, stomach and bowel.

Genetic testing is also considered for sarcoma patients who were under the age of 50 when diagnosed, those who have also been diagnosed with other cancer types and those with a strong family history of cancers, particularly breast cancer in the under 30s, childhood cancers, brain tumours and other sarcomas. 

Download Dr George's presentation slides 'Cancer Genomics - ovarian cancer and sarcoma'

Patient-reported outcomes

A cancer diagnosis and the side-effects of treatment can have a considerable impact on a patient’s quality of life, affecting physical, social and mental functioning. Dr Olga Husson discussed the importance of gathering patient reported outcomes to help us better understand the benefits and risks of treatments.

Several studies have been established to recognise the experiences of sarcoma patients, including the QUEST study, which is gathering information on how patients are diagnosed and the impact that a delay in diagnosis has on a patient’s quality of life.

The HOLISTIC study has also been established to gain an understanding of the impact of chemotherapy on quality of life in advanced soft tissue sarcoma patients. The findings from the study will enable clinicians to provide patients with information on the predicted impact of chemotherapy on their quality of life, helping to guide treatment decisions.

Download Dr Husson's presentation slides 'Assessing health-related quality of life of cancer patients'

Machine learning and MRI

In addition to the tumour itself, sarcomas are comprised of other biological matter, including fat and dead tissue. We want to be able to more accurately distinguish between these different materials to get a more precise view of how the tumour is responding to treatment.

Dr Matthew Blackledge, Leader of the Computational Imaging Team in the Division of Radiotherapy and Imaging at the ICR, explained how artificial intelligence and machine learning is being used to enhance MRI imaging. The ultimate aim is to be able to offer patients a ‘digital biopsy’ which can reveal the biological make up of a tumour and how it is responding to treatment.

Figure 2: Breakdown of attendees at gynaecological cancers and sarcoma patient event

The impact of diet and nutrition 

Natalie Harris, a cancer specialist dietician at The Royal Marsden, discussed the research into diet and lifestyle risk factors for gynaecological cancers and sarcoma, and the importance of nutrition and physical activity in preparing for, and recovering from, treatment.

Although there are no known nutritional and lifestyle risk factors for sarcoma, research has identified several factors linked to gynaecological cancers.

There is strong evidence to show that body weight is associated with an increased risk of endometrial cancer, and it is a probable risk factor for ovarian cancer too. There is inconclusive evidence to link specific foods and vitamins to an increased or decreased risk of either of these cancers, with the exception of coffee which is associated with a decreased risk of endometrial cancer.

The interplay between nutrition, psychology and exercise is also key to preparing patients for treatment and the physical challenges they will encounter and can help to enhance recovery, reduce the side effects of treatment and improve quality of life.

Download Natalie's presentation slides 'The impact of nutrition'

Radiation therapy in sarcoma

Dr Aisha Miah, Consultant Clinical Oncologist in The Royal Marsden’s Sarcoma Unit, discussed the research being carried out to improve radiotherapy, and outcomes, for sarcoma patients.

One of the key aims of radiotherapy research is to reduce side effects from radiotherapy and understand why some patients are more susceptible to side effects than others. Researchers want to know if there is a difference in the side effects experienced by patients who receive a higher dose of radiation to healthy tissue over a smaller area, compared to patients receiving a lower dose of radiation over a larger area.

Researchers also want to understand how patient outcomes can be improved by combining radiotherapy with other treatments. Radiotherapy is known to provoke an immune system response and studies, including the APPLE trial led by Dr Shane Zaidi at The Royal Marsden, are underway to whether a combination of radiation and immunotherapy drugs, such as avelumab, can increase tumour cell death in metastatic soft tissue sarcoma.

Download Dr Miah's presentation slides 'Radiotherapy for sarcoma'

Radiotherapy research in gynaecological cancers

Treating gynaecological cancers with radiotherapy presents several challenges, such as the risk of toxicity to the surrounding organs and tissues and variation to the target area due to factors such as filling of the bladder and bowel.

Dr Susan Lalondrelle, Consultant Clinical Oncologist at The Royal Marsden, discussed how research has identified that a combination of ultrasound imaging and a type of CT scan called ‘cone beam’ CT, can improve the visualisation of uterine cervical cancers, making it easier to locate the tumour and distinguish it from the surrounding tissue.

The PRIMER study is also investigating the use of new technology, the MR Linac, to deliver radiotherapy more accurately. The MR Linac delivers an MRI scan and radiotherapy simultaneously, allowing tumours to be targeted with increased precision. This method takes into account daily changes in the tumour’s position, caused by factors such as filling of the bladder and bowel, which allows radiation to be delivered more accurately, reducing side-effects and damage to surrounding tissues.

Download Dr Lalondrelle's presentation slides 'Radiotherapy for gynaecological cancers'

The role of research nurses in clinical trials

Research nurses Liz Barquin and Sally Gill from our Gynaecology and Sarcoma Research Units discussed their roles and provided advice for patients considering taking part in clinical trials at The Royal Marsden.

Although clinical trials can enable patients to access treatments which may not otherwise be available on the NHS, patients should consider the risks and benefits of the trial treatment, and the practical aspects of taking part such as expenses and travel arrangements. Patients were also reminded that they can change their mind about taking part in trials and withdraw their consent at any time.

It is also the research nurse’s role to screen patients for recruitment to trials and provide support throughout, from providing preparation and counselling to tailoring the patient’s experiencer within the restraints of the protocol, such as accommodating for holidays and minimising hospital visits.

Download Liz and Sally's presentation slides 'Caring for research patients'

A patient's perspective

We were also joined by ovarian cancer patient Kat Vitou, who discussed her experiences following a diagnosis in 2015 and treatment at The Royal Marsden. Kat shared the roller coaster of events that this diagnosis brought to her life, as a young woman with two small children, and how she was inspired by her experiences to re-train as a health coach and established her own well-being business.