BY ANTONIA FILMER
At the end of 2022 Professor Sir Mike Richards gave a presentation at the Royal Free Hospital in North London. Sir Mike is currently working with NHS England to help implement a major expansion of diagnostic capacity and a new model of service delivery. He is also a trustee of Cancer Research UK and since April 2022 he was appointed as Chair of the UK National Screening Committee. His distinguished career spans the soup to nuts of cancer treatment and NHS strategy.
Professor Sir Mike Richards
The Royal Free Hospital is part of the Royal Free London NHS Foundation Trust group offering a wide range of acute medical services including paediatrics, dermatology, gynaecology, orthopaedics and cancer services as well as robotic-assisted surgery and ground-breaking transplantation research.
Sir Mike’s introduction to William Marsden (portrait below), 1796-1867, was full of admiration for an exemplary humanitarian known as the compassionate surgeon, chronicled in a book by the same name by Frieda Sandwith. A Sheffielder, William Marsden trained at St Bartholomew’s hospital in Smithfield and in 1827 was admitted to the Royal College of Surgeons based in Lincoln’s Inn Fields.
The defining moment of Marsden’s life was when he found a young woman suffering on the steps of St Andrew’s Church in Holborn, desperately sick from syphilis and malnourishment. In vain he tried to find her a free hospital bed at St Thomas’ Hospital and at Guy’s Hospital to alleviate her suffering, eventually he took her to his home and nursed her himself until she died two days later. Haunted by this, on February 14th 1828, William Marsden convened a committee of 27 people to establish a Free Hospital at 16 Greville Street in Hatton Garden, initially called “The London General Institute for the Gratuitous Care of Malignant Diseases”, here he initially provided a dispensary, then inpatient beds for women and outpatient services for men, poverty and sickness were the only criteria required. During the 1832 cholera epidemic this was the only foundation in London to admit and treat victims of cholera, they also treated prostitutes with sexually transmitted diseases when others would not. Thus Marsden was popular with the poor and unpopular with the medical profession, he faced endless struggles raising funds but was supported by Royal patrons George IV and William IV, in 1837 his hospital became, by royal charter of Queen Victoria, the Royal Free. Success brought more patients and more donors – Michael Faraday (Philosopher), George Grote (Historian) and Thomas Wakley (founder of The Lancet) were among original Marsden’s philanthropists. After an interim move to Gray’s Inn Road, The Royal Free Hospital moved to Hampstead in 1978, by which time Marsden’s principle of free treatment at the point of use had become a founding pillar of the NHS.
Following the death of his first wife, Elizabeth Ann (Betsy), from cancer in 1846, Marsden reflected on how “absolutely nothing” was known about the illness that had claimed her. Five years later he founded the Free Cancer Hospital, dedicated to the study and treatment of cancer, initially based at 1 Cannon Row, Westminster. In 1862, helped by funding from the philanthropist Baroness Burdett-Coutts, the hospital moved to its current site in the Fulham Road. In honour of its founder, it became the Royal Marsden Hospital in 1954, and today it is among the world’s leading centres for cancer treatment and research.
Sir Mike reflects that Marsden was full of love for his wife and family, full of compassion for the poor and sick, full of vision for the need of better care and persistent with his endless fundraising efforts, full of principle in his opposition to quack medicine, full of courage in that he was unafraid to take on the medical establishment… Marsden died of bronchitis, and Marsden’s obituary in the British Medical Journal was understated “an energetic and worthy gentleman … like all men of mark [he was] self-contained, and did not ever give up an object he had fixed his heart upon [even when] he was opposed by great and authoritative personages.”.
Sir Mike applauded the compassion and values of the NHS and said cancer care and cancer research have come a long way in the past 170 years, but cancer survival rates in the UK still lag behind those in other developed countries and UK’s diagnostic services have been neglected for too long. It seems that patients with possible cancer still have to wait too long to be seen, diagnosed and treated. This is partly because the UK doesn’t have sufficient scanners, in 2017 UK had a only similar number of scanners per 10,000 people as Hungary, and partly because of historical outdated attitudes towards cancer even among the medical profession. Today the number and percentage of breast cancer patients waiting more than 104 days to begin treatment after an urgent referral is circa 3.5% higher than in 2015, and for gastrointestinal cancer this rises to just over 70%, which is above the designated Faster Diagnosis Standard.
Having lost our daughter Miranda to neuroendocrine cancer last year, my contribution to Sir Mike’s compelling account is that early diagnosis and early treatment can significantly improve outcomes for most cancers. However some cancers are secretive, they may take years to present and to diagnose, often symptoms go unrecognised, as in neuroendocrine cancer, as tumours can present anywhere in the body and symptoms can vary between individuals. Not many doctors know a lot about NETs (neuroendocrine tumours), like our daughter many will endure extensive periods of unidentified excruciating pain without a diagnosis. The medical profession have an expression and a symbol for rare diseases, a zebra. Clinicians are often told, “when you hear the sound of hooves, think horses, not zebras”, clinicians are urged to assume that the simplest explanation of a patient’s symptoms is correct to avoid misdiagnosing them with rare conditions. However, medical ‘zebras’ do exist even in young apparently healthy people like Miranda, and it is vital that clinicians are equipped to diagnose and treat them when they occur; raising awareness about zebras across the whole NHS establishment is essential.
In the spirit of William Marsden and Sir Mike Richards, the Neuroendocrine Cancer Alliance have made a clinical information and awareness video called “Think NENs” to familiarise GPs and primary care physicians about neuroendocrine tumours and neoplasms. Professor Martyn Caplin, NET specialist at the Royal Free Hospital, explains both low grade and more aggressive tumours, their commonality, their incidence vs their prevalence and their heterogeneity in various ethnicities. The other participants Dr David Bartlett, Dr Elizabeth Zide and Dr Mehmet Ungan pose questions about how does neuroendocrine cancer present, to which Prof Caplin said patients who present repeatedly with abdominal pain or any recurring symptoms, but who can look generally well, should be immediately referred to a specialist. He also said that examination can be a great help as the patient might present with hepatomegaly, a swollen liver that can have many causes. However the most valuable clinical information will come from a CT scan, so patients presenting with ongoing symptoms will benefit most from lower NHS thresholds for CT scans.
The new Royal Free Charity Fund established for our daughter Miranda Filmer will conduct clinical research into the most aggressive form of neuroendocrine tumours, high grade neuroendocrine neoplasms (G3 NENs) which have poor survival outcomes. Little is known regarding the underlying genetic make-up of these rare tumours and scientists lack an understanding of the genetic differences between G3 NENs and G3 NETs, and how these differences may be utilised to better understand how tumours develop. The research program will undertake genetic profiling (looking at changes to in the DNA of genes) and epigenetic profiling (looking at changes that control gene expression) and immune assessment with a view to identifying novel therapies for individual patients. A paper is forecast for peer review at the end of 2023.
Another department going further at the Royal Free London is the rare diseases hub, conducting research into rare disorders: haemophilia, amyloidosis, immunodeficiencies, lysosomal storage diseases, pulmonary hypertension and scleroderma, these are all “zebras”. Their 10-year strategy for rare diseases will create a specialist interdisciplinary hub for the treatment of patients of some zebras, including an outpatients centre and becoming a gene therapy centre of excellence.
The Royal Free Hospital campus already is home to the UK’s most advanced research into the human immune system – the Institute of Immunity and Transplantation in the Pears Building.
The Royal Marsden hospital also is going further, recent initiatives include: The Libra Study, where data from circa 500 patients was used to develop an AI algorithm that could help doctors diagnose cancer nodules in the lungs earlier. Alongside the Libra Study the new joint venture between the Royal Marsden and the Institute of Cancer Research, the Integrated Pathology Unit will bring pathology into the modern era through state-of-the-art laboratory techniques, sophisticated computing tools and AI, helping pathologists design new research programmes and improve diagnosis and treatment of cancer for patients at The Royal Marsden and other cancer centres, they calculate 80% of diagnoses and treatments in hospitals are dictated by the pathology analysis. The Royal Marsden also are pioneering the Da Vinci Xi surgical robot, with a minimally invasive operation for oesophageal and gastric cancers; consultant surgeon, Asif Chaudry has already helped train robotic surgeons to do the operations in cancer centres in the UK and around the world.
All the above are steps in the right direction but possibly William Marsden would still say it is not far or fast enough.
Antonia Filmer is former British Vogue Fashion Editor, Home Furnishing Design Director of Laura Ashley Ltd, producer of Garden Operas for 10 years to benefit a children’s charity. Antonia is an inveterate traveller and is currently the London correspondent for The Sunday Guardian of India.