Q&A with Dr Rowan Miller, Clinical Lead for Oncology

I’m a medical oncologist. So as a clinician, I look after patients with gynaecological cancers, ovary cancer and endometrial cervical cancer. In addition to that, I also have a role as Clinical Director for Oncology so I have an oversight of the running of the clinic and the governance, as well as working with the team on the cancer strategy for the hospital.

We’ve seen a trend across multiple cancer types with the age of diagnosis reducing and it’s not entirely clear why that is. We’re seeing it particularly in colorectal cancer, but also gynaecological and other cancers.

There are probably a variety of different factors, some of them being lifestyle driven, such as changes in diet. As a consequence of younger cancer diagnosis, there are more patients who may seek out treatment in the private sector because younger people tend to be in employment with associated private medical insurance.

This was for a study for patients with advanced ovarian cancer that had returned and was resistant to standard chemotherapy. For many years we’ve done lots of trials in this space to try and find improvements and all of them have been disappointingly negative.

I ran the clinical trial at UCLH where I do my NHS practice, but it was also run in multiple other centres throughout the UK and worldwide. The trial was randomised; so patients received the drug mirvetuximab or standard chemotherapy. Those treated with the mirvetuximab had a higher chance of their cancer shrinking and longer period of cancer control.

This is the first trial in this setting of advanced ovarian cancer that demonstrated an improvement in overall survival of about 30%, which is really quite remarkable and which translated to about a four-month improvement in survival.

The drug binds to the cancer cell and delivers the chemotherapy directly into the cancer cell rather than standard chemotherapy, which goes throughout the circulation, therefore, we are able to deliver a much higher dose of chemotherapy directly into the cancer, which in theory results in less side effects. This is what was seen in the trial.

These types of drugs, called antibody drug conjugates and are approved in many different cancer types. This is the first one to be approved in ovarian cancer, but there are ADCs we’ve been using in breast and bladder cancer for some time. There are a number of different drugs like these in clinical development, and it is an exciting space to be in doing research in.

Many of my patients who’ve been on this treatment say that out of all the chemotherapy that they have received in the past, this is the easiest one to live with, and they can get on with their life, which is great. The reason the mirvetuximab story made the press was because it was approved by NICE and the NHS. This means we are now able to give to patients within the NHS, which was great as the drug has been available in the USA for sometime, following the positive trial results.

We have been fortunate to be able to use Mirvetuximab in The London clinic for a bit longer, since the drug received MHRA/EMA approval. This is certainly a benefit of private medical insurance.

It is very rewarding to run clinical trials. Me and all my colleagues at The London Clinic that have NHS practices are all very heavily involved with clinical trials in our respected NHS hospitals. The great thing about clinical trials is that it increases the opportunities for patients to access a drug that wouldn’t otherwise be available and therefore increases the number of options they have for treatment.

One of the good things about running a clinical trial with a novel therapy, is that we have a strict protocol to follow, which helps with management of any side effects. It gives us experience of using the drugs in a controlled manner before the drugs are more widely available. Furthermore, if you are involved with the trial design, you get to shape the landscape of the future research for your disease type, which is really important and exciting.

Not all clinical trials are positive and lead to new drug approvals, but the process of being involved in a clinical trial is often a positive one for patients.

That’s a very interesting question.

We have been doing a lot of work on that at UCLH looking at inequalities in clinical trial participation. In general, when you look at the populations of patients enrolled in a global trial, it doesn’t necessarily represent the population of patients that you treat on a day-to-day basis. There’s a lot of underrepresentation of certain ethnic minorities, of particularly older and younger patients, and other various protective characteristics are often underrepresented.

It is important that the trials that we do represent the patients that we treat because the results have to be applicable. We’ve been doing a lot of work on that, trying to identify why people may or may not take part in clinical trials. As you would imagine there’s a variety of different reasons.

In my experience, patients are happy to be considered for a trial, but I think it’s all about the way that you explain the information to them and offer choices. We have to make trials more accessible to patients, for example where English is a second language, or for those who have other medical problems. We also need to try and deliver clinical trials closer to their home. There’s quite a lot of unequal access to clinical trials across the country.

There’s certainly plans underway and there are a couple of clinical trials that we’re looking to set up in the near future involving cancer patients with novel treatment.

There is a lot of excitement about doing potential research with Northwestern Medicine and the consultant body are developing ways to collaborate with the team in America, across multiple different cancer types.