At The Royal Marsden, we offer a comprehensive cancer service, which includes patients coming in at all stages of their cancer journey. The usual referral route for UK patients is that they go to their doctor with any concerns or symptoms, then, if their doctor suspects it might be cancer – a breast lump, for example – then they can refer to The Royal Marsden and the fast-track service, whether privately or through the NationalHealth Service.
When a patient is referred they will be examined by a specialist and may also have some tests, such as a biopsy of a lump, or a scan.Should the tests confirm a diagnosis of a cancer, then the patient’s case is discussed in what is called a multidisciplinary team meeting, or MDT, which was pioneered at The Royal Marsden. At that meeting, you'll have doctors, nurses, surgeons and other experts, including those who specialise in chemotherapy and radiation. Within this group discussion, the treatment plan is agreed, which can then be reviewed by the team on a regular basis.
We see patients coming into The Royal Marsden at all stages, from those suspected of having cancer to those who have already been diagnosed. We are a very large, comprehensive cancer centre, so we often receive patients who have been diagnosed with either rare cancers or more complicated cases – perhaps those who have had cancer that has returned or cases that have become difficult to treat, including those that have been treated at another centre and have been referred to The Royal Marsden as a more specialist area for treatment.
We also care for many patients as part of research trials, as we have one of the largest cancer research portfolios in Europe. If a patient is in a position where perhaps their cancer has not been responding to treatment, they may consider taking part in a research trial.
There are some well-known and well-established screening programmes, including mammographic screening for breast cancer and smear tests for cervical cancer for women, and prostate cancer screening for men. One of the areas we're particularly interested in at The Royal Marsden is lung health, for patients who have been smokers in the past and are at risk of getting lung cancer, including those who gave up smoking as much as 10 years ago. Too many patients present with lung cancer that is well advanced, perhaps even with disease that is no longer curable at that stage. Similarly, those with abnormal moles and lumps in the skin are also encouraged to come forward for testing, before any disease becomes too advanced.
One of the problems with diagnosis of the most common cancers, such as bowel or lung cancers, is that they historically could not be detected with a blood test. With these diseases, screening has required scans or, in the case of bowel cancer, an endoscopy – an examination carried out by inserting an endoscope into the back passage.
In the past few years, it has been discovered, if a patients’ cancer is slowly growing, it is releasing debris into the bloodstream, so there are new methods emerging to try and identify this genetic material –known as circulating tumour DNA (ctDNA) – in the blood.
Obviously, cancer cells have a different genetic makeup to the patient’s own DNA. So, if this additional material disappears after the treatment, then you can be confident that it has been successful. This technique is already being used for treatment monitoring, but the hope is that the detection of cancer DNA in the blood could also become a method of screening for a wide range of cancers, in a way that hasn’t been possible so far. That's a very exciting potential advance for the future.
A major hospital, such as The Royal Marsden, takes in tensof thousands of cancer patients a year at a fairly constant rate. However, after the first UK lockdown started in March 2020, the referral rate dropped considerably.
When the lockdowns ended there was a rebound in referrals, but there are still patients that appear not to have come forward yet and the figures are still behind what would have been expected. If that is a true reflection of what has happened, that means there are patients out there who, in normal circumstances, would have been diagnosed by now, but who are still in the community.
Following the pandemic, I came across patients who said that they had hardly been out the house for a year, which isn’t uncommon. As a result, these people neglected their health, but I think there is a specific subset of patients with cancer symptoms that resemble those of Covid – for example, those with lung cancer. Their common symptoms are coughing and breathlessness, which could quite easily be mistaken for Covid. Some of the people with these symptoms will have had undiagnosed lung cancers that were not detected as quickly as they should have been.Such delays in diagnosis are a major concern for cancer specialists.
Professor Chris Nutting is a consultant in clinical oncology at The Royal Marsden NHS Foundation Trust and clinical director of The Royal Marsden Private Care at Cavendish Square in central London