A conversation with Consultant Urologist, Mr Raj Nigam.
Joining me today is Raj Nigam, Consultant Urologist at the Royal Surrey County Hospital and the Focal Therapy Clinic. Raj’s clinical specialties centre around urological oncology and andrology. He manages men with all andrological conditions including erectile dysfunction, male infertility, Peyronie’s disease and male hormonal problems. He also has a major interest in prostate cancer and in particular, precision diagnostics and focal therapies Raj is widely published in national and international journals, and has lectured extensively over the last 20 years. His current research interests are in advanced diagnostics in prostate cancer and the evolution of new treatments to treat prostate conditions. He’s here today to address perceptions and misperceptions on personalised medicine –a term that we hear a lot about and which means many things to many people. I’ve asked him to join me and give his views on what personalised medicine means for diagnosing and treating prostate cancer.
Clare Delmar
Hello and welcome to On Focus brought to you by The Focal Therapy Clinic, where we engage you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided or even ignored. Prostate cancer is the most commonly diagnosed cancer among men in the UK. With this sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. As we move into 2022, I’m going to be diving deeper into some of the more challenging issues faced by both patients and clinicians, including technology, clinical adoption of innovations, inequalities and non-clinical aspects of prostate cancer. Joining me today is Raj Nigam, consultant urologist at the Royal Surrey County Hospital and The Focal Therapy Clinic, Raj’s clinical specialty centres around urological oncology and andrology. He manages men with all andrological conditions, including erectile dysfunction, male infertility, Peyronie’s disease and male hormonal problems. He also has a major interest in prostate cancer and in particular, precision diagnostics and focal therapies. Raj’s widely published in national and international journals and has lectured intensively over the last 20 years. His current research interests are in advanced diagnostics, in prostate cancer and the evolution of new treatments to treat prostate conditions. He’s here today to address perceptions and misperceptions on something called personalised medicine. It’s a term that we hear a lot about in the media, in various clinical studies, at the GP surgery. We’d like to learn a little bit more about what this means, and I’ve asked him to come to talk a little bit about what that term means to him. Raj, welcome. Very long intro, but I thought it was important to set the context. It’s lovely to have you back.
Raj Nigam
Thank you very much, Clare. Thank you for having me.
Clare Delmar
So what does that mean when I say personalised medicine? You know, I mean, I’m making the allegation that it is talked a lot about. I sort of look at this stuff a lot. How would you define it and what do you think it means for men diagnosed with prostate cancer?
Raj Nigam
Sure. I mean, personalised medicine is not really a new concept. I mean, doctors have been trying to personalise medicine for throughout the history of medicine really. It’s just a term that has gained much more traction over the last 15 to 20 years or so, particularly with the launch of the Human Genome Project and so on, people started musing about what that could hold for an individual once their whole genetic code had been mapped, people could figure out what sort of conditions they might be more prone to and therefore target detection and diagnosis of those conditions in those people. So it’s a term that is relatively new, but not a particularly new concept. And really, the NHS itself has embraced this, and they actually quote and say that we want to move away from what they call a one size fits all theory to a more personalised approach, particularly in terms of prevention, detection and even diagnosis and treatment options. And those particular categories people have gone along part of the way, shall we say, but there’s a lot more to come.
Clare Delmar
It’s interesting. That’s interesting because it’s so it’s not something that’s kind of like a consumerist term, you know, like we’re going to treat you differently than somebody else. It’s actually has very deep, very valid roots in science. And then that it’s like you mentioned the genome project. And then that itself is manifested in a wealth of personal data that can be used to both prevent diseases and treat conditions.
Raj Nigam
Yeah, absolutely. Yeah.
Clare Delmar
OK, that’s interesting. Well, I guess there’s also kind of a qualitative side, if I can call it that? We understand more about each individual through the things we just talked about, but also we address them differently or we deal with them differently. And one of the things I’m interested in getting at is that the majority of our patients come to us for a second opinion, so they’ve already had some engagement with the medical profession for lack of a better term. Do you think that the experience of having gone through something before and the information they bring helps you and helps us to provide a more personalised service?
Raj Nigam
Yes, absolutely. I mean, I think that we can personalise the service more once we have that knowledge and also the patients have that knowledge. So once the patients have been through the standard NHS approach, they would have had certain aspects of their condition discussed to a greater or lesser extent, and they would have been offered certain treatments. The truth of the matter is that in prostate cancer, it isn’t as much a personalised approach as we would like. And the very fact that patients are coming to us for a second opinion almost implies that they are a self-selecting group who would like to know more about their condition and what other treatment options they are in order to have a more personalised approach. I’ll give you an example. I mean, in prostate cancer, we see men of all ages from 50 up to beyond 80. And it’s important to note that those men at different ages may have very individual goals of their therapy. The older patient, for example, who is over 80 years old, may be quite happy to have control of their prostate cancer with minimal side effects for another five to ten years. The younger patients may still even want to have their family. I’ve had some patients who still want to have further children, so the approach to their treatment should really be targeted and personalised, taking into account the needs of that particular patient. And that’s how I see personalised medicine and focal therapy offers them an option along that approach.
Clare Delmar
Mm-Hmm. So I mean, given that focal therapy patients are very carefully selected as well. I mean, based on some of the qualitative or sort of non-clinical aspects you’ve just discussed, but also on very comprehensive diagnostic criteria, do you think that that’s a very highly personal form of medicine, even more than many other treatments, just because it has this combination of very individually specific data that’s come out of all the diagnostics plus these discussions that you have in order to select a patient?
Raj Nigam
Yes, absolutely. The process that we go through in selecting whether a patient is suitable for focal therapy is very precise and detailed. You know, we carry out a review of their particular MRI. We then personalise that to their pathology and check that the two are concordant. And sadly, it often isn’t. And that sort of approach is not necessarily required for a whole gland approach, such as radiotherapy or radical prostatectomy. Because that degree of concordance defining exactly how much cancer there is exactly where it is in terms of locality, is absolutely vital for focal therapy surgeons. Whereas in a whole gland approach, it is not so personalised because the approach is very much to remove the whole gland or treat the whole gland with radiation. So the diagnosis of cancer in itself is not sufficient for us, and we go much deeper than that to select those patients that are suitable for focal and indeed taking into individual desires of that particular patient, in terms of acceptance of certain side effects and so on. So like I said, we like to think we’re offering a much more personalised approach than that offered through the NHS.
Clare Delmar
So when you talk about this review and the actual discussions that you have with other professionals to actually select a patient and actually define their suitability, that’s actually what you’re referring to there is the MDT, correct?
Raj Nigam
Absolutely right. The multidisciplinary team meeting.
Clare Delmar
Yes. So how do you see that the MDT? I’d like to get a little bit more sense of how this is very distinctive and how it actually drives this personalised treatment. I mean, when you discuss both the technical or medical or clinical aspects of each patient, as well as his family life, his mental outlook, everything else.
Raj Nigam
Sure. The MDT meeting is a concept that has arisen through the NHS and has been present for many years, at least ten years. Its initial goal was very much to individualise the patient and discuss their particular situation. Unfortunately, certainly on the NHS, the meetings have got so big that they become a tick box exercise. What I think it is important to your listeners to recognise is that the MDT is there to make recommendations. It is not there to make decisions on the treatment or not. One of the biggest criticisms of MDTs in various articles and scientific papers is very much that the patient is not present. So the one person who we are discussing is not there to put their side of the story. Now we like to think that within our MDT forum, the advocate for that patient, i.e. the surgeon that has seen them and spoken to them is present, which again, is not always the case within the NHS. So our MDT, we like to think, are far more personalised because, for example, I will be able to say that, look, this particular chap has got recently married, you know, erectile function is extremely important for him or indeed, our eighty year old gentleman who normally, you know, if nobody knew that patient was being discussed, would be thought of as, Oh, let’s just watch and wait and not treat his prostate cancer. Whereas I would be saying, I’ve met this guy. He cycles ten miles every day. He looks after his wife and so on, and he really would like to have treatment and has got a good life expectancy ahead of him. So I would like to think that, you know, our particular MDTs are a bit more personalised for that particular patient, and therefore we hopefully come to the right conclusion for that particular patient.
Clare Delmar
And do you see any additional drivers of personalised diagnostics or treatments coming in the near future? I mean, you spoke in earlier part of this conversation about the genome project and various biomarkers that might be associated with that. Do you think you know, whether it’s biomarkers, genomics, advanced imaging that some of this will contribute even further to better personalisation?
Raj Nigam
Yes, I think all of the above, I think that there already have been certain strides, particularly in terms of targeted therapy for other cancers. And also targeted diagnosis, and we’re probably about 15 – 20 years behind in terms of research compared to breast cancer. So a woman’s breast cancer is very individually characterised right at the outset in terms of the the genes and the receptors for those genes that are present within that cancer. And we know that certain of those characteristics allow different treatments. So that already exists. And in other cancers, immunotherapy for melanoma, for example, you know, the characteristics of that individual’s tumour are present and therefore targeted therapies towards that are being developed. We already know that the genomics and so on are there to discuss risks that the patient may or may not have cancer. So, for example, they have their PSA test and might have their MRI. There are tests that are already available whereby we’ll be able to judge on that individual’s readings, whether they should have a biopsy, for example. And what are their chances of having cancer? Similarly, post biopsy, once you diagnose the cancer, there are tests that one can do, genetic markers, to see that their individual cancer, how likely it is that they are going to have an aggressive cancer, for example, that needs more urgent treatment. We also know that one fascinating preorders, A.I. artificial intelligence, in terms of imaging, we know that imaging techniques are improving all the time. And I suspect in 10 – 15 years time, I may be saying to you that we don’t need to biopsy men anymore and that, you know, the imaging is so good that we can avoid biopsies. We’re not there yet, unfortunately, but I think we’re moving in that direction and there will be algorithms that you can feed in the patient risk factors, you know, their family history, their ethnicity and so on into the algorithm for AI and you know, they will come up with the relevant readings on the MRI scan.
Clare Delmar
So the MRI will actually be highly personalised because it will have taken into account some of these emerging biomarkers or other genetic information that goes into the algorithm. It then tells you through the image whether or not this person has cancer, how how bad it is, how severe it is, how fast it’s moving, where it’s located, etcetera?
Raj Nigam
Yeah, I mean, that’s what I foresee. I think AI is still in its infancy. I mean, basic programs have been developed, but I think that we still have got some way to go to actually maximise the potential of imaging. And like I said, I think we’re already there in some cancers where we don’t need to biopsy. The imaging is strong enough for us to make that diagnosis, and I suspect that prostates will be a few years away from that.
Clare Delmar
But it’s almost like the more information you have, not only is it more personalised, so to speak, but it also means you can be far less invasive in how you do further diagnostics and potentially treatment ultimately.
Raj Nigam
Absolutely. I mean, like I said at the moment, we just have a relatively crude marker, which has been around for many years, which is a Gleason grade to assess whether a patient’s prostate cancer is aggressive or not. But within that, there are lots of other measurements that can be made, you know, on the biopsies and so on, which will help guide us as to how truly aggressive it is and therefore, what sort of treatments would suit that patient better.
Clare Delmar
Well, Raj, that’s been absolutely fascinating. And thanks so much for coming in today to share that with me. And for our listeners, it’s really helpful. And I want to thank you once again for joining me.
Raj Nigam
Pleasure, thank you.
Clare Delmar
A transcript of this interview. And links to Raj’s clinical practice and research are available in the program notes on our website, along with further information on diagnostics and treatment for prostate cancer, as well as additional interviews and stories about living with prostate cancer. Please visit www.thefocaltherapyclinic.co.uk and follow us on Twitter and Facebook at The Focal Therapy Clinic. Thanks for listening and from me, Claire Delmar. See you next time.