“There is nothing so patient, in this world or any other, as a virus searching for a host.”- Mira Grant– however, we need to put Covid-19 into perspective and as radiotherapy professionals we are well positioned to do this.

Out of interest Mira Grant was born and raised in Northern California, where she has made a lifelong study of horror movies and horrible viruses!

An alternative title for this blog could simply be “Wot-No Loo-Rolls” but that is probably too light hearted based on the critical issues we all face presently. I was recently staring at the empty shelves where toilet rolls used to live in my local store and at the fruit and vegetable isles that had been stripped clean bar one or two dodgy bananas when I had an epiphany.

Pic: Why are toilet rolls and cat litter being hoarded?

Why do people with cancer tend to look at life so positively while at the start of the latest coronavirus pandemic, the greater population exhibit greed and a complete lack of empathy for others, especially the vulnerable and those working in health care who simply can’t form two-mile queues outside supermarkets at 6am to stock up on Andrex. Before I go any further, I have put a very relevant and life-affirming quote at the end of this blog to cheer you all up!

The fact that Covid-19 is seen as a silent killer has created mass panic largely driven by social media, fake news and doom-laden newspaper selling headlines that continue to drive fear, misunderstanding and mistrust. However, cancer pre-dates social media and so has not been infected with the hype, leaving its own wake of death and destruction largely on the back pages.

While the majority of people seem to suffer mild symptoms and often no worse than a cold or flu, the virus is dangerous to vulnerable people with underlying health issues and the elderly. Depending on your point of view this could be seen to be good or bad as this article below suggests.

Coronavirus could be ‘quite useful’ in killing off NHS bed blockers, says ex official

Professor June Andrews admitted her comments sounded “horrific”, but insisted they were an honest assessment of the consequences of a pandemic in the UK

“If you’re on the board of a care home company, a pandemic is one of things you think about as a potential damage to your business because of the number of older people it’s going to take out of the system. “Curiously, ripping off the sticking plaster, in a hospital that has 92 delayed discharges, a pandemic would be quite useful because your hospital would work because these people would be taken out of the system.”

Read more: https://www.mirror.co.uk/news/uk-news/coronavirus-could-quite-useful-killing-21646425

We are deliberately creating a social, economic and financial crisis to save the NHS from meltdown

My understanding is that if the NHS was able to cope with the sudden increase in death rates over a short period of time, it might be wise (some say) to let the virus run its course without any massive impact to most of our lives. This would enable us to gather antibodies and protection individually and en masse creating some form of herd immunity, a thought-provoking concept in that this virus emanated from one live animal in a Chinese food-market via some bats in a form of “Zoonotic transfer”.

I heard someone say recently that in an ideal world, all the vulnerable people would be moved to the North of Scotland while all the younger, healthier population would be moved to the South-East to share the virus and become largely immune. You then slowly reintroduce everyone, light the touch paper and stand back. This is not going to happen however imaginative it sounds.

However, the NHS is not able to do this and so the death rate is being manged by the government to prevent the impact of a sudden explosion. The other reason for managing the spread is that friends and relatives will not want to lose loved ones earlier than they might expect as the virus’s main impact is bringing the what is often imminent or in the short-term death of the at-risk people forward in time.

Pic: A typical coronavirus image that will be imprinted in our memory for years to come

Official figures (SAGE/Imperial College) forecast death tolls as follows using current models. If nothing is done to prevent spread then 510,00 deaths would occur, if the virus is allowed to spread more slowly by simply isolating the vulnerable and those with symptoms totals deaths would be 250,00 but suppressing the virus including school closures, reducing social contact and isolating the vulnerable and those with symptoms, the total deaths would amount to only 20,000.

All these people above, to put things into perspective would probably die anyway as in the UK annual deaths rates are circa 600,000 and so coronavirus related deaths would not be on top of these numbers. There would be some overlap but still a reasonably normal annual number of deaths would occur but with a great majority brought forward. Nevertheless, as discussed above the NHS can’t cope with any sudden surge and so social, financial, economic and political depression is the only answer and confers a huge change to all our lifestyles.

However, we do need to keep things in proportion as this article from David Attenborough stresses and in the next section I’ll look at more closely at cancer, our professional field.

David Attenborough: why at 93 I’m only ‘mildly worried’ about coronavirus

The broadcaster on how reports of his death have been greatly exaggerated and the need to keep a sense of proportion over Covid-19

Read more: https://www.telegraph.co.uk/men/thinking-man/david-attenborough-93-mildly-worried-coronavirus/?li_source=LI&li_medium=liftigniter-rhr

Cancer deaths are much more prevalent in the UK

Pic: UK cancer deaths annually (CRUK)

This is obviously a rapidly changing crisis and so this blog is only intended to review a moment in time (March 23rd) but the emergency does need to be put into some perspective with a proper sense of proportion in my opinion.

As an individual working in radiotherapy with cancer patients for almost 40 years I thought it would be perceptive to review cancer incidence and mortality in the UK to try to do this.

There are around 367,000 new cancer cases in the UK every year, that’s around 1,000 every day and where death rates from cancer in the UK alone exceed 165,000 every year. (figures courtesy of www.cancerresearchuk.org )

The current number of deaths in the UK due to Covid-19 as I write stands at around 350 and as just mentioned on the latest Radio 5 news well over 90,000 people world-wide are now all clear having been proven to have been infected previously. In China no new cases have been reported for some days and in Germany cases have levelled out. Here in the UK we are being told that this country is soon to be very badly hit, we will find out soon.

Each year more than half (53%) of all cancer deaths in the UK are in people aged 75 and over while mortality rates for all cancers combined in the UK are highest in people aged 90+ and so a similar demographic to those impacted by the virus but cancer as we know is no respecter of age at all and many people lose their lives to cancer at much younger ages than with this virus. The virus will shortly be last-years news but cancer deaths will continue year on year.

Pancreatic cancer is also a silent killer

Pancreatic cancer as an example is also a silent killer and largely asymptomatic initially as is Covid-19 is until it’s too late to prevent their spread either metastatically, systemically and/or to others in the case of the virus. So why is pancreatic cancer not in the national news headlines every day, a silent killer with largely noiseless publicity aside from specialist organisations representing these patients such as PCUK? https://www.pancreaticcancer.org.uk/

These are some of the stand-out statistics from CRUK based on an individual tumour site basis

There are around 16,300 bowel cancer deaths in the UK every year, that’s 45 every day

There are around 11,400 breast cancer deaths in the UK every year, that’s 31 every day

There are around 35,300 lung cancer deaths in the UK every year, that’s 97 every day

There are around 11,700 prostate cancer deaths in the UK every year, that’s 32 every day

There are around 9,200 pancreatic cancer deaths in the UK every year, that’s 25 every day

Background to pancreatic cancer

Despite the important improvements made in the fields of surgery, chemotherapy and radiotherapy, pancreatic cancer remains one of the most lethal malignancies. Even with novel treatment with neoadjuvant chemotherapy and chemoradiotherapy, few patients are able to proceed to surgical resection and survival is poor.

Surgery currently offers the only potential monomodal cure for pancreatic adenocarcinoma, however only a few patients present with tumours that are amenable to resection, and even after resection of localised cancers, long-term survival is rare.

Pancreatic cancer has the highest mortality rate of all major cancers and 74% of patients die within the first year of diagnosis

This is fundamentally a radiotherapy blog and so going back to that subject there is some good news in the treatment of pancreatic cancer

I work closely now with HPB surgeons in the UK where they are looking at using Intra-Operative Radiotherapy or IORT to treat locally advanced and borderline resectable pancreatic cancer cases as data in the USA (see below) is now showing that these patients have very interesting and improved survival rates.

Out of interest in Southampton at UHS over 50 patients have now been treated with IORT for pancreatic and colorectal cancers.

What is locally advanced pancreatic cancer?

Pic: Stage 3 cancer is called locally advanced cancer ( image courtesy of CRUK)

The potential role of IORT

As discussed, pancreatic cancer is one of the few cancers for which survival has not improved substantially in over nearly 40 years while locally advanced pancreatic cancer is a poor prognosis group with no international gold standard treatment regimen or consensus with dismal outcomes.

Advancements in systemic treatment has increased the importance of local control and about 30% of patients with pancreatic cancer die from local progression in the absence of metastatic disease.

Patients with locally advanced disease who do not develop metastatic disease during systemic treatment might benefit from local control of the tumour with radiotherapy and so IORT has the potential to significantly improve radiotherapy for pancreatic cancer by reducing normal tissue dose and simultaneously, allow for dose escalation to further enhance local-regional control as this recent paper below highlights.

The role of Intra-Operative Radiotherapy in the New Era of Locally Advanced Pancreatic Adenocarcinoma at Massachusetts General Hospital (MGH)

Dr Ferrone, HPB surgeon at MGH in Boston has highlighted recent results on a prospective series of 48 borderline resectable patients which was published in JAMA Oncology earlier last year. It summarises their experience leveraging folfirnox and individualized neoadjuvant chemoradiotherapy followed by surgery and electron beam IORT in the treatment of locally advanced and borderline PDAC patients.

The results show that the Median Progression Free Survival (PFS) was reported at 37.7 months for all patients – and notably for those patients able to undergo resection and IORT (32/48 – 67%) the Progression Free Survival (PFS) was reported at 48.6 months and so some very good news for these cases.

Read more: https://intraop.com/clinical-research/intraoperative-radiation-therapy-iort-for-borderline-resectable-and-locally-advanced-pancreatic-ductal-adenocarcinoma/

An alternative perspective from Jeremy Clarkson -ex Top Gear presenter in the Sunday Times

Jeremy Clarkson’s blog in the Sunday Times this weekend (21.3.20) takes a much more dystopian and depressing look at the current coronavirus crisis whereby he sees it as some form of dark vision of the future, one driven by extinction rebellion and climate change activists where there are no more flights or holidays and one that ends in what sounds like a “Mad Max” lifestyle. Faced with a choice of having a glass of wine with friends or clean air he would be down the pub in seconds and that amongst the death and despair, the world as we know it is ending. I hope not but do see his point.

An Astronomer’s Quote

And to finish this blog I showcase above the quote as promised by the famous astronomer Galileo which has been put into the context of surviving cancer to mean; If you love your life before cancer, do not be afraid of life after cancer, you will find beauty again.

I do realise that this viral pandemic is very serious, that the NHS will be under extreme pressure, people will die needlessly and before their time but I hope that is quote is somewhat inspiring in the current climate.

Duncan Hynd – March 23rd 2020