Podcast "Let's Talk Cancer": Multi-cancer early detection could save millions of lives

In this edition of Let's Talk Cancer, Dr Dan Milner, Executive Director of the Access to Oncology Medicines (ATOM) Coalition explains how a simple blood test could detect up to 200 cancers in the early stages and why he is optimistic that it will help turn the tide on cancer.

When a cancer is either detected before symptoms develop, or very shortly after, the chances are higher than it can be treated successfully. 

Screening tests for breast, cervical, colorectal, lung and prostate cancers are already in place in many countries. They are conducted “routinely”, in other words not when there are symptoms or suspicions of disease but according to specific criteria that contribute to a higher risk of developing the cancer – such as age, health and family history.

For many cancers, however, such as lung or pancreatic cancers, there is no proven strategy for early detection. Therefore, these cancers are most often diagnosed at an advanced stage when treatment options are more limited and less successful. 

This situation might soon change. Over the last years, there have been important advances in laboratory methodology for the discovery of biomarkers, or those indicators that reveal the presence and severity of a disease. These advances have generated the potential to conduct cancer screening for several organs at the same time with a single blood test, rather than a separate and often more invasive test for each different cancer type. 

In this episode of "Let's talk cancer", Cary Adams, CEO of UICC, talks about this new technology of multi-cancer early detection with Dr Dan Milner, a global consultant for medicine, science, business and health; former Chief Medical Officer for the American Society of Clinical Pathology; and currently Executive Director of the Access to Oncology Medicines (ATOM) Coalition.

"Multi-cancer early detection sits in a potential position to completely change how we approach cancer as a society and as a public health system. You'll be able to live in a society where cancer is more like an infection."
– Dr Dan Milner, Executive Director of the Access to Oncology Medicines Coalition

See podcast transcript below

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Podcast transcript

Cary Adams: Welcome to Let's Talk Cancer. I'm Cary Adams, a CEO of UICC. When a cancer is either detected before symptoms develop or very shortly after, the chances are higher that it can be treated successfully. Screening tests for breast, cervical, colorectal and prostate cancers are already in place in many countries. They are conducted routinely. In other words, not when there are symptoms or suspicions of disease, but according to specific criteria that contribute to a higher risk of developing a cancer, such as age, health and family history. For many cancers, however, such as lung or pancreatic cancers, early detection is incredibly difficult. Therefore, these cancers are most often diagnosed at an advanced stage when treatment options are more limited and less successful. This situation might soon change. Advances have generated the potential to conduct cancer screening for several cancers at the same time, with a single blood test rather than a separate and often more invasive test for each different cancer type. Here with us today to talk about these new technologies for multi cancer, early detection is Dr Dan Milner, a global consultant for medicine, science, business and health, former chief medical officer for the American Society for Clinical Pathology, and currently the executive director of the Access to Oncology Medicines Coalition. Atom, as we call it, which you set up with many partners in May 2022. Dan, thanks for joining us today and help us understand what sounds like a really promising advance in tackling cancer around the world.

Dan Milner: Thank you so much for having me.

Cary Adams: How does multi cancer, early detection technology work and what types of cancers can be detected?

Dan Milner: So MCED, as we refer to it, has the potential to completely change how we approach cancer as a society and as a public health system that typically uses a single patient sample. For example, blood, urine or stool to determine if there are known aberrant signals or abnormal signals that indicate cancer. And this is done for a large number of different cancer types that can range from 20 different cancers to over 200, depending on which Imcd platform you're talking about.

Cary Adams: How does that differ from the technologies that we have for traditional cancer screening?

Dan Milner: In traditional cancer screening, we're typically looking for performing one test or one series of tests that are directed at a specific cancer type. So, for example, in cervical cancer, women may have an HPV test performed, which is a molecular test. They may have a pap smear or they may have colposcopy, a more advanced in-office exam to evaluate the cervix for pre cancer in breast cancer. On the other hand, a combination of a breast exam mammography, which is the radiographic looking at the breast, which requires pain and pressure for women on their breasts and ultrasound. Another test using imaging may all be used to locate a lesion just for sampling it to see if it represents cancer. In Imcd, we're using a single test and we can screen for dozens to hundreds of cancers. So you can see, you know, immediately the differences for for the patient is the interaction with the with the system is much simpler and much more efficient.

Cary Adams: How accurate is the technology?

Dan Milner: These platforms have high detection rates for stage three or stage four cancers. As the volume of tumour in the body is smaller by stage – stage ones are very tiny tumours, whereas stage 3 or 4 are very large tumours – the cancer may be harder to detect at early stages. And what we mean by that is where MECD may detect 90% of patients with, say, a stage four lesion, it may only detect 10% of patients with stage one. However, the technology is improving. The signals are refined. More and more data is collected as more patients are  using the test. And it's also done across all stages as well as in non cancerous populations, which is very important for the false positive rate. As we do that, this detection limit will increase and will improve. So  when we compare MCED to, say, a mammogram for breast cancer, at the moment, the earliest point of detection is actually quite similar. So the benefit of course, is that that MCED is looking for the breast cancer and dozens to hundreds of other cancers, but it's doing so at still at a stage that's treatable and curable. What we would love is for MCED to detect cancers at what we would call a pre cancer stage or an early enough stage that all cancers were curable.

Cary Adams: What about implementation then? Where are we in terms of that? I mean, is it in general use anywhere or is this something that is in trial stage?

Dan Milner: So actually there are multiple commercial entities that already have approved tests for MECD that are on the market and available for patients to use. Now how these tests and the results are integrated into current. Medical care structures, however, is yet to be determined. And one example, I don't want to name any specific tests, but one example is that where traditionally we would go have a colonoscopy to look very complicated procedure to have a look and see if we see anything, there are many populations now that simply submit a stool sample and they are screened for colon cancer using that, which is a very early version of what MCED is actually doing.

Cary Adams: So what are the limitations, some of the limitations or challenges in terms of getting this this technology being used for the wider community?

Dan Milner: This is probably the most difficult question you could ask and it really depends on who you ask that question. If you're asking oncologists, right, our colleagues who actually treat our patients who are diagnosed with cancer, they're immediately going to say that false positives for these tests are going to be a major problem and cost a lot of money and time. If you ask pathologists like myself, they will probably immediately say that MCED is going to cut into our scope of practice and make it more challenging by forcing us to try to identify cancers that may be undetectable by conventional means, i.e. the very early cancers that MCED promises to find. Radiologists and surgeons would similarly  argue about these undetectable lesions. Patient advocates, on the other hand, are really demanding this type of technology for rare cancers where we currently have no way to screen. For example, pancreatic cancer. And payers are sort of torn because they're concerned with the cost of these tests and what they might look like in a public health market that they might have to pay for. But they're also simultaneously very excited about the potential benefits to patients and the overall savings by detecting all of these cancers at an early stage, and we know when we detect a cancer earlier, the patient has a better survival rate.

Cary Adams: It sounds like a typical cancer challenge with different perspectives and views from different communities. And you mentioned that the patient advocates obviously clearly will be right behind this.

Dan Milner: Current cancer care is a journey for the patient. The patient is always at the centre and they interact with a chain of people one after the other to get to their outcome. Imcd could shorten that chain considerably. And what about those links that they avoid in that chain? Do they vanish? Do they get shifted to some other test or some other process? It's definitely a scary thought for many people in medicine. And if you ever ask the question what is best for the patient, that fear becomes sort of moot because no one would say it is not best for the patient to have a single test that can direct them down a clear path towards treatment and survival.

Cary Adams: You mentioned the payers earlier and obviously this is a critical component of the health system in many, many countries around the world. Who's going to pay for it? So what's the cost of these MCED technologies at the moment and how do they compare to the traditional screening methods that we have?

Dan Milner: If you just peruse the websites of some of these companies which are offering tests to private patients who can just order the tests and have it done, the tests can be between 750 and 1000 USD, again, for 20 to 200 cancers. It sounds like a lot, but when we think about the traditional screening, this becomes a very challenging question because the economic argument is that it's so less expensive to do that. Let me let me walk you through that. So only about 30% of cancers can be reliably screened for by traditional methods. So if we just compare the cost of screening, only that 30% to the current MCED pricing, the MCED is very inexpensive. If you imagine what it costs to go have your mammography, your colonoscopy, a screening chest x-ray, a cervical cancer exam, and maybe some peripheral blood testing that's well into the thousands right there. If you can sample all of those and a whole bunch more for 750 to 1000, the economic argument kind of falls apart pretty quickly. And we have to also think about measuring this from the patient's perspective, not from the systems perspective. MCED saves an enormous amount of time, money, stress, discomfort and fear for these patients, that it's almost intangible from the point of view of money, but for patients it's huge. It's a huge burden lifted off of them of not having to go see the doctor four times to find out about one cancer, for example. And it will also cost the system less time, money, equipment, reagents, supplies and personnel time. And although that's a negative from the creative destruction side, because we're going to lose some jobs, it's positive from a sense of overall health care because it moves us towards universal health care coverage in a way that's economically efficient. Then you have to add in the fact that the other 70% of cancers that we can't screen for are also included in this, and suddenly the financial argument becomes completely moot.

Cary Adams: I guess the other financial argument is the earlier we detect, the less expensive it is to treat all those cancers anyway. So, you know, stage three cancer is very expensive in any of the cancers compared to a stage one. So you've got that added  value. But are you confident that we'll circle around a mutually agreed way forward on this?

Dan Milner: There really is an opportunity for this to be a new paradigm, a new way forward for entire populations to be screened for and possibly treated for cancer. It creates a whole different approach to advocacy. It creates an entirely different approach to primary care, for example. And I think that that's always scary and frightening. But I think we'll get there eventually, and I hope that that is sooner rather than later.

Cary Adams: UICC is a global organisation then, and we're passionate about cancer, whether it's in a high income country, middle or low income country. Clearly, an ambition across many members of UICC is to address the inequity gap that we see around the world. So this technology presumably has the potential to leapfrog technologies into low middle income countries and potentially improve the ability to detect cancers earlier in pretty fragile health systems with, you know, pretty basic cancer treatment facilities. So are you optimistic about that, that leapfrogging?

Dan Milner: Absolutely. Absolutely. So when we think about MCED for high income countries, you know, we're talking about multi-cancer early detection. That same test would really be multi-cancer early diagnosis in an LMIC and have great value. Why? Because these populations, many of them are untouched from the point of view of of screening or public health. And so the vast majority of patients with cancer at that point have stage three or stage four, which we know MECD will easily detect. Not that our goal is to is to have the population be at stage three, stage four. But if we were to implement an MECD in that type of population, we could very rapidly identify all of those patients, get them into treatment programmes, palliative care, et cetera. And then have a system for down staging that population very rapidly to stage one or stage two where we know we can achieve cures. And because of the lack of infrastructure for LMICs, as you mentioned, is so common, the attractiveness of a blood test to confirm diagnosis as opposed to all of the other things we mentioned, is really key. Centralised blood tests are already very common in Africa. From the PEPFAR era, we have HIV testing and viral load that's done centrally in most countries and the results are gotten back to the patient and their clinician very quickly. So we know the infrastructure for the laboratory testing is already there. It's just a matter of transferring this technology over and then figuring out how to use it in a public health perspective to treat all of those patients.

Cary Adams: So following a diagnosis, for instance, the blood test reveals a possible tumour in the colon. What would be the next step in your mind, Dan? Have a colonoscopy to double check? Or is it actually so good that we move to a treatment, a solution?

Dan Milner: This is probably the best question that we need to answer for MCED. This is the this is the one where we need data. We need information. An we need the community to come together and work together to figure this out. So take, for example, the currently available stool screen for colon cancer, which is like MCED. I mentioned that earlier. If that test is positive, you get a colonoscopy. Why? Because the vast majority of lesions that you're positive for are precancerous or adenomas that can be easily removed, which is curative to the patient. However, if there's an invasive cancer, the colonoscopy can find it, biopsy and confirm it and mark it so the surgeon now can do the definitive treatment procedure. So either way, if a signal comes from from from an MCED test or from the current existing stool screening test, you know, you're going to get a patient that could be at various stages and we know what to do with that because we've had that test for a while. But when we consider the rare cancers like pancreas, this is not well defined. There's not an obvious way to proceed because the current natural history is that all of these patients present so late. So if you were to walk into your doctor's office and say, Hey, doc, I've got a stage one pancreatic tumour that this test tells me, is there what are they going to do? Well, they're going to start with imaging, which we hope would show a lesion. But what if it doesn't? Right. We can't take out the pancreas of a patient who's completely asymptomatic by current traditional methods or standard approaches. So we really have to think about that and do some work to refine these pathways for each patient.

Cary Adams: Let's step forward ten, 20 years, Dan, you and I will be retired on the beach somewhere, you know, watching the the waves go in and out. But where is this technology going? Do you think it's going to be absolutely commonplace around the world in in that period of time? Do you think it will have a major impact on the way that we detect and then treat cancers. More survival rates? What do you envisage?

Dan Milner: At your annual doctor's appointment you would have a blood test for MCED that your insurance company or government for low resource patients would happily pay for because it will detect cancers very early, creating the opportunity for cure and survival along with the huge cost savings for that system. You'll need a repeat at some interval probably every two years, maybe five years. It's not clear. And you'll be able to live in a society where cancer is more like an infection. You detect it early enough to eliminate it completely, using some treatments and reduce the huge burdens on patients physically, emotionally, financially that later stage cancers currently create. And so I think that's where we're headed. There are a lot of companies working on this. So there's going to be a lot of competition that's going to drive the cost down really quickly. That cost benefit ratio is going to go up massively and at some point the burden will just be on the system to accept this tool and then figure out how to move forward. But on the other side of that, as you're asking, it will be a well defined sort of well oiled machine for screening and treatment.

Cary Adams: There's a form of words which I sort of balk whenever I hear it. It's like a paradigm shift. But actually what you've just described is potentially a paradigm shift. And let's hope that it gets into common practice and people's lives are saved. So, Dan, we'll have to end there. We've run out of time, but just to say fantastic to talk to you. Very best of luck. Leading the ATOM Coalition over the next few years. It has great promise to get medicines available in countries around the world where they're not available today, and surely this technology must follow. So thank you very much, Dan, Have a great day.

We launched Let's Talk Cancer a year ago with a first episode about cancer in conflict zones at the onset of the conflict in Ukraine. Every month since then, we've dived into a range of topics most important to cancer control, which you can go back and listen to from the harms of tobacco and inequities in care to new technologies shaping the medical world. Now it's time for us to hear from you. Give us your feedback. Let us know what you want to know more about. Send us a message on social media or an email to communications at archive.org. And if you enjoyed this or any episode of Let's Talk Cancer, please leave us a review and follow us wherever you listen to your podcasts.