Behind the Genes

In this episode of Behind the Genes, we explore how personalised cancer vaccines are being developed, and how genomics and AI could help make these treatments more precise. 

Our host, Florence Cornish is joined by: 

Dr Victoria Goss, Associate Professor of Early Diagnosis and Translational Research at Southampton Clinical Trials Unit and head of the Southampton Clinical Trials Unit Cancer Vaccine Launchpad team 

Professor Lennard Lee, Associate professor at the University of Oxford, Consultant Medical Oncologist, NHS 

Ali Richards, a participant who took part in a cancer vaccine clinical trial 

Together they discuss how cancer vaccines train the immune system to recognise cancer, how genomic information can help identify the unique features of an individual’s tumour, and how AI could help researchers analyse genomic data and accelerate the development of new cancer vaccines. 

 “The reason I said yes was because my treatment really was punishing. It was so many side effects to it. The cancer never made me feel sick, but the treatment made me really sick. So I said yes because I just wanted to help other people not have to go through what I went through.” 

 

Transcript

[00:00:00] Florence: What if a vaccine could help treat cancer? Hello and welcome to Behind the Genes, the podcast that brings you the stories, research, and innovations shaping the future of genomic healthcare. Today, we're going to be talking about cancer vaccines, how they're being developed with the help of AI, what role genomics has to play, and what it could mean for patients. 

[00:00:23] Florence: I'm Florence Cornish, and joining me today we have Dr Victoria Goss, who leads cancer vaccine research at Southampton Clinical Trials Unit; we have Professor Lennard Lee, who is a medical oncologist and Associate Professor at the University of Oxford; and Ali Richards, who took part in the Southampton Cancer Vaccine Programme. 

[00:00:45] Florence: I think before we get into cancer vaccines specifically, it might be good to start with the basics. So vaccines are something most of us have heard of and probably experienced as well, but we don't always necessarily understand how they work. So Lennard, can I come to you to explain what a vaccine actually is, how it works with our immune system, maybe at the most basic level for those who might not have a scientific background? 

[00:01:19] Lennard: Thanks, Florence. What's a vaccine? Very, very simply, something that protects your body from disease. We've had a few when we were younger, like which protects you against meningitis or hepatitis or different types of infections that can affect children. 

[00:01:36] Lennard: And it really does show that your immune system is really powerful. Every day, it looks around trying to work out what's there which shouldn't be there and takes care of it. And ideally, your immune system just works in the background without causing any problems. And so what a vaccine does is it really helps the body understand something that's abnormal. 

[00:01:55] Lennard: And the vision here is that you can use this technology to hopefully patrol against cancer, because half the people out there will never get cancer. They are the maybe the lucky ones or maybe the ones with a good immune response. And so a vaccine is basically giving your immune system a wanted poster: 

[00:02:11] Lennard: "This is what threat looks like. This is what you need to control".  

[00:02:16] Florence: And I think you mentioned some great examples there. There are lots of common examples of vaccines people might have heard of. I think maybe the flu vaccine is probably a common one that people are thinking about in the wintertime. I think another one is maybe the HPV vaccine. 

[00:02:29] Florence: Lennard, could you explain a bit more to our listeners about the HPV vaccine? What it is, how it works? I think people often think of it as a type of cancer vaccine, but actually it's targeting a virus. Is that right?  

[00:02:41] Lennard: Yeah, that's correct. So this is now a vaccine which has been rolled out across the NHS, and it's actually worked really well to get rid of a few cancer types, which is incredible. 

[00:02:51] Lennard: And why is that important? Well, cancer can be caused by many, many different things. Sometimes it's because you've done things like smoking or weight plays a role or just bad luck or the genes that you've inherited. But some cancer types are caused by viruses. And so many people nowadays are getting the HPV vaccine to stop cancer types like cervical cancer, hopefully head and neck cancer, and many of the rarer cancer types. 

[00:03:21] Lennard: And so again, what you're doing here is you're taking the immune response, telling it the body shouldn't get this virus and hopefully prevent some of the bad consequence of getting this viral infection, like cancers.  

[00:03:33] Florence: Thank you. That's really helpful to understand. So we've talked about how vaccines can be used to treat viruses, and I think most of us, when we hear the word ‘vaccine’, we probably do associate it with something that stops us from getting ill. 

[00:03:46] Florence: Victoria, could you tell us about how vaccines could be used to treat cancer?  

[00:03:50] Victoria: Yeah, absolutely, and it is great to be here today. Thank you. So Lennard's already sort of spoken about preventative vaccines, and when we think about cancer vaccines, we're thinking about therapeutic vaccines. So we're thinking about training the immune system to recognise the cancer as something that needs to be dealt with because cancer is really tricky because it's our own cells that have gone wrong, if you like. 

[00:04:16] Victoria: But that means it also is very good at evading those signals which tell the immune system that it needs to be cleared. So the analogy that Lennard has already given of a cancer vaccine sort of creating a wanted poster sort of builds on an analogy from one of your previous podcasts where they described the immune system as like the police almost trying to catch criminals, which are the cancer cells. 

[00:04:41] Victoria: And the cancer vaccine analogy builds on that. So you've created a wanted poster which is training and giving the police more information about what those cancer cells look like. And then when we think about building on that with sort of personalised cancer vaccines, which is an incredibly exciting step when we think about the development of how cancer vaccines can be used, sort of really individualised therapy going forward, that wanted poster gets even more specific. 

[00:05:07] Victoria: It's almost like giving a phone number or an address for that specific cancer type that is very specific to that patient. So the therapeutic vaccine is, is targeting the immune system. It's training our immune system to recognise the cancer as something that needs to be dealt with.  

[00:05:26] Florence: It's funny you mentioned that analogy because I was just about to point listeners to that episode. If anyone wants to learn more about cancer vaccines specifically, you can check out our previous Genomics 101 podcast episode called ‘What Are Cancer Vaccines?’ So Ali, I think I'd love to bring you in at this point because you have experienced this from the patient side of things. 

[00:05:49] Florence: Could you tell us a little bit about your journey, your cancer diagnosis and treatment, and maybe more about the clinical trial you were part of, if you feel comfortable sharing that?  

[00:05:57] Ali: Yeah, sure. Hi, Florence. It was Christmas 2015, and I felt a lump in my neck. And maybe because I'm a woman and we're always taught to treat lumps seriously, in the January I made an appointment with the GP, and she very quickly fast-tracked me through to the hospital. 

[00:06:19] Ali: And January 2016, I got a diagnosis. It was a tumour on the base of my tongue at the left, and I was told it was caused by a variation of the HPV virus. So yeah, that was all a bit of a shock. I was shocked and I was scared, but I was also really angry because I look after myself. I eat well, all those things. 

[00:06:45] Ali: It's just bad luck that it was a virus that my body couldn't deal with. I just, I felt guilty as well because of what I was gonna put the family through. So I had various scans and tests. I had an operation to remove my tonsils, although we soon discovered there weren't any left anyway. And they took a biopsy, which I didn't know at the time, but turned out to be important later on for the trial. 

[00:07:15] Ali: Then I had to have a whole load of prep beforehand because of the impact of the treatment. So I had to have restorative dentistry, audiology tests. I had a PEG fitted, that's a feeding tube, in my stomach, and I thought, "Surely it's not going to be this bad." But that PEG, that feeding tube was a blessing in the end. 

[00:07:40] Ali: And I had a mask made, and the mask fits you and basically pins you down to the radiotherapy table so you don't move when... because it's very precisely targeted at your tumour. So yeah, I went on to have five sessions of chemo, which felt quite easy. The radiotherapy was the really, really tough part. I had, uh, seven weeks of it, 35 sessions. 

[00:08:08] Ali: So that was, yeah, that was a challenge.  

[00:08:11] Florence: Thank you, Ali. Thank you for sharing that. I think it's always really valuable to get that patient perspective when we're talking about things like this. Lennard, I wanted to come back to you now to talk about the different types of vaccines that exist and which ones are being used specifically in the treatment of cancer. 

[00:08:30] Lennard: Um, thanks, Florence. And Ali, are you 10 years now down the line since your diagnosis?  

[00:08:34] Ali: Yeah, it feels good.  

[00:08:37] Lennard: Congratulations.  

[00:08:38] Ali: Yeah, yeah. It feels good. I really valued the follow-up checks that I had, both from my oncologist, but also I got some through the trial, and it really helped restore some confidence in myself and my body to deal with things and to be able to move on as well. 

[00:08:56] Lennard: Oh, well done. That's fantastic because you telling us that story just really brings it to life about how scary this can be and also the fact that you had to go through all those sessions, thirty-five sessions and, um, and now you're 10 years down the line and still talking and giving hope-  

[00:09:11] Ali: Yeah ...  

[00:09:11] Lennard: that new technology still comes, so thanks, Ali. 

[00:09:13] Ali: That's a pleasure.  

[00:09:14] Lennard: Um, yeah, so Frances, this is what's really exciting. What types of vaccines are there? Well, first thing to say is that we're really good in this country about vaccine research. If you look around the world, what are we good at? Well, everyone knows that we developed the pandemic vaccine, and actually that technology is something that we can control. 

[00:09:31] Lennard: We're world leaders at. It's quite cheap technology, and it's something that we are really good at bringing to patients. And Ali's our testament where she got on the trial, she helped test it and really pioneered new ways of research. So what types of vaccines are there? Well, I think we talked to the first bit where Victoria taught us that some of them can treat cancers and some of them can maybe prevent cancers. 

[00:09:53] Lennard: And the HPV's one which is maybe be able to do both one day, which is brilliant. What would like... what else do people know about? Well, people might know that there are different types of technologies. So if we think back a few years now, back to 2020, there are some which are viral-based, and some which are mRNA based. 

[00:10:12] Lennard: Both of these were new technologies which the whole population of the world came together to create and some of them are peptide-based. So there's probably three different types here. The protein ones or peptide one, which you always had, and then in the last five years, it's an incredible time to be alive, where new vaccine technology comes through, it's more effective and safer. 

[00:10:32] Lennard: These are the viral ones and mRNA ones, and everyone's now pursuing all of these to try and make sure that we can maybe treat cancer in future.  

[00:10:41] Florence: Can I possibly pick your brain a little bit more about the mRNA ones specifically? I think as you mentioned, lots of people might have heard of those during COVID. 

[00:10:50] Florence: Could you maybe explain a little bit more about those and how they work?  

[00:10:53] Lennard: Yeah. So this is going to take us all the way back to GCE biology now. If you remember - and we are Genomics England, so we, we got to work out why genomics is important, and we'll probably get to this. But remember, genes make RNA, which then makes protein. 

[00:11:11] Lennard: And so if you're trying to reprogramme the immune response, you could give your body a protein, the back end of it. You can maybe give it an RNA, which is a blueprint too. And so what an mRNA vaccine is, it's a way of giving the blueprint or the instructions to the body of what to recognise, what the cancer looks like, um, um, or what the virus looks like, and target it. 

[00:11:32] Lennard: If you want the analogy, well, for those people who had the pandemic vaccines, the ones which was mRNA based was, uh, the Pfizer one, and that worked really, really well. Cheap to make, easy to produce, and, uh, it's just a jab. And so people are now exploring that for cancer treatment now. Take new technology, which has only been developed five years ago, technology, which is just a blueprint, cheap to make, easy to update, and now we're targeting cancer. 

[00:11:59] Lennard: Um, so that's basically what an mRNA vaccine is, giving the body the blueprint or the instruction of what a cancer looks like and trying to target that cancer.  

[00:12:08] Florence: And you kind of alluded to it a little bit in your answer, but, um, it would be good to know more about where genomics comes into all of this. You know, why is it such an important part of developing vaccines? 

[00:12:18] Lennard: And that's a great question, and really comes back to our second strengths, which is that we're really good at vaccine research, and yet we are also world leaders at genomic research. It's a really exciting time because, um, when Victoria and me and Ally at school, we would-- we, we learnt about that race to sequence the first human genome. 

[00:12:38] Lennard: It was really exciting because for the first time, we can see every single genetic base in every human, and that used to cost billions of pounds to do that, and it would take many months or years to do that Fast-forward a few years, and then now Genomics England delivered the next success for humanity. 

[00:12:57] Lennard: I think it was about 2015 to 2017 where they, they did 100,000 Genome Project, where the UK led the world in sequencing 100,000 people, including people with cancer, to try and understand what caused their cancer, what the risk factors are. And why is that relevant now? Well, it's because if you know what a cancer looks like, then you know what the abnormality is, well, then you can vaccinate against it. 

[00:13:22] Lennard: So we've now gone from this amazing arc of discovery here, where when we were at school, we worked out what the human genome looks like. We can sequence it end to end and see in all its detail. Then a, an amazing organisation came out the ground called Genomic England, which shows that you can run it in the NHS. 

[00:13:39] Lennard: 100,000 people could do it. And now we're making the next big jump now, which is it's not just going to give you a diagnosis, but maybe becomes a drug and a vaccine in future. And actually, probably it already has because Ali's that example, a success example of it happening.  

[00:13:54] Florence: Yeah, I wanted to actually ask you about that, Ali. 

[00:13:56] Florence: So just as you were saying, Lennard, it kind of... The cancer vaccine sounds quite futuristic, but as you said, it's, it's sort of already happening. So Ali, do you remember kind of how you first heard about the cancer vaccine trial?  

[00:14:11] Ali: Yeah. I had a bit of an unfortunate time because after all that radio and chemo, my cancer still hadn't gone, and I had to have an operation to remove lymph nodes. 

[00:14:22] Ali: But my oncologist at Poole Hospital, who's a fantastic woman, she had been involved, unknown to me, in the some of the thinking behind the trial, and particularly that she could recruit people because they were sat in her office. So she asked me if I'd like to take part, and without knowing anything, I said yes. 

[00:14:49] Ali: And the reason I said yes was because my treatment really was punishing. It was so many side effects to it. The cancer never made me feel sick, but the treatment made me really sick. So I said yes because I just wanted to help other people not have to go through what I went through. I didn't really understand it, if I'm perfectly honest. 

[00:15:16] Ali: I didn't really know what was going on, but then I'm not, you know, a super brain like Lennard and Victoria. I knew that I just wanted to do something to help people going forward, not having to deal with the same. So yeah, I put my hand up and there I was on the trial.  

[00:15:37] Florence: So you mentioned there the, the really horrible side effects that you got from your original treatment. Did you have, um, what was your experience with side effects with the vaccine? Was it similar? Was it different?  

[00:15:47] Ali: Oh, no, the, the vaccine was like a holiday compared to the treatment. Absolutely. At, at worst, in the first few treatments, you felt a bit like you had a cold, bad cold coming on, maybe slightly flu-y, but you took, you were given Ibuprofen at the same time as you had the vaccine. 

[00:16:10] Ali: So no, it, the treatment with the vaccine was an absolute breeze. Which is kind of like, yes, this is what I want for people. You know, not, not the radiotherapy, not the chemo. So yeah, it was, it was really very easy by comparison.  

[00:16:29] Florence: Oh, I'm so glad to hear that that was your experience. I'm just curious now also, was there anything that surprised you about the trial? 

[00:16:35] Florence: You said there that you didn't really, like, have an understanding of cancer vaccines. You, you agreed to it straight away. Was there anything that maybe, like, you weren't expecting or surprised you?  

[00:16:45] Ali: I think it surprised me that it was really quite easy.  

[00:16:48] Florence: Yeah.  

[00:16:49] Ali: Uh, I was delighted to have the team I had looking after me because they were fantastic. It all felt very simple. 

[00:16:59] Ali: And how nice that was. You know, if I could've had that instead of all my previous treatments, um, it would've, it would've made everyone's life so much easier. And I guess, I don't know about the cost of drugs, but I guess the cost to the NHS would've been less because I wasn't in and out of hospital, I wasn't having to have all these extra things done, and all this extra support like dieticians and so on because I had to have my feed tube replaced. 

[00:17:35] Ali: So all of that is impacts on the NHS, whereas this was very simple.  

[00:17:40] Florence: I wanted to come to you now, Victoria, and ask you about the outcomes of this trial that Ali took part in or other trials like it, and whether we know yet what the broader implications of, of these advances might be.  

[00:17:55] Victoria: So I think what we need to think about when we're thinking about developing these treatments and sort of evaluating the treatments at each stage is that it goes through a very clear pathway of progression, and Ali was involved in one of the, the earliest stages of that progression. 

[00:18:09] Victoria: And it's, it's always amazing to me to hear your story, Ali, and to know that patients are willing to take part in the research and that's what allows us to develop these treatments. So the trial that Ali was part of has now gone on to develop into a, a larger scale study which will be evaluated again. 

[00:18:27] Victoria: And that all starts to form the evidence for how these treatments can be shown to be effective, and also how they can show... Also, you know, Ali's already touched on there about the cost implications, so how we can show that that can be beneficial as well. And then we can start to think about how they can be taken up and become part of routine standard of care for patients like Ali, as she was describing. 

[00:18:50] Victoria: And all of that evidence comes together, which then gets evaluated and then it, and then it moves forward through that progression. But it's-- we have very clear, um, you know, a, a route that each new, new treatment has to go through, um, to be able to, to become part of standard of care.  

[00:19:07] Florence: And Victoria, you also play a key role in the Cancer Vaccine Launchpad. 

[00:19:12] Florence: For any listeners who might not be familiar with the Cancer Vaccine Launchpad, could you maybe tell us a little bit more about it?  

[00:19:18] Victoria: Absolutely. So in its simplest terms, the Cancer Vaccine Launchpad is designed to help find patients who might be eligible to take part in trials like the one that Ali was part of. 

[00:19:30] Victoria: It's an incredible project. Cancer Vaccine Launchpad is quite long, so we tend to abbreviate it to the CVLP, which I'll do from now on, if that's okay. The CVLP to me really demonstrates the power of collaboration because it's brought together so many different teams that have been necessary to make sure that, that what we're trying to achieve, so finding as many patients as possible for these trials, is possible. 

[00:19:52] Victoria: We deliver this project on behalf of NHS England. I know that Lennard was involved right from the start as well. The reason that we need the CVLP is because one of the biggest challenges in research of these new treatments is finding the patients who might be eligible. So one of the reasons for that is because when we are running the trials to test these new treatments, there's a lot of different infrastructure that's needed to support the delivery of those trials. 

[00:20:19] Victoria: So you need special pharmacy services, special research nurses. All of that has to come together to be able to deliver trials of new treatments. And actually, that means that actually those studies can often only take part in a small number of hospitals. So historically, you only had the opportunity to take part in those trials if you lived near one of those hospitals, which is, you know, like Ali did. 

[00:20:42] Victoria: So what the CVLP is, what, what it has done, it has created a formalised network which enables referrals to happen from ... we're opening 83 hospitals now across England. We've just expanded out to the devolved nations as well, which is a really exciting development, and it creates that, that network which allows patients who might live further away from a hospital delivering one of those vaccine or immunology trials to be able to be referred in to see if they might be eligible. 

[00:21:09] Victoria: So essentially, it's a bit like creating a big funnel. So you're finding all of the potentially eligible people that could take part in that trial, and you're funnelling them into the trial site to find those patients who are eligible.  

[00:21:22] Florence: And what impact do you hope that this could have for the NHS and also for, like, individual patients as well? 

[00:21:29] Victoria: So we've seen such positive results from the CVLP so far. The first study that we worked with was for a colorectal cancer vaccine trial. Before the CVLP started working with this trial, only 17% of the eligible patient population in England had the opportunity to take part because they lived near one of those hospitals delivering the trial. 

[00:21:52] Victoria: After the CVLP started working with it, we had increased that to over 60% of the eligible patient population. So you could really see how it has expanded out access, and that's just a fantastic opportunity to be able to bring, to bring patients. We also were able to show that the UK was screening, so looking for patients at three times the global average. 

[00:22:14] Victoria: So we really were able to see how the CVLP is supporting and accelerating recruitment to those trials I think the key thing for me has been the patient enthusiasm that we have seen though. So when we open up to a new trial where, that the CVRP is working with, we are always inundated with people who contact us to find out how they can be part of this network because they want the opportunity to take part. 

[00:22:40] Victoria: We know that some patients have travelled for two hours to a trial site to find out if they could be eligible because actually they want the opportunity. So the CVRP has really sort of enabled that patient choice, which is a fantastic thing to be able to do. But it also builds on what Lennard was talking about earlier, which is the UK is really good at this research and actually what the CVRP is then doing is showing how we can really support recruitment to these trials to accelerate these trials and that only brings more trials to the UK which again creates more opportunities for patients which is exactly what we're trying to do. 

[00:23:14] Victoria: We're trying to create more and more opportunities for patients to take part in these studies if they want to.  

[00:23:20] Florence: Yeah. That's really incredible. Thank you for sharing that with us. I wanted to ask you a question now, Ali, because I think when we were talking about trials and projects like this, as Victoria said, we often think about kind of the high level impact, but also it's an opportunity to create connections as well between patients and families and, and I know that you, you had a patient's family reach out to you about advice as to-- about whether they should take part in a trial. Is that right?  

[00:23:47] Ali: Yeah. I think it was the wife of a guy up in Liverpool who had throat cancer, and, um, she must have done some really good research on the internet. I'd done various bits of publicity both for Southampton Uni and cancer research around the trial. So she obviously found me and then stalked me on Facebook , which was absolutely fine. 

[00:24:13] Ali: I didn't have a problem. So her husband was down to go on the trial, which is the next stage that Victoria had spoken about, and she just wanted to know, would I recommend it, would-- what was it like, that kind of thing. So I said to her, "I would absolutely recommend it, of course," and told her what my experience was. 

[00:24:35] Ali: I couldn't guarantee his would be the same, of course, because things might have moved on. But it was a really, it was a kind of a nice feeling that I could say to her, "Get him to have it done because it's got to be the best outcome." I think his stage was much further on than me. So yeah, it had to be the way as far as I could see for him. And as far as I know, he went on the trial. Which is great.  

[00:25:05] Florence: How, how did it feel to kind of make that human connection, maybe not something you were expecting to come out of a trial?  

[00:25:13] Ali: No, it was really, it was really nice. I am a bit of a, a fangirl for, for Lennard and Victoria and all the team at Southampton. 

[00:25:22] Ali: If anybody asks me about vaccines and cancer vaccines, I'm like, "Oh, yes." And you-- So yeah, I'm, I'm a bit of an evangelist. So to, to have somebody real-  

[00:25:33] Florence: Mm ...  

[00:25:34] Ali: ask me about that was great feeling.  

[00:25:37] Florence: I think that's a, a really great example of how research can have impact far beyond, uh, one individual. And I think another great example of this is also artificial intelligence or AI as a potentially transformative force in, in healthcare. 

[00:25:54] Florence: Lennard, when we come onto this topic, I wanted to hand over to you because I know that you've recently received funding for a project exploring AI, and how it could support cancer vaccine development in particular. Could you tell us a bit more about this project?  

[00:26:08] Lennard: Thanks very much, Florence. And I also want to add, I feel very proud about what Ali did just there, where she's able to bring through opportunity for other people, too, which is amazing. 

[00:26:19] Lennard: The NHS is there to not just do the technology of today, but also be one of the best healthcare systems in the world to bring through new technologies. And it's just really exciting about people wanting to help the NHS, advocating for new technologies to be tested, and actually that's what Genomics England i there to do, make sure the NHS gets new technology in there so that patients will get new treatments. 

[00:26:41] Lennard: I just wanna just reflect what Victoria noted In the NHS, in their Cancer Vaccine Launchpad, patients are getting in at three times the rate of other countries.  

[00:26:51] Ali: Mm-hmm.  

[00:26:52] Lennard: That's really special. And also she's increased coverage to, uh, did you say 60% of population? That's 42 million people have potential access to this. 

[00:27:01] Lennard: So that is huge, and I think it's really a passion project for so many people out there, PICT trials units, the research nurses and doctors, and also patients who make this all happen. So it is quite impressive. It is very impressive. Oh, yes, and AI. I probably should cover that too. Just beyond what's special about the NHS and Genomics England. 

[00:27:22] Lennard: Well, AI I think is changing everything. I went to a garden party, and actually everyone's talking about how they're using AI to make their lives simpler, make them do things that they've never been able to do before, get the information instantaneously there. And I think that there's technologies which come through every so often in our lifetimes, which changes how we think, how we communicate, and actually makes us better in many ways. 

[00:27:47] Lennard: And so the great opportunity here is what happens if we take that third strength now? So we've already said we're really good at vaccine research in the UK. The UK invented vaccines. We also are world leaders at genomics. We did the 100,000 Genome Project. What happens if we use this new technology now? 

[00:28:06] Lennard: And what's a problem that we can solve? Well, let's say we did a whole genome sequence on someone, which is what Genomics England does every day for the NHS. Well, that creates a lot of data. Um, I tried to do the calculations before we went online. It's about 100,000 photos. You know, when you take on your phone, that's a lot of data. 

[00:28:25] Florence: Wow. Yeah.  

[00:28:26] Lennard: And that's a miracle what's happening in the NHS and Genomic England, and we need to make a cancer vaccine out of that. And so you need to process that. So that's time-consuming. It could be automated. And so what AI could do now in future is that we could use the supercomputer we built in the UK. 

[00:28:43] Lennard: In fact, we are doing this already. We've built supercomputers in the UK, and we're going well beyond other tools out there and designing cancer vaccines. And the AI scientists which can do that can do it at weekends, at nights, and help design the drugs. And so what it does is it heralds a future where every patient can contribute into a model that's created in the UK, stored safely in our supercomputers. 

[00:29:07] Lennard: It can now be made into drugs, and the UK will start to make things again, which will hopefully change cancer care across the world. We can deliver that legacy whereby our three strongest strengths come together - vaccines, AI, and genomics. It then super powers the NHS and everything that Victoria's done in the Cancer Vaccine Launchpad, so many millions of people around the world can get access to trials. 

[00:29:31] Lennard: And people like Ali can also help hold up the NHS even further. So people once again look back to us and say, "If you want to get things done, come to the NHS because it provides world-class care for patients." And so that's a big initiative now. Use AI to make better drugs, safer drugs, more effective, more precise in the UK. And it's only possible because of everything that we've built here with our funders, ARIA, MRC, Cancer Research UK, people raising, raising money through cake bake sales to make this happen. 

[00:30:02] Lennard: So it's very exciting.  

[00:30:04] Florence: Yeah. I think AI can be a topic that people often have very strong opinions about. When it comes to AI in, in your line of work, are there any misconceptions you think people might have, or are there any benefits to using it that maybe people might not be aware of?  

[00:30:21] Lennard: Oh, that's a tricky question, isn't it? I think you're right. Any tool that comes through can be used for good things and, and things that people will question because maybe we don't want to cross those boundaries. And yet I think what we're doing here is really special because we want to - as long as your heart's in the right place - we want to give more people like Ali hope so that she knows that one day the drugs in the NHS will be much safer so you don't get all those side effects, much more effective, much more precise. 

[00:30:52] Lennard: And on top of that, people like Victoria will be able to bring even more trials in the UK which will change lives and change practices around the world through an amazing working launchpad. So I think that's the right use of AI, make people's lives better. I think there are other uses of AI which I probably scratch my head and say, "Well, should we be doing that?" 

[00:31:10] Lennard: And that's what I think it's really special that we do think about these and talk about these things here, and then bring the public with us because I know that people reach out, and Ali's been reached out in the past before, and I think we need to have this discussion here. Is AI right to develop cancer drugs using capabilities from Genomic England to go through the NHS Cancer Vaccine Launchpad? 

[00:31:31] Lennard: I say cautiously, yes, and we should do more of this. And I think the most important thing is there's a lot of people starting to use AI for benefit, and you know my views, Ali, and I don't know if they're right. Um, I'll be a bit cautious, but I do want to ask you, Ali, is this the right use of AI? Should this be what we develop? 

[00:31:50] Lennard: I don't know what you're going to say.  

[00:31:52] Ali: For me, I think it is. I do think AI is a bit if you put rubbish in, you get rubbish out. But if you- If you ask the right questions, if you give it data analysis and experts like you have set up the protocol in the first place and it makes everything faster and reliable, then it's got to be the right thing. 

[00:32:16] Ali: It gets used and abused for things, that isn't what AI should be doing, in my opinion. It should be used to do-- to help us, to supplement the work that we're doing, uh, and make it even faster than you're already making it. 

[00:32:38] Florence: Well, we've covered so much today from how vaccines work to the role of genomics, NHS trials, and of course, what all of this could lead to. So before we wrap up, I have two final questions for each of you. What do you think is the most important thing for listeners to understand and take away from personalised cancer vaccines? 

[00:33:01] Florence: And what are your hopes for the future? I think we'll start with you, Victoria, if that's all right.  

[00:33:08] Victoria: Yeah, absolutely. It's been a great conversation. Uh, there's so much to think about. I think when I think about what I'd like listeners to take away, I think it's that cancer vaccines, and particularly personalised cancer vaccines, really support and represent this paradigm shift that we're seeing towards a much more personalised, uh, treatment pathway. 

[00:33:27] Victoria: You know, like we've described, generating a cancer vaccine that has come from the patient's tumour, so the, the, the vaccine is, is designed to recognise mutations that are specific to that patient. It is such an incredible thing to be sort of witnessing and to see how that's developing through into sort of really changing patient care, and that's, you know, we've spoken about this so much, but that's been due to such incredible collaboration across scientific disciplines, across the NHS, pathologists. 

[00:33:58] Victoria: Everyone has come together to make all of this possible, and that's, that's an amazing thing to be a part of. In terms of my hopes for the future, well, I would like the Cancer Vaccine Launchpad to be open in every hospital across the UK to really sort of underpin that acceleration and to provide that opportunity for patients. 

[00:34:17] Victoria: You know, I'd just like to give a, a final shout-out to everybody who has been part of the Cancer Vaccine Launchpad from its very start, who's enabled this to happen and, you know, it's just been fantastic to see how this has, you know, supported patient choice for trials. And I guess if there's one tiny other thing, perhaps we could see how this, you know, this, what we've put together could be applied to other disease areas as well. 

[00:34:39] Victoria: But yeah, that, that would be my hope for the future, is it's open everywhere one day.  

[00:34:43] Florence: And Ali, I'll come over to you next.  

[00:34:45] Ali: I think what I'd say to any patient that was asked to go on a trial is, is just go for it. 

[00:35:02] Ali: And you know, Victoria, Lennard, all the rest of the team, you know, you are not doing jobs. You're leaving a legacy in my view. That's such an important thing. So yeah, if you're offered a trial, get on it. And my hope for the future is that everybody can have kinder, gentler treatments. The radiologists and chemo nurses I came across were lovely, lovely people. 

[00:35:31] Ali: But yes, I'd like to see them out of work and doing other things within the NHS because they don't need to do that work anymore. That, that's my dream.  

[00:35:40] Florence: Mm. And Lennard, any, any final thoughts?  

[00:35:44] Lennard: Thanks, Ali. I mean, your words gave me goosebumps about the amazing stuff that the whole community's doing for cancer vaccines, AI and genomic research. 

[00:35:51] Lennard: It's so powerful. Um, okay. What's the final thing? I think it's hope. Look, the country's in a new place now. You've got brilliant scientists running clinical trials, like the Cancer Vaccine Launchpad, which is reaching out to every single hospital. You've got patients who are building up the NHS again to deliver future care, and scientists using AI and genomics to make cancer vaccines. 

[00:36:11] Lennard: That is a good reason to be hopeful. When lots of things are going in other places of the world, great things are happening in the UK.  

[00:36:20] Florence: This has been such a brilliant conversation. 

[00:36:25] Florence: A huge, huge thank you to our guests today, Dr. Victoria Goss, Professor Lennard Lee, and Ali Richards, for joining me in our brilliant discussion about cancer vaccines.  

[00:36:50] Victoria: Thank you so much for having me. 

[00:36:55] Ali: Thank you, as always. I've learnt a lot.  

[00:37:00] Lennard: Thank you very much, Florence, too, from me.  

[00:37:10] Florence: If listeners have enjoyed this episode and you'd like to hear more, please subscribe to Behind the Genes on your favourite podcast app. 

[00:37:16] Florence: I've been your host, Florence Cornish, and Behind the Genes is produced by Deanna Barac, Sharon Jones, Sophie McLachlan, and Patrick Wallace at Bespoken Media. Thank you for listening.

In this explainer episode, we’ve asked Dr Antonio D'Alessio, Medical Oncologist at Guys and St Thomas Foundation Trust, to explain cancer vaccines and how they work.

You can also find a series of short videos explaining some of the common terms you might encounter about genomics on our YouTube channel.

If you’ve got any questions, or have any other topics you’d like us to explain, let us know on podcast@genomicsengland.co.uk.

You can download the transcript or read it below.

Florence: What are cancer vaccines and how do they work? My name is Florence Cornish, and today I'm joined by Antonio D’Alessio, who is a medical oncologist ay Guy's and St Thomas' Foundation Trust and King's College. And he's going to be telling us much more about the topic.

So Antonio, before we get into cancer vaccines, I wanted to first ask you about cancer. I know it's a pretty broad term, and it refers to the uncontrolled growth of cells in the body, but maybe it would be helpful for you to explain a little bit more about what cancer actually is, like what that term means, especially for listeners out there who might not have that scientific background.

Antonio: Yeah, of course. And first of all, thanks for inviting me today. Well, that's a big question. The point is that we know that in our bodies there are billions of cells, and all of these cells, they divide, they do their job, and they know when to die on schedule. The point is that sometimes there are cells that ignore this instruction and just keep reproducing and growing, and this is when cancer grows.

Our bodies have systems, which is the immune system, to recognize when this happens so that the immune system can recognize the cancer cells that are growing too much. They attack them and destroy them. But unfortunately, sometimes cancer is quite clever, they manage to escape from the immune system and starts growing without control, and that's when cancer starts.

Florence: And so, what are the standard treatments that we use for cancer at the moment?

Antonio: Well, broadly speaking, I would say that we have three types of cancer treatments. One, it's surgery, where we just cut the cancer out. Then we have radiotherapy, where we basically induce targeted damage to the cancer. And then we have a very broad umbrella term that is systemic therapy.

Systemic therapies can be chemotherapy, can be targeted therapies, and that can be immunotherapy. In particular, immunotherapy is quite exciting because over the past 20 years, we have learned how to boost the immune system of patients, so that's the white blood cells, the immune system of patients that can recognize cancer cells and attack them.

Sort of imagine that cancers hide behind an invisibility cloak, and immunotherapy helps unveil the cancer so that the immune system can recognize the cancer again and attack it. And vaccines and cancer vaccines are part of this family of immunotherapy drugs.

Florence: Yeah so speaking about that, I think lots of listeners might have heard of the term cancer vaccine before, obviously, its the topic of this episode.

And I think the term cancer vaccine sounds very interesting and promising, but also maybe a little bit intimidating as well. So maybe you could tell me more about what a cancer vaccine is kind of at the most basic level.

Antonio: Well, cancer vaccine is a vaccine, and we have received so many vaccines in our lives that our body basically has learnt already how to process a vaccine.

Imagine a vaccine as a wanted poster. So, we give the body the instructions to recognise something that shouldn't be there, and the immune system knows how to do it. So, the job of the immune system is to recognize strangers in our bodies - that can be microbes, bacteria, viruses, and also cancers.

And sometimes with a vaccine, we sort of help the immune system to do its job a bit better. And with vaccines, we provide the instructions to recognize these strangers in our body and help the immune system to, to get rid of them. And in particular, for cancer vaccines, we have different types of cancer vaccines.

There's a family of cancer vaccines that are called preventative, where we can try to give a vaccine even before the cancer develops to reduce the risk that the cancer develops. And, this is more early in the development.

While we have, another family of cancer vaccine, which are mostly mRNA cancer vaccines that are called therapeutic. So these are cancer vaccines that are given to patients who already have cancer, maybe who had the surgery for their cancers, so that the aim of the cancer vaccine is to boost immune system and reduce the chances that the cancer comes back after surgery, or, help other types of immunotherapy work better together with vaccine against the cancer.

Florence: So, I think for me at Genomics England, the mRNA cancer vaccines are probably most relevant to the work that we do here as an organization. Could you explain a little bit more about how those ones work specifically?

Antonio: Yeah, that's an exciting field, right? The mRNA vaccine. So, let's split this into different words, mRNA and vaccine.

We have just covered what vaccine means. We just have to think mRNA as just instructions. So we give the body of the patients the instruction to recognize the cancer. And the mRNA is basically the instruction for the immune system to recognize some of the proteins that are expressed on the cancer cells, so that's the white blood cells, the own white blood cells of the patients that can be more alert and identify the cancer cells if they are around.

And in particular, imagine when we give the mRNA vaccine, it's like we are giving the picture of a suspect to the police, right? The police is the immune system of the patients, and the suspect is the cancer.

And so, the immune system, so the police of our body, can go around the body, can go around the bloodstream, can go around the organs, and if they see the suspect, they are, they are already alerted, and they can tackle it, attack it, and destroy it before it develops into, into a cancer that can be seen on the scans.  

Florence: And are these types or other types of cancer vaccines being used in the clinic at all in real medical settings already?

Antonio: Well, I wouldn't say that we are using that in clinical practice, but probably in the future we will, and we are working hard to make sure that we will be able to use cancer vaccine for our patients.

At this stage, we are using cancer vaccines as part of clinical trials, and these clinical trials cover different types of cancer types, different types of setting, together with other drugs or given alone after surgery, for instance. And the NHS England, Genomics England and NIHR, they launched this massive infrastructure that is called the Cancer Vaccine Launchpad.

And it is aimed specifically to match the NHS cancer patients with personalized mRNA vaccine trials, so that once we have the results of those trials and we are ready to deploy it in clinical practice, then we already have the infrastructure to do that promptly, hopefully in the next future.

Florence: Mm-hmm. Yeah, so do you see a future where cancer vaccines are used in routine care?

Antonio: Well, we are working towards that. And I, and I do see a future where we're going to use that. I don't know when. Probably it will take still a few years.

But the, for example, in the UK and in England in particular, we have a national cancer plan, and the national cancer plan for this year has identified cancer vaccine as a top priority for our health system.

And this is because this is a technology that can be scalable, that can be widely deployed once it's demonstrated to be working. And at this stage, there are still some open questions, like which cancer types in which setting, which patients would benefit from it.

But once we address these open questions in clinical trials, then I do believe that we'll be able to use that in the, in the future.

Florence: I think we'll finish there. Thank you so much, Antonio, for coming on and for taking the time to talk to us.

Antonio: Thank you Florence, and thank you for the invite.

Florence: If listeners want to hear more explainer episodes like this, you can find them on our website at www.genomicsengland.co.uk or wherever you get your podcasts.

Thank you for listening.

Two years after researchers identified ReNU syndrome, where are we now?  

In 2024, two independent research teams identified the genetic cause of ReNU syndrome, a rare neurodevelopmental condition affecting thousands of people worldwide. The discovery marked the beginning of a new chapter for families searching for answers and opened up exciting new avenues for research. 

In this episode, host Sharon Jones revisits the story to explore what has happened since that breakthrough. She is joined by:

Professor Nicky Whiffin, Associate Professor and Wellcome Career Development Fellow at Big Data Institute and Centre for Human Genetics, University of Oxford

Christina Cox, Co-founder of ReNU Syndrome UK and parent of a child with ReNU syndrome

Dr Ana Lisa Tavares, Clinical Lead for Rare Disease at Genomics England

Together, they discuss how researchers around the world have built on the original discovery to deepen our understanding of ReNU syndrome, why studying the non-coding regions of our DNA is revealing previously unknown rare conditions, and how collaboration between researchers, clinicians and families is accelerating progress. They also explore how the growing ReNU community is supporting newly diagnosed families and what the future could hold for new treatments. 

Links: 

Previous episode detailing the discovery of ReNU Syndrome 

ReNU Syndrome UK's website 

Original research paper from Nicky's team in Oxford 

Original research paper from the team based in New York 

 “It's been only two years since our paper came out about this, and in that time, there are now patient family groups that have been set up all around the world. There is the one in the UK led by Christina and the others. There's the one in the US that's led by a group of four women, and there are ones in France, Spain, like, literally all around the world. And all of these groups are also somewhat coordinated. The leads of these groups meet with each other. They've organised meetups. I've been to ones in the US, the UK, and in France. So the fact that they can mobilise all of that and create such a community so quickly is absolutely incredible.” 

You can download the transcript, or read it below.

[00:00:00] Sharon: In 2024, two independent research teams identified a genetic cause of a rare neurodevelopmental condition affecting thousands of people around the world. Since then, that initial groundbreaking discovery has grown into something much bigger, bringing together families, researchers, and clinicians, and building a clearer picture of what we now know as ReNU syndrome. 

[00:00:26] Sharon: Welcome to Behind the Genes, the podcast that covers everything from cutting-edge research to real-life stories in genomic healthcare. I'm Sharon Jones, and in today's episode, we're looking at what's happened since that discovery, what researchers are continuing to learn, and what the future could hold for people living with  ReNU Syndrome and their families. 

[00:00:46] Sharon: To help us understand more, I'm joined by Professor Nicky Whiffin, Christina Cox, and Dr. Ana Lisa Tavares. So, two papers were published around the same time for this condition. To start us off, Nicky, you worked on one of these papers. Could you explain how this journey first began?  

[00:01:05] Nicky: Yeah, so this was two years ago now, back in early 2024, where two research teams, so us based in Oxford and a, a group based in New York, were both looking at the data within the National Genomics Research Library, and we both kind of somewhat simultaneously found that there was variance in this very, very small gene, it's called RNU4-2, were found in individuals with previously undiagnosed neurodevelopmental disorders. 

[00:01:39] Nicky: And this was very, very striking because we initially actually identified the same single DNA change or mutation in 40 or so different individuals within the National Genomics Research Library, and we normally expect to see a whole host of different variants. We don't expect to see the same one. 

[00:01:59] Nicky: So this was a really, really surprising finding. And it was through a collaboration, large scale collaboration across the world where we started contacting our other collaborators who have similar collections of patients who have been genome sequenced to ask if they had any individuals with DNA changes in this gene. 

[00:02:17] Nicky: And we found some in the US, some in, in Australia, some in France and Germany. So very, very quickly built up this, this complete picture of variants in this gene, causing this rare neurodevelopmental disorder  

[00:02:35] Sharon: of people finding it at the same time, what, what did that feel like? 

[00:02:39] Sharon: Like, give us a ense of, like, that compelling, "We think we found something." What was that like?  

[00:02:46] Nicky: I didn't believe it initially. You're always told when you're a scientist that if it looks too good to be true, it's, it's not true, and this basically lit up like a beacon. There's this particularly one DNA change that we found in, um, I think it was about 40 different individuals, and we don't really expect that to be the case. 

[00:03:04] Nicky: We normally expect these genetic variants to be somewhat randomly distributed across the genome. So to find 40 individuals with exactly the same DNA change was very, very surprising. So initially, I didn't believe it. The whole team, including folks at Genomics England, spent a lot of time trying to check that these variants were real and tried to disprove the result, tried to find any other way in which any other reason why we would be seeing this. 

[00:03:31] Nicky: And after a little while, we had to concede that we couldn't disprove it, so it must be true, and that, that was a very exciting moment.  

[00:03:38] Sharon Jones: Was it the case that over in the States, the exact same thing was happening?  

[00:03:42] Nicky: I think we found out when we were both speaking at the same conference, actually. So we didn't actually know that we, that we'd both come across the same result. 

[00:03:49] Sharon: If you want to check out our previous episode on this initial discovery, you'll find a link to it in the episode description. 

[00:04:00] Sharon: So Christina, tell us a bit about your situation, your family situation, and for our listeners, what ReNU is.  

[00:04:05] Christina: So ReNU is, to us, is a family. We got a family when we got diagnosed with  ReNU. Beau - Arabella - already had other diagnosises, but people had always said to us, "Oh, there's something else. There's something else. 

[00:04:20] Christina: We're not sure what it is, but there will be something." And then when we got  ReNU, it was like, "Oh, okay, amazing. What do we do? What is it?" Because there was only four lines on Wikipedia when we first got told about it, and there wasn't anything that, ourselves could find. So we kind of went onto Facebook and looked for groups and different people, and there wasn't really anything except for Jess in America. 

[00:04:46] Christina: And then it grew, and then it kind of, we ended up finding more people in the UK and, like, all over. But for us, it didn't really change how we perceived Beau. It just made life easier. Like, knowing there was other families out there that we could find advice from and support from, and that we kind of knew what we had and going forward then, like, finding researchers and connecting with everybody. 

[00:05:15] Sharon: Yeah. And for those who don't know, can you talk about what  ReNU is? Like, how does it affect Beau?  

[00:05:20] Christina: So with Beau and  ReNU , it affects her with developmental delay. She's non-verbal. She's incontinent. She suffers for walking, so she can do a little bit of walking, but she needs a wheelchair It affects her mood swings. 

[00:05:38] Christina: It just affects everything. Although she has it, she's still a happy, outgoing, very stubborn, just kind of "keep-going" child. But it affects her in everything, like eating, sleeping.  

[00:05:51] Sharon: It sounds like life is, you know, very challenging on a day-to-day basis, lots of considerations. How did you feel when you finally got this diagnosis after years of wondering and waiting, not knowing? 

[00:06:02] Christina: Finding out was, like, really emotional because it was like, "Oh, wow, so we have this diagnosis. Now what? What are we looking for? What's going to happen?" And then we were kind of like, "Oh, but there's not many people that had it." Because we found out in the August, so then it was trying to find people. But it has been life-changing to know that we're not on our own and that there is other people around. 

[00:06:28] Sharon: Yeah, tell us a bit more about that. How did it feel to get that diagnosis?  

[00:06:32] Christina: It was quite strange because our pediatrician rang us and said, "Oh, we've got a diagnosis. She's got RNU4-2." And we were like, "Okay, so what's that?" And she's like, "I don't really know. There's four lines on Wikipedia at the moment." 

[00:06:46] Christina: She goes, "I don't like Wikipedia," but we still kind of... That was it. So then we went on a mission to find and look for where we could find support and find other families.  

[00:06:58] Christina: At that point, I didn't know of anybody in the UK, and my husband found Jessica in America. What then, kind of, we had somebody to talk to, and then families in the UK kind of started appearing. 

[00:07:09] Christina: So we ended up getting a whole network of people to bounce ideas off and talk about how it affects their children and what's for the future and things like that. It was really nice.  

[00:07:22] Sharon: Yeah, yeah, I can imagine. So Ana Lisa, how do these findings contribute to a growing understanding of the condition? 

[00:07:29] Ana Lisa: So this was an amazing discovery. Although we're finding new rare conditions quite often, not on this sort of scale. It was also an amazing finding because a lot of the genes that we know are associated with rare conditions are genes that encode proteins, and in the 100,000 Genomes Project, we were doing whole genome sequencing, and Nicky and her team were looking in the parts of the genome that don't encode for proteins. 

[00:08:03] Ana Lisa: And so this was, uh, exciting from that point of view as well. So the vast majority of our genome, more than 98%, does not encode for proteins, but it's relatively unexplored. And if we think about our genome and the letter code that makes it up, which is the manual for how our bodies are built, and grow and function day-to-day. 

[00:08:30] Ana Lisa: Those 3 billion letters, if you, if you printed them out in a 12 font regular print, it would stretch so far you could fly, I think, from London to Paris several times, maybe three times or something. And so, this actual gene is a very, very small gene, less than 150 of those letters. So again, it was incredible to find that by comparing across many, many different genomes in the National Genomic Research Library. 

[00:09:00] Ana Lisa: Going back to your question about a growing understanding of a condition, it was a completely new condition, but it also opened up looking at other related genes and actually now more disorders that are being found, like RNU2-2 by colleagues in the US, and that might be one of the most common recessive genetic neurodevelopmental disorders. 

[00:09:27] Ana Lisa: So it's really, really opened up this understanding about these types of disorders and also those non-coding parts of our genome and the power of collaboration and being able to look across many different whole genomes at the same time.  

[00:09:44] Sharon: Yeah. And Nicky, you've been involved in much of this research journey. 

[00:09:50] Sharon: What have been some of the biggest advances or learnings for you so far?  

[00:09:55] Nicky: I think the biggest one is just how common, or how frequent, these disorders are. So what we discovered recently in terms of new genetic disorders were rarer and rarer conditions, and that's why we hadn't seen them before. But from going from looking at the protein coding genes to looking at these non-coding genes, we found something that was as frequent as disorders that were found in the early 2010s when we first had large-scale sequencing projects that looked at the protein coding genes. 

[00:10:26] Nicky: So that was really, really surprising. And we now know there's this whole class of disorders. So RN4-2, this gene encodes this -- Well, it produces this small RNA that works in this huge molecular machine that is called the Splicer Zone, that mediates the processing of most of the other genes across the genome. 

[00:10:50] Nicky: And there are lots of these little RNAs that work in this molecular machine that are called the small nuclear RNAs or the snRNAs And we now know that there are a whole multitude of different disorders associated with different ones of these spliceosomal small nuclear RNAs, and that's really incredible. 

[00:11:09] Nicky: And for RNU4-2 itself, we also now know that there are, there's not just RENE syndrome, uh, which is a dominant disorder caused by chance de novo variants that are newly arisen in a child, but also a recessive disorder where a child inherits one, uh, gene mutation from each parent. And also another finding that there is a region of the gene where we find DNA changes that cause retinitis pigmentosa, so a retinal phenotype. So we now know a huge amount more about this single gene, but also all of this different class of genes or RNAs that work in the same molecular machine, uh, which is, is really fascinating biologically  

[00:11:52] Ana Lisa: Vicky, while you were talking, I was thinking about the splicing and how a bit like this podcast recording, you're going to splice out the kind of extreme, the noise that wasn't supposed to be there. 

[00:12:03] Ana Lisa: And actually, you could make slightly different versions of this podcast, couldn't you? And that's, that's what, what's happening in our bodies for a lot of our genes that, that the kind of output can be varied slightly.  

[00:12:15] Sharon: So Christina, how has collaboration been involved across the community and with researchers? 

[00:12:21] Sharon: You know, what sort of things have you been doing?  

[00:12:23] Christina Cox: So it's amazing to have researchers that are so open and amazing to work with the families. So at the moment, we are just putting together like a panel to discuss questions from families, to then be able to answer families, to work very closely with the researchers for what things are happening and the progress within. 

[00:12:47] Christina: It's just amazing to be able to work with researchers. They're just fantastic.  

[00:12:52] Sharon: And from what I understand, like, you, you have a charity, don't you? Can you tell us a bit more about that and how that came about?  

[00:12:58] Christina: So we have ReNU Syndrome UK, and it came about as there was a group of us parents that were like, we wanted to be able to support other families, knowing what it was like for us when we first started. 

[00:13:12] Christina: It was very difficult. So we wanted to start a charity that can support families and signpost them, give them the opportunity to have family meetups once or twice a year, so we can work with scientists and specialists to keep everybody in the community, like the ReNU family, up to date. But being able to connect with so many families, because a lot of the doctors don't really know of ReNU Syndrome yet. 

[00:13:46] Christina: So if we have a problem or a question, we put it in the WhatsApp group, and then somebody can answer it because they've been through it, or they, they've just asked the question. So it's just an amazing resource for everybody  

[00:14:02] Sharon Jones: That sounds amazing, and it sounds like you've all obviously become experts by experience. 

[00:14:04] Sharon: So, like you say, you kind of know more, you know, as the science develops, but you're living it every single day  

[00:14:10] Christina: It's kind of, you go into the hospital and they're like, "Oh, what's ReNU Syndrome?" And then you're like, "Ugh." So, then you just have to say it all. But, and then it's kind of them bringing, teaching new people who don't know about it in the medical professional. 

[00:14:26] Christina: We always give them the website so that they can go and then find, but being able to put more medical stuff on the website, it just helps everybody, and it's just broadening it out to as many people as possible. Because there's still a lot of people undiagnosed with RNU syndrome. It's, now it's easier to be signposted, but it's just keeping that connection. 

[00:14:49] Sharon: Yeah. And, and from what I understand, it's got quite an interesting sort of origin of a name, RNU. Where did that... Do you know much more about where that came from?  

[00:14:57] Christina: So, Nicky is the amazing person who, um, sorted the name and um, the origin. So, I'll pass that over to Nicky to answer that question because she's just amazing  

[00:15:11] Nicky: Uh, so the name ReNU syndrome is an interesting story. 

[00:15:13] Nicky: So, a lot of disorders or diseases are named after people. So, we all know Alzheimer's, Parkinson's, etc. And they're often scientists or clinicians that have spent a lot of time working on them. I think that's a little bit odd. I don't think it's the first thing that somebody should know about a disorder, is the name of somebody who's, who's worked on it or studied it. 

[00:15:36] Nicky: But they're a very, it's very hard to find an alternative. When we were initially doing the press release around our paper, we had a quote from one of the mothers, Nicole Cedar, who has a, a wonderful daughter called Mia Joy, and she said that within their family, they like to refer to RNU, to RNU4-2 as ReNU, which is a really nice play on the RNU in the gene name. 

[00:16:00] Nicky: So then I had an idea, okay, let's just change the spelling to make the, the kind of big R, little E, large N-U, then it would link to the gene name, but also would be a name that speaks to hope and the renewed hope of being given a diagnosis.  

[00:16:13] Sharon: Yeah, absolutely, and that's a great, a great story and a great way of kind of making it feel like there is, there is always hope. 

[00:16:20] Sharon: So, you know, Nicky, you're now part of the patient community. In a way. You know, so how does it feel to be on that other side of it from that sort of research perspective and now kind of, you know, in that, in that community?  

[00:16:34] Nicky: It's amazing. I've got a new family as well. It's not, not just Christina and everybody. 

[00:16:39] Nicky: I kind of, I'm a, a basic scientist. I'm not a clinician. Up until this point, we've always been one or two steps removed from actually interacting with the families themselves. Um, so my life has changed an awful lot over the last couple of years, uh, where now, um, I kind of talk to Christina or the folks in the US, really regularly, kind of on a weekly basis. 

[00:17:02] Nicky: Um, so that's really different. And I just kind of want to highlight just what these families have achieved. So it's been only two years since our paper came out about this, and in that time, there are now patient family groups that have been set up all around the world. There is the one in the UK led by Christina and and the others. 

[00:17:26] Nicky: Um, there's the one in the US that's led by a group of four women, and there are ones in France, Spain, like, literally all around the world. And all of these groups are also somewhat coordinated. The leads of these groups meet with each other. They've organised meetups. I've been to ones in the US, the UK, and in France. 

[00:17:46] Nicky: So the fact that they can mobilise all of that and create such a community so quickly is absolutely incredible. And they've got families, they've got so many researchers that are interested in the cause. They're interacting with the pharma companies. They've upskilled themselves to learn so much about genetics. 

[00:18:04] Nicky: And it's just an absolutely incredible thing to watch. They're so, so inspiring.  

[00:18:09] Sharon: And from what I understand, Christina, you feel, you know, very passionate about Nicky in the same way, about your paths crossing in this way.  

[00:18:16] Christina: Oh, my, yes. Every time I see Nicky, I've met her a couple of times, like, in person now, I just cry. 

[00:18:22] Christina: I literally, we saw her at the UK meetup, and she walked in the door, and that was it. I was done. I was like, it's just meeting somebody who has changed so many lives and brought a community to other families. It's just amazing. And the support that Nicky's giving us weekly, daily, is just amazing. It is just life-changing for all of us. 

[00:18:49] Sharon Jones: It's such a powerful connection. So Ana Lisa, why is collaboration between researchers, clinicians, and families so valuable in the rare disease research space? You know, and what role do large scale research projects and data sharing play in discoveries like this?  

[00:19:06] Ana Lisa: Collaboration is completely incredibly valuable and for progress in the rare disease space where there's just so much still to learn. 

[00:19:16] Ana Lisa: So more than half of patients and families where, uh, they're seeking a potential diagnosis, we're not yet able to, to find one, and there's so much yet that we still need to learn, and collaboration in so many different spaces and directions and across different spheres enables this progress. So for example, the fact that we have a really connected, uh, National Health Service and really close working between the NHS and Genomics England so that we can, for those patients and families that, that consent to their de-identified data being shared in the National Genomic Research Library, be able to work with many, many different researchers, uh, whether they're academic, institutions, industry, and try and find all the patients that could benefit from a new diagnosis and, uh, potentially new therapies in future clinical trials. 

[00:20:21] Ana Lisa: And without that collaboration, it would be really, really hard to find all those people So because we sort of have a clinical research interface where we can go back to clinical teams and therefore to patients and families, even if there's a really, really ultra-rare condition with very few people known to have it that could be under different specialties in different regions, we would be able to contact their clinical team. 

[00:20:51] Ana Lisa: So I think that, that collaborative working with the NHS is really powerful across researchers worldwide. Like in this example where a group in Oxford and a group in US were able to make this finding and then all the other findings that are coming from it. And really, without being able to compare across thousands of genomes, one wouldn't have been able to see this, this particular signal and see that there were more than 100 patients, and that was really powerful. 

[00:21:20] Ana Lisa: If you just had one genome, you could never have made this novel discovery. I think the other thing is that, and Nicky will say that, you know, she, she then contacted her collaborators who also had access to, to, to data that had been shared by other families and could compare. And again, it's a whole sort of network across the globe. 

[00:21:41] Ana Lisa: And we know that there are going to be many more diagnoses to be found. But also, um, I think collaboration will allow us to find new, new treatments. So if we can start to design treatments that target the DNA and RNA at, at source, then actually you could collaborate and say, "Well, this type of genetic mechanism could be targeted in the same way, potentially across even more than one rare condition and reach even more patients." 

[00:22:13] Ana Lisa: And actually the power of collaboration across the ecosystem is that hopefully we'll end up with a pathway that can actually go from finding a new genetic finding, like Nicky and her team made, to helping all the people who could benefit from a diagnosis, having one, and then can one develop a treatment and get it to as many patients? 

[00:22:42] Ana Lisa: And, and I think that will really demonstrate the power of collaboration.  

[00:22:47] Sharon: Yeah. Absolutely, and it can only, you know, benefit those families who have to wait such a incredible amount of time.  

[00:22:55] Ana Lisa: There's been such a diagnostic odyssey, and as more diagnoses are made, it becomes obvious that there's, uh... 

[00:23:03] Ana Lisa: and it was, it's already well-described, the therapeutic odyssey. Um, but hopefully these sort of novel understanding of our genome and opening up new biological avenues to treat, um, hopefully will also enable many more new treatments to be developed.  

[00:23:21] Sharon: Absolutely, and that is the key word there is, is that hope. 

[00:23:24] Sharon: So, so looking ahead, Nicky, what developments are you most hopeful about over the next few years?  

[00:23:31] Nicky: That's a difficult question. There's so much, so much happening. One thing is that we are gearing up to do large scale studies across the world to understand more about the progression of ReNU. So you might call them large scale natural history studies or just large scale profiling studies where we can do a range of different tests on ReNU patients and, and monitor them over time. 

[00:24:02] Nicky: So do those at regular, regular intervals over time so we can see what the progression looks like. And that's really important for trying to think about whether we can treat RNeU syndrome. And on that note, I'm very also excited about the potential for therapeutics. There's lots of people all around the world, both, uh, in academic settings, but also in pharma companies trying to work out whether this is something that we can treat. 

[00:24:30] Nicky: There's some very promising early data to show that we can selectively remove the RNA containing the mutation from cells, uh, leaving the copy of the RNA that doesn't contain the mutation intact so that can do the correct function. And biologically, we think this should be an effective treatment. 

[00:24:54] Nicky: Um, so we can do that in cells in a dish. We don't yet know whether we can do that in a patient with ReNU. Uh, but that's really, really promising early data. Um, so I'm very hopeful about where that, those studies might lead.  

[00:25:08] Sharon: And Ana Lisa, what role will genomics continue to play in improving understanding and care for rare conditions like this? 

[00:25:15] Ana Lisa: So following on from what Nicky said, I think the really big hope is that we will be able to develop many, many new treatments collaboratively across the world. And whether these are individualised treatments made for one patient but then shared because we can find perhaps other patients who could benefit from the same treatment, whether we understand the genetics better so that we can design treatments from the start that will work for a lot of patients. 

[00:25:46] Ana Lisa: So I think there will be sort of fancier and fancier ways of targeting rare conditions. And right now we're in a phase where the ecosystem is trying to work out how could we make an end-to-end pathway with initiatives like the Rare Therapies Launchpad in the UK, and that's going to require truly collaborative working. 

[00:26:08] Ana Lisa: No single organisation can do that. And I think having these incredible use cases will be really powerful for turbocharging the development of these pathways. And the hope is that once you've worked out how to do this across a range of different rare conditions, that one might reach a stage where one could do that a lot faster for many other rare conditions. 

[00:26:35] Ana Lisa: Because at the moment they're so underserved in terms of treatments available and there's a huge gap between being able to make a genetic diagnosis and then having treatments. The big hope is that understanding the genetics better will help to open up new pathways to treatment. I do hope that we'll also understand other aspects. 

[00:27:02] Ana Lisa: So for example, it might be that understanding the genetics better also helps us to understand different ways a condition might manifest in somebody, why it may be different from one person to another, why somebody might be more mildly affected and somebody perhaps more severely. And that might, may also help us to understand ways to treat a condition by getting, gaining these insights which are, are useful in and of themselves and may also lead to new therapeutic, uh, possibilities. 

[00:27:36] Ana Lisa: I think that would be one of my hopes that a lot of these areas overlap and lead to real benefit for patients and families, that we can translate that hope into concrete improvements in treatment for rare conditions. 

[00:27:57] Sharon: Do you have a sense of time, how long you think this could all take, that amount of collaboration? 

[00:28:06] Ana Lisa: Yeah, and I think this is actually another reason why sometimes it's quite tricky to make progress in this area because being able to predict those timelines is notoriously difficult when you look back historically. I'd like to hope that we're on the cusp of having an explosion of novel treatments that can target DNA and RNA, for example, or treatments that target something in the underlying biology that we now understand that we didn't before. 

[00:28:34] Ana Lisa: And I do think that there is going to be a big shift. But I think that the sort of confidence intervals around how big that range of time might be is very hard to predict. And that's why I think Christina and Nicky being able to share these stories and about their collaborative working really shines a spotlight on, on what could be done and how progress can happen. 

[00:29:02] Ana Lisa: That's really exciting. The other day at a conference, someone from industry stood up and said, "Oh, actually, we set up a clinical trial in the UK because we knew there were patients who could benefit from our work in the National Genomic Research Library," and that was really exciting for us because that's what we want to do; move forwards the opportunities for treatment for patients. 

[00:29:28] Sharon: And so finally, Christina, as a parent and member of this community, what are your hopes for the future, and what would you say to families who may still be searching for answers today?  

[00:29:39] Christina: It is a long journey, but there is the support and the help out there. If you have any inclination that you think you might have ReNU, reach out to your paediatrician or your doctor to see if you can get your genetic testing done because it's fighting to get the test, to go to people and say, "I think this is what we may have. Can we look into getting it tested?" And reach out to other families and the website and things because it's all about community and supporting and helping people find that diagnosis.  

[00:30:16] Sharon: Thank you, Christina, and we'll put the website in the episode description. A huge thank you to Professor Nicky Whiffin, Christina Cox, and Dr. Ana Lisa Tavares for joining me today and sharing their insights and experiences. To learn more about ReNU Syndrome, visit renusyndromeuk.org. If you'd like to hear more stories about the people, research, and discoveries helping to shape the future of healthcare, subscribe to Behind the Genes on your favourite podcast app. 

[00:30:45] Sharon: Thank you for listening. I've been your host, Sharon Jones. Behind the Genes is produced by Deanna Barac, Florence Cornish, Sophie McLachlan, and Katie Revell at Bespoken Media.

In this explainer episode, we’ve asked Ella Davyson, Genomics Data Scientist, to explain the meaning of the term genomics.

You can also find a series of short videos explaining some of the common terms you might encounter about genomics on our YouTube channel.

If you’ve got any questions, or have any other topics you’d like us to explain, let us know on podcast@genomicsengland.co.uk.

You can download the transcript or read it below.

[00:00:00] Florence: What is genomics? My name is Florence Cornish, and today I'm joined by Ella Davyson, who is a genomics data scientist here at Genomics England, and she is here to explain the topic in much more detail So, Ella, we obviously both work at Genomics England. This podcast is called Genomics 101, so I guess it's fitting that we have an episode dedicated to explaining the term 'genomics'.

[00:00:26] But before we get into that, I think it would be good if you could first explain what we mean by the term 'genome'.

[00:00:32] Ella: Thanks, Florence. The genome is, essentially you can think of it like a manual booklet, or instructions that the body uses in how to grow, survive, and function, and this is a manual that's in every single cell within our body, and it tells our cells exactly how to divide, how to survive.

[00:00:54] For example, the genome in the pancreas, in pancreatic cells will tell those cells how to produce proteins such as insulin that we need to control our blood sugar. And also, the genome within our eye cells will tell the cells how to generate photoreceptors to enable us to see. So the genome is essentially like the ultimate guide that our body uses to tell it how to create everything that we need to survive going forwards.

[00:01:25] Florence: So then, what do we mean by the term 'genomics'?

[00:01:30] Ella: So, genomics is essentially the study of the entire human genome. So we study its structure and also how it functions, in terms of how is this instruction manual being read by the body, and how does that result in healthy human beings that we see today.

[00:01:48] Florence: So when we're talking about studying DNA, lots of our listeners might have heard the term 'genetics', which kind of also refers to the study of DNA and genes, so it might be a little bit confusing.

[00:01:58] So what's the difference between the two? What's the difference between genetics and genomics?

[00:02:04] Ella: So genetics is specifically the study of genes in the genome, and genes are part of the instruction manual, that specifically tell the body to produce a certain thing. So, in our insulin example, there is an INS gene, so, which is the gene in the genome or the instruction manual that specifically tells the cells to make insulin and to produce this product.

[00:02:30] There are many different genes in our genome, and genetics is the study of all of these. In contrast, genomics is the study of the entire instruction manual altogether, so that includes all of the genes in genetics and also everything else in the manual.

So, genetics is limited to the study of these parts of the manual that clearly encode certain proteins or products such as insulin. Genomics is the study of everything all at once, everything under the bathroom sink. So yeah, the confusion I think can arise a lot because historically when we first started looking at DNA and researching genetics, we didn't have the technology to look at the whole genome all at once, and with older sequencing technologies we would focus on particular genes that we knew important for certain diseases.

[00:03:19] So in diabetes, for example, they would instead specifically look at the insulin gene and see how does this influence diabetes, rather than looking at the entire instruction manual at once. Nowadays, we do have that technology, and that is what we do here at Genomics England, just use that to look at the entire genome rather than specific subsets of the genome, so specific genes.

[00:03:45] We can look at everything in its entirety. So, you can kind of think of genomics as a much broader, more complete study of genetics.

[00:03:56] Florence: So speaking of genomic testing, I don't know if you saw, but in the government's 10-year Health Plan that they published last year, they predicted that genomics could play a role in up to 50% of healthcare interactions.

[00:04:08] Could you tell me a bit about why genomics is important in healthcare?

[00:04:12] Ella: So that's a really exciting point, and I think one that we should be all striving towards. So, genomics can play a role in healthcare in so many different ways. I think before going into each of them, it's kind of maybe important just to illustrate that our genomes between two, two people are 99.9% the same.

[00:04:38] So we're both humans. We are both the same species. There is 0.1% difference between two people's genomes, and those differences underlie all the uniqueness that makes a person a unique individual.

[00:04:54] So personality, appearance and also risk to different health and disease outcomes. So that is where the role of genomics can come in, is to understand how the differences between people and their genetic makeup can influence maybe their risk for being more predisposed to developing a condition. Conditions such as Cystic Fibrosis or Huntington's disease that are specifically caused by genetic variants or mutations in genes that directly cause the condition. So it's a bit more maybe obvious, if you like, about how studying genetics in those, in those conditions can directly inform on how they arise, potential ways that we can better treat them.

[00:05:52] So another way that genomics can be used in healthcare is through screening. So this is being piloted at the moment in the Generation Study by Genomics England which is applying whole genome sequencing to newborn babies to look for a range of conditions which are caused by genetic changes, all of which are treatable.

[00:06:13] But importantly, screening will enable clinicians and families to know about these conditions much earlier and start life-changing treatment much, much sooner. So this is kind of already beginning to be, I think it will be showcased with this study in the next couple of years and the power of this in healthcare, I think can't really be overestimated.

[00:06:40] Florence: And finally, just to finish off, is there anything coming up in the field of genomics that you're especially excited about?

[00:06:48] Ella: There are loads of different things that I'm excited about in the field of genomics. I think probably maybe one that's most kind of relevant to clinical care is the possibility of doing more personalised medicine with treatments.

[00:07:05] Often, at the moment, we majority have kind of one treatment for all when treating certain conditions, and sometimes these treatments aren't tolerated well by some people, and also some of these treatments just don't work well in some people as well. Sometimes there's a clear reason for these things, but more often than not, it's not entirely clear why some people might benefit more for some treatments or some people don't respond or don't react well to some treatments as well.

[00:07:35] And understanding more, so there's a whole field about how genomics interacts with drugs and medicines, which is called pharmacogenomics, and its aim is to understand which medicine might be most effective or well-tolerated in certain people based on their genetics. And I think that will be kind of life-changing as well for some people, who are suffering from diseases where the medication is either not effective enough or is also affecting their quality of life.

[00:08:10] Florence: Mm-hmm.

[00:08:10] Ella: Because that is a whole other part of it as well is that sometimes these treatments for certain conditions are really hard to tolerate.

[00:08:19] Other things that I'm excited about are just the technologies that are coming out at the moment mean that we can measure and understand a whole lot more about genomics than we used to be. So now we can say this gene is influencing this disease, but sometimes, you know, it's more complicated, and we now have the technology to measure all sorts of different things, so how our environment can influence our genes and how our genes react with each other.

[00:08:57] So we're just getting, we're getting able to look at more and more, and I think we'll expand our understanding in a lot of conditions that unfortunately aren't very simple.

[00:09:12] Florence: Well, I think we'll finish there. Thank you so much, Ella, for coming on and for taking the time to explain genomics to us.

[00:09:18] Ella: Thank you, Florence. Thanks so much for inviting me, and it was a pleasure to be on the podcast today.

[00:09:23] Florence: If you want to hear more explainer episodes like this, you can find them on our website at www.genomicsengland.co.uk or wherever you get your podcasts. Thank you for listening.

A daily low dose of aspirin could significantly reduce the risk of bowel cancer in people with Lynch syndrome, an inherited condition that increases the likelihood of developing certain cancers.  

In this episode, we explore the findings from the landmark CaPP3 trial, hear from a participant living with Lynch syndrome, and discuss how genomics could help shift healthcare from treatment to prevention. 

Our host, Sharon Jones is joined by: 

Dr Katie Snape, Principal Clinician for Population Health at Genomics England 

Professor Sir John Burn, Professor of Clinical Genetics at Newcastle University 

Drew Hyde, participant in the Cancer Prevention Programme (CaPP3) 

Links: 

Listen to: How can genomics help us understand cancer? 

"I think knowing is always a good thing. And obviously, I wish I'd known earlier, and then, I could have taken more measures earlier on. So I think knowledge is definitely a good thing. And it would be great if more people could be tested or could find out if they were carriers at an early age, I think." 

You can download the transcript or read it below.

[00:00:00] Sharon: Welcome to Behind the Genes. In today's episode, we'll explore the research which shows how a low dose of aspirin can halve the risk of bowel cancer in people with Lynch syndrome. We'll hear about the real-life impact of living with the condition, and look at how genomics can help shape a more preventative approach to care in the future.

[00:00:20] I'm Sharon Jones, and to help us unpack all of that, I'm joined by our guests, Dr. Katie Snape, principal clinician for population health at Genomics England; Sir John Burn, professor of clinical genetics at Newcastle University; and Drew Hyde, a participant in the Cancer Prevention Programme, which is also known as the CaPP3 trial.

[00:00:42] So to start with the basics, Katie, can you walk us through what cancer is in simple terms?

[00:00:50] Katie: Sure, Sharon. So, our body is made up of cells. Those are the building blocks that, that make us as humans and other creatures and plants. And our cells need to keep dividing throughout our lifetime as our bodies are growing and working normally.

[00:01:06] And so we need to have processes in place in our body where our cells can divide, but then also stop dividing when we don't need them to carry on dividing. What happens in a cancer cell is basically that cell becomes abnormal, and it doesn't follow the normal checks and balances and rules of cell division.

[00:01:23] So it starts to divide and grow uncontrollably, and it can start to invade other tissues and obviously, that can cause serious consequences.

[00:01:33] Sharon: We'll hear a lot more from Dr. Katie Snape in this episode. But before we move on, I just wanted to flag that there was an episode of our Genomics 101 explainer series with Katie dedicated to helping us get to grips with how genomics can help us understand and diagnose cancer.

[00:01:47] Do go and check that out. We'll put a link to that in the episode description.

[00:01:54] So the World Health Organization estimates between 30 to 50% of all cancers are preventable. So, Katie, when we talk about cancer being preventable, what does that actually mean? And what's an example of cancer prevention that people might already know?

[00:02:11] Katie: Yeah. So some cancers are due to chance or just mistakes happening as our cells copy.

[00:02:19] Other cancers are because there has been damage to the genetic information within the cell that can be caused by certain things that can cause damage to DNA. So for example, a sort of obvious answer would be skin cancer. Skin cancers can be caused by sunlight, the, the UV light in the sun, and particularly if we burn our skin or, or get sun damage to our skin, increases the chance of us developing a skin cancer.

[00:02:44] So you can think of lots of other examples such as cigarette smoking and lung cancer, and so we know that there are a number of different risk factors that increase the chance of our cells developing damage and becoming abnormal cells and growing uncontrollably. So when we talk about prevention, we might think, well, could we reduce some of those risk factors and therefore reduce the chance of those cells getting damaged and becoming cancer cells?

[00:03:10] So I gave the example of skin cancer. We might put sun cream on if we're going out in the midday sun, for example. That reduces the damage of the UV light onto our skin cells. Or we might help people to go into a smoking prevention programme or, you know, other risk factors, such as we know that being very overweight can increase the chance of cancer.

[00:03:31] We might help people get into more exercise regimes or improve people's diets. So those are the sorts of things that we might do sort of for environmental risk factors. But we also know, particularly in this context, that sometimes people are born, they carry genetic changes within their cells that they're born with, that are inherited, that run through families, and those can also increase the chance of some cancers developing.

[00:03:56] And for those people at higher genetic risk, then we might look to other ways that we might reduce that risk. We can't change the genetic changes in their cells, but we might be able to put things in place to reduce the risk for those individuals, and that might be medication, it might be surgery, or there could be other things that we might be able to offer.

[00:04:15] Sharon: Yeah, and with that in mind, is there anything more, you know, that you can share about some of those risk factors that someone is more likely to develop cancer?

[00:04:25] Katie: Yeah. So actually, the, the biggest risk factor for developing cancer is age. The older we get, the more times our cells have divided, the more chance there is of a copying mistake that, that, that can cause that cell to become abnormal and start growing uncontrollably.

[00:04:41] And that's why cancer becomes more common the older we get. We obviously can't change our aging process. Then, as I've said, sometimes we're born with certain specific inherited factors that increase the risk. That might be one big high-risk genetic factor, such as having a cancer gene that's important for, for that process of cell division that isn't working properly.

[00:05:04] Or it could be that we have multiple lower genetic risk factors that can kind of add up together to increase the risk. And those often interplay with some of those environmental factors that we've talked about, like smoking, for example, or weight, or alcohol or other things like that. So most cancers are due to aging, and then there's a sort of interplay of genetic factors, but environmental factors as well.

[00:05:30] Sharon: That's really interesting to understand. And the focus of this podcast is sort of looking at kind of Lynch syndrome and what findings have come out around aspirin and having a low dose of aspirin. So I want to kind of explore what Lynch syndrome is and, and then bring in Drew to talk about his experience of having Lynch syndrome and how he got involved in the trials themselves.

[00:05:49] So from what I understand, Lynch syndrome is a genetic condition that can make some people more likely to have the chances of developing into bowel cancer. And Drew, this is your opportunity to sort of talk about what that's been like living with Lynch syndrome. And, you know, I'd like to understand more about your story and how it came about that you discovered that you had Lynch syndrome, and to share with our listeners your journey.

[00:06:13] Drew: Yep. So in my case, I discovered I had the colon cancer before I discovered I was a Lynch syndrome carrier Basically, at the age of 50, I noticed some change in my health. You know, I was becoming a little bit more tired. My bowel movements had changed or whatever. So, I went to the GP and the GP basically said, "Well, you're probably too young for cancer, so let's look at other alternatives."

[00:06:37] And I had blood tests and I had low iron, so I was on iron tablets for three months and whatever. Then eventually I went back and finally the GP said, "Well, let's try a colonoscopy." And the colonoscopy revealed that I did actually have colon cancer. And then very quickly I had surgery and, uh, then following that, I kind of asked the question, "Well, why me?"

[00:06:59] You know, I'm only 50, 51. Yeah. You know, why me?

[00:07:02] Drew: And basically, I was told, "Well, it's probably genetics." And then I was referred to, you know, St George's and Katie and I had the test and discovered that I was actually a Lynch syndrome carrier, and that's why, you know, I'd got the colon cancer at the age of 50, so.

[00:07:17] Sharon: I mean, that's quite a journey. I mean, how did you feel when you're already on one pathway and then having to kind of find out more, you know, what was your experiences? What was the impact on your life? How did you, how did you feel?

[00:07:27] Drew: I think I was lucky in that I had a very good surgeon. I had surgery very quickly, so that was the first hurdle.

[00:07:32] Then I had to go on to chemotherapy, and the chemotherapy obviously is far worse than any surgery or anything else that comes before or after. But having got through that, then I went through the St George's onto the Lynch syndrome system. So, the most important thing then really was to basically identify what that meant for me, but also because it was an inherited characteristic, what it meant for my family.

[00:07:57] One thing that was interesting, and I say, you know, the, the GP was saying, "Well, you're too young to have cancer," is that there wasn't any history of cancer in my family, you know, looking at older relatives. So, you know, to be fair to the GP, that wasn't an obvious marker. So basically, yeah, it was let's, you know, find out what it means now going forward.

[00:08:21] Sharon: So, can you just take us back to when you were diagnosed with Lynch syndrome? What sort of guidance were you given at the time about managing your cancer risk?

[00:08:30] Drew: Well, following the surgery, I was given various statistics which were fairly grim on what your percentage survival rate were in three years, five years, 10 years based on the surgery, whatever.

[00:08:39] And that was kind of a bit harrowing. But, you know, assuming I'd get through five years, I felt it was, my chances were quite good. As for myself living with, living with Lynch syndrome, that, you know, I was aware that having had the colon cancer, I then had increased risk of other cancers. So since then, I've been on a screening programme, and I have colonoscopies or gastroscopies every year or two years.

[00:09:04] So that's been very good. So, I believe now that if any other cancers were to appear, I would probably know very early on because they would be detected through a screening process before they got to a point where they would be, you know, maybe too difficult to resolve, so. So that's-- I think the screening programme, has been very, very good.

[00:09:23] The main issue for me was what it meant for my family, being a genetic thing. So very quickly, my children, who were teenagers at the time, were both tested, and they went through some counselling with Katie beforehand, you know, about what it would mean for them to get a positive or negative result.

[00:09:42] Unfortunately, my daughter was tested as negative, but my son was tested as positive, so he's now on the same cancer screening programme, and has colonoscopies every two years. So yeah. The mystery really, though, is where I inherited it from because my father died when I was very young. My mother was in a care home at the time, and I wanted to get her tested.

[00:10:07] And at the time, her GP wouldn't test her on the basis that she was unable to give consent. But fortunately, I had power of attorney, and we could persuade him to do the test. But she tested negative. So I'm assuming I inherited it from my father's side. But most of my grandparents on that side of the family lived into their nineties without any apparent cancers.

[00:10:32] So it's still a bit of a mystery how I inherited it, but what was important for me was to know which side of the family I'd inherited it from because obviously with cousins and whatever on different sides of the family, I wanted to be able to tell them what the situation was. My brother also tested negative, which was a positive.

[00:10:54] So at the moment, it's just my son and I that have the defective gene.

[00:10:59] Sharon: I'm sorry to hear that about your son, but does it-

[00:11:01] Drew: Well, well, I mean, he, you know, he has to go through a colonoscopy every couple of years, which, you know, obviously is not a pleasant experience. But at least he knows that, you know, the first sign of any problem, the medics will be aware of it, and he'll be able to react.

[00:11:16] Sharon: Has it changed your outlook on life, having this window in possibly knowing stuff or not knowing stuff? How has that affected you and, and your son as well?

[00:11:25] Drew: I think knowing is always a good thing. And obviously, I wish I'd known earlier, and then, I could have taken more measures earlier on. So, I think knowledge is definitely a good thing. And it would be great if more people could be tested or could find out if they were carriers at an early age, I think.

[00:11:42] Sharon: Yeah. That is really important. And moving into about the trial more broadly, scientists have known that there's been a link between cancer and aspirin for some time, with fewer cancers observed in people who take aspirin. So coming to you, John, could you share a bit more about the history of inherited cancer research and how the focus of Lynch Syndrome came about?

[00:12:02] Because this isn't new, is it?

[00:12:06] John: No, absolutely, Sharon. And in fact, this story, my story in this space begins 40 years ago when I was one of the geneticists who set out to try and find the genes that we've just been talking about. At that time, the group of patients who were the most obvious to begin with were young people with a condition called familial adenomatous polyposis, or FAP for short.

[00:12:26] And they'd get thousands of polyps in their bowel, and the only way to treat that was to actually remove the whole bowel when they reached adulthood, which is a fairly extreme intervention. And I was running, I was setting up a registry. We were trying to find the gene at that time, and we'd just found it, in fact, but we also were trying to find all the families.

[00:12:44] And I'd taken over responsibility for all the genetic services in the north of England, in the North East and Cumbria. And we'd, I'd started identifying families with FAP, and we went to visit one of those families, and this was the kind of light bulb moment for me because I walked into the room and mum had had her colon removed, and her son, Jonathan, had just had his first colonoscopy at the age of 12, and it was clear.

[00:13:07] And I was about to give them the good news, but as I walked in, I noticed that he had little bumps on his forehead called osteomas, little bony bumps. His mother had them just the same, and it was one of the features of this condition. So I knew he had the gene even though he hadn't yet got the polyps.

[00:13:21] Sharon: Wow.

[00:13:22] John: And it made me think, wouldn't it be nice if we could do something to prevent these things happening rather than just waiting for an operation? And as it happened at the time, I was leading the English end of a big study, which you'll probably be aware of, which we're, we're, we were doing the vitamin study on women with spina bifida babies, and we were just about to identify folic acid as a way of preventing spina bifida in pregnant women.

[00:13:45] So I had these two thoughts in my head. Maybe we could set up a trial like this folic acid trial, and then one of my friends in Edinburgh said, 'Have you seen this paper from Melbourne?' Gabriel Kuhn had just done a big study looking at people with colon cancer. It seemed that people who took a lot of aspirin didn't seem to get as much bowel cancer in Melbourne as those who didn't. So that was the design set up.

[00:14:08] We were applying to Europe for a concerted action, so we had to think of an acronym that began with CA. So I, I came up with Concerted Action Polyp Prevention. But then in 1993, just as we started that trial, we were involved in finding the first of the genes for Lynch syndrome. We had a big family in Northumberland where there were lots of people like Drew's family, and there were three generations of cancer in the family.

[00:14:31] So CaPP2 was immediately born in my head. In 1999, we had our first recruit, and we recruited until 2005. We found, in total, 1,000 people in 16 countries to join in, and we gave them two aspirins a day or two dummy tablets. Two aspirins is quite a big dose, but back in my day when I was a junior doctor, we used to give many more tablets of aspirin to people with arthritis.

[00:14:57] So two tablets wasn't such a big deal. Nowadays, it's seen as a very high dose. And it worked. Basically, to cut to the chase, when we looked in 2010, the people who were getting the aspirin were getting less bowel cancers. In fact, it was a 50% reduction. So the people who took two aspirins had half as many bowel cancers and fewer cancers of other types as well.

[00:15:19] We realised, although, at this point, immediately we saw that it was working, we knew we'd need to do another trial to see whether a smaller dose of aspirin would be just as effective. So CaPP3 began, and the great news is that what we'll be reporting in the journals in the next few days when it gets published, is that the people who were taking  CaPP3 aspirin in any dose were tracking exactly the same as the 600-milligram group in CaPP2.

[00:15:46] So we're pretty sure that it works. We're pretty sure that the small dose is just as good. And the great news was that we had fewer side effects in that group. And so in fact, no one had to go to hospital for a transfusion or anything, you know, like that. Whereas in the 600-milligram group, we had a few people who needed treatment because, as you know, and everyone knows, if you take aspirin, there's a higher chance of having an ulcer that causes a bleed.

[00:16:10] And that was always the anxiety. But people like Drew were courageous enough to take the chance because they knew we needed to know the answer to this. And of course, when you compare it to the risk of getting cancer, taking an aspirin is a relatively small risk.

[00:16:26] Sharon: So, what were your kind of considerations when you were designing the trial, having that knowledge?

[00:16:32] John: Well, the first thing is it has to be fully informed consent, which means that you have to explain to people what that risk is. The important thing about aspirin is that doctors have a much worse opinion of it than it deserves because if you work in a hospital, you'll often see people coming in who've had a bleed.

[00:16:48] It's not always caused by the aspirin. The thing is, if you're coming with a bleed and you're on aspirin, everyone blames the aspirin. Right. About half of them would've happened anyway. In fact, the, the irritation of the stomach is much more of a problem in older people So in fact, the average age of the people in CaPP2 and CaPP3 was about 45, 46 when they started.

[00:17:08] Drew was a little bit older, but, but people in that sort of middle age group are much, much less likely to get into trouble than people in their 70s and 80s. And it's people also who've had a history of ulcers that have a bigger problem. We also knew that if you had a stomach infection called H. Pylori, which is itself a risk factor for cancer, and about one in six people carry that bug, and we knew that if we fixed that with antibiotics, that would significantly reduce the risk of bleeding as well.

[00:17:37] So it was a manageable risk. It was something we could share with people. They knew they were taking a bit of a chance. But actually a good way of putting it in terms of the risk, for people in middle age, the risk of a low dose of aspirin is about the same as the risk of having a colonoscopy, which is very small, but it isn't completely without risk.

[00:17:56] Sharon: Yeah, and Drew, kind of like hearing this sort of incredible, like, backstory about how we've got to these trials and where we are today What was your experience like as a kind of participant of this trial?

[00:18:08] Drew: I understood I was going to be on 100, 300, or 600, but wouldn't know for at least three years, or was it five years? I can't remember.

[00:18:15] And then sometime later in the post we got these packs, and it was ... I remember at the time thinking it was like a rather dull advent calendar - ... in that you'd have the days of the week- ... with the little, with the little windows, and you'd, you'd pop the tablets out three times a day and take them.

[00:18:31] So I did that. I think, you know, I, I don't think I ever missed a day or whatever. Initially, I thought I must be on a really low dose, because I didn't actually notice any side effects. You know, I remember saying to my wife, I said, "Oh, I think I must be on the lowest dose, because I don't see any side effects."

[00:18:46] It was a surprise years later when I was told actually I'd been taking 600, so.

[00:18:51] Sharon: Wow.

[00:18:52] Drew: It was quite an easy experience really.

[00:18:54] John: We had a lot of problems. We had to pack the aspirin in six-month packs, because it was very expensive to pack this stuff up. It cost... We got the aspirin free from the Bayer company, but it cost us more than a million pounds to actually put it in, in the packs to satisfy the regulations.

[00:19:10] Uh, and a lot of people complained that the packs were a bit big and awkward, but that was just, you know, a constraint. But it was not that big a deal once people got into it. But we did get a lot of complaints about the size of the packets, which we couldn't do anything about that.

[00:19:24] Drew: They came regularly through the post, and, you know, so every three months or whatever I got another supply, and I just carried on taking them.

[00:19:30] Yeah, so.

[00:19:31] Sharon: What was going through your mind when you were kind of waiting for this potential outcome, Drew? Because you, like you say, it was, you know, it was a long time taking part. What was... Especially as you were opening your, you know, your package a day, knowing exactly what you were going to get.

[00:19:44] Drew: Well, I, I kind of knew it would be a long-term thing.

[00:19:47] I think I was committed for five years initially. But I carried on taking the aspirin for another probably five years after that. So yeah, I was just sort of happy to take the aspirin and then sort of wait to see what the results would be. As I say, that I didn't really notice any side effects, so I wasn't really worried that it was having any detrimental effect on me.

[00:20:09] So I was curious to see what the, what the results would be.

[00:20:12] Sharon: Yeah. John, the trial has provided like the evidence that, you know, low-dose aspirin can prevent bowel cancer. But are there any challenges that still exist with translating this research into clinic and ultimately patient care?

[00:20:26] John: Well, yes, and I'm going to hand back to Katie, who's actually leading the charge on, on getting it into practice as well.

[00:20:32] But just to say that I, I'm actually now literally on my other computer finalising my bid to go back to Cancer Research UK because we want to go for three more years. Wow. We said that we would follow people for 10 years after they'd finished their ... or after they'd started, so, you know, for at least 10 years.

[00:20:50] So the last person to join didn't finish until 2024, so we won't get to that person. It's Robin and one of my patients. We won't get to Robin's 10-year anniversary until 2029. Oh, yeah. By which time, obviously, Drew will be even further on. But that will give us at least 10 years of follow-up because we know that there is this delayed effect, and that was seen right back at the beginning when people looked, for example, the nurses study in America, where they followed 86,000 nurses and just asked them if they took aspirin.

[00:21:18] And nothing happened for 10 years, but those who were taking aspirin for more than 10 years saw a benefit. So in the general population, it probably takes that long to kick in. And so we need to keep going for just a while longer. It's not as expensive now because we're not giving people aspirin anymore.

[00:21:33] Sharon: Yeah.

[00:21:34] John: But one of the reasons we g- we made Drew's dose blind was because we wanted to know what the side effects would be when you didn't know how much you were getting There's a danger if you're getting a higher dose, you're more likely to complain. And actually, it did work out that the people on the lowest dose had the fewest side effects, even slight side effects.

[00:21:51] The only thing we can't escape from is if you're taking aspirin, you get bruising more easily because it blocks the platelets, which are the little tiny blood cells which plug up little holes in your blood vessels when they leak. The good news is we now know that platelets turn out to be right, a major factor in triggering cancer.

[00:22:09] And so the aspirin, by blocking the platelets, is actually reducing the risk of cancer, but also reducing the risk of cancer spreading in the body. So this is new research, and we've got another big research project in collaboration with a team in Cambridge who are, uh, pursuing this. Also, the other exciting news is that my other partner, Ruth Langley, is running a big trial of people with cancer, and those who are given aspirin as part of their treatment have less likelihood of getting spreading cancer later on.

[00:22:39] So the aspirin is clearly doing something good at many levels in the system. Surprisingly, and we think it might be partly, partly because we used to have a lot of salicylate in our diet, which is what aspirin's made from. And we think that maybe we're putting back something that the body actually was used to having.

[00:22:57] Yeah. But modern diets don't contain any, any salicylate because of the way we prepare our food. So it may well be that a little bit of aspirin's a good thing for everybody, but obviously, that's a choice that each person will have to make.

[00:23:09] Sharon: Yeah. I mean, it's a real powerhouse of a, of a drug essentially, which you're finding out more about its benefits as, uh, as research goes on.

[00:23:18] So Katie, can you just give us a bit of a broad overview of Genomics England's new adults program, which is kind of looking at this sort of area of work and, and what, how can it benefit people?

[00:23:29] Katie: Yeah. Thank you, Sharon. So, the adults programme at Genomics England is being funded by government, and the government wrote about it in the 10-year NHS Health Plan, the Life Science Sector Plan to run a large-scale genomics population study.

[00:23:44] So looking at how we can obtain genetic information from people in the population and look at more proactive and preventative healthcare, and can we generate evidence on where, how, and why the NHS should start applying genomics into kind of more population health measures. So, there's sort of two sides to this.

[00:24:05] So the first is thinking about pharmacogenomics, which is basically about how genetic factors influence how we respond to drugs. So lots of people have had experiences of having side effects from drugs, we've just been talking about that with aspirin, or for drugs not working so well for them. And we know that there are certain drugs that genetic factors can influence whether you should take the drug at all, or if you do, what dose you should take, whether it's going to work for you or not, whether you might be more likely to get side effects or adverse reactions.

[00:24:34] So part of the programme's looking at that. And then the other half of the programme will be looking at sort of is, are the genetic factors relevant for sort of serious and high-risk conditions in the adult population? So we could take bowel cancer as an example of that, a common condition, breast cancer, you know, common cancers or cardiovascular disease.

[00:24:58] We know there are certain genetic factors for some people that have significantly increased their chance of developing those serious adult onset conditions. Can we find those people in the population and then put measures in place to prevent that? So, you know, even just thinking about Drew's story, he didn't have a family history of cancer.

[00:25:16] The first time that he knew he had Lynch syndrome, he'd already developed bowel cancer. And we know that many people that have Lynch syndrome or other high-risk cancer genes are unaware of their status in the population, and so, um, the idea of this program is to really look at, well, if we were to, to look for some of these very high-risk genes in the general population, could we then put measures in place to reduce the chance of them developing the serious condition as a consequence?

[00:25:44] So instead of Drew presenting with his bowel cancer, we'd actually already picked it up, despite the fact he doesn't have a family history, and we'd offered him, let's say, aspirin if we'd known the information at the time, and we could maybe have prevented him from developing bowel cancer.

[00:25:58] So it's really exploring looking at that a little bit more.

[00:26:02] Where can we get genetic information in the population? Where might there be a really well-evidenced, like all the work John's done over 40 years, is really well-evidenced now. Yeah. Yeah. Where are there these opportunities for us to turn the dial on some of these common adult onset conditions?

[00:26:20] Sharon: What other challenges do you think with getting this out there do you see?

[00:26:25] Katie: Uh, I think there's, there's lots of challenges. I think it's a really com- ... complex programme of work. The first thing is that the risks might be different for people in a population than have a family history. So where I've worked for, for years, and John as well in, in clinical genetics, we've seen the highest risk people, the people with lots and lots of cancer in their family because they're the people that are presented to healthcare services. So we've worked out the risks based on that population. It will be really different when we move to the population setting. We'll find fewer people, and the risks might be lower because there might be other factors that are giving them a lower risk. But that's not to say the risk is zero.

[00:27:05] It's probably still raised. So then what we need to do is we need to consider, okay, well, what can we do to intervene, taking into account this change of context from people that we found through clinical services to people that we see in the population. And aspirin is a great example of this.

[00:27:22] So, you know, if we find that someone has a Lynch syndrome gene, then taking aspirin, unless there's a really good reason for them not to take aspirin, is almost certainly going to be low cost to the NHS and really significantly reduce the chance of them developing bowel cancer with a low risk profile. So where are those opportunities?

[00:27:41] And that isn't clear cut, and that's why we need a large scale research programme that can try to help the NHS answer some of those questions, so it can decide how best to spend its money in, in the people that are most likely to benefit from it with the least amount of risk or harm to them.

[00:27:58] Sharon: That makes sense. And, and so, you know, going to you, Drew, what are your kind of thoughts on some of the challenges that Katie's highlighted? And is there anything else that you think needs to be improved in better supporting people living with inherited risk of cancer in the future?

[00:28:14] Drew: In the brief sort of 10, 15 years or whatever since I've been s- suffering, awareness has increased greatly.

[00:28:21] I mean, for example, my GP now knows about Lynch syndrome, whereas I don't think she did when I was first diagnosed, and I think there is a little bit more awareness out there, but I still think it's a lot less than there would be for, say, for breast cancer. So for example, when a high-profile personality reveals they've got breast cancer, you often get information about inherited risks.

[00:28:44] You don't seem to get that with colon cancer. You know, when it's announced that so-and-so has died or is whatever, you don't get that same, you know, it, it might be a genetic thing. I mean, when I was first told people that I had bowel cancer, the response I got usually was, "Oh, poor diet, was it?"

[00:29:04] And I always felt a bit upset, that, you know, actually my diet was fairly healthy. And that was the assumption that people had. So I think anything that gets the message out there that there is a risk, an inherited risk, I'm not sure what the statistics are now, Katie, is it one in 400 people might be a Lynch syndrome carrier or something like that?

[00:29:24] You know, it's relatively high for something that is, if you know in advance you're at risk, you can do something about it. But like me, you know, I waited until it was too late, because I didn't know, and then had to have the surgery, so anything that promotes the message that there is a risk. I know some people don't want to know about their genetic makeup. Obviously, that's a choice. But I think to give people, as many people as possible, the choice must be a good thing.

[00:29:54] Sharon: Yeah, absolutely. And I think one thing I've noticed through this thread is the sort of theme of funding and what gets funding and the amount of time it takes to, to kind of get that funding.

[00:30:05] Is there anything you wanted to add around the kind of funding model, around why some things get funded, you know, uh, more prominent, like Drew's point, obviously, talks about if someone high profile kind of comes forward and says XYZ, that gets the spotlight shone on it, and there might be research going that direction compared to s- to, to other cancers.

[00:30:23] John: So maybe I could speak at that. So partly because of my experience, I've now been made chairman of the grant committee at Cancer Research UK for prevention and population research. And there is a real drive to push more resource into prevention for the obvious reasons.

[00:30:39] Katie: Yeah.

[00:30:39] John: And also, it's got to be remembered, it's very difficult for the drug companies to fund this because it takes such a long time that the drug's- Mm

[00:30:46] out of its patent before they actually get to use it. So, it's very difficult from a business point of view to fund research into prevention. But they are keen to help us, uh, but we really need sort of central government and the charities to focus on prevention if it's going to make a difference.

[00:31:02] And just on Drew's point on diet, I mean, diet is still important even if you have Lynch syndrome. In our CaPP2 trial, the people who were overweight were more than double the risk of cancer. So it's not like an either/or. If you've got a higher genetic risk and you have a bad diet, then that's, you know, is going to contribute.

[00:31:21] But the other exciting thing is, of course, we now have medical ways of treating obesity in, in people. So, one of the interesting areas is whether we should be, in the same way as we are for other high-risk populations with overweight, we should be giving overweight people with Lynch syndrome, help to lose weight because that will also reduce their risk.

[00:31:41] It's also worth just dropping in at the last moment here is that this is also a good news story in terms of treatment and further prevention. We now have a new class of drugs called immune checkpoint inhibitors, which specifically target the types of cancer that Drew had and are much more effective in curing them And also, we've just been given funding to do a project called LynchVax, which I'll be helping with, but it's led by David Church in Oxford.

[00:32:05] And this is developing a vaccine against cancers in people with Lynch syndrome. The great news is it'll probably work alongside aspirin because we know the aspirin is enhancing the immune response. So the two together may make this a curable condition.

[00:32:18] Sharon: That's actually incredible. I mean, that, it gives so much hope for people.

[00:32:23] And I just wanted to find out if you had any more kind of reflections as we close, because we're going to come to the end of our podcast today. If there's anything more that you wanted to share, anything that has been missed, or anything that you want our listeners to know, and I think I'm gonna come to you, Drew, first, because you're the person who's had to sort of live through this and, and go through this journey along the way.

[00:32:41] Drew: I think just basically, if you're not sure, get tested. Obviously, there are financial constraints. I'm sure that running a DNA test is quite an expensive business. But I think if you've got any history of bowel cancer in the family, you've got any concerns about your health, speak to a GP and see if you can get tested as quickly as possible.

[00:33:00] And then, to get a better message out there that there are risks of inherited colon and other similar cancers, so.

[00:33:11] Sharon: Yeah, so it's getting that, messaging out, um, for people to understand more and make those informed choices. And Katie?

[00:33:18] Katie: I mean, I would say that the power of, of our, you know, NHS and our academia and, and our healthcare system has been collaboration.

[00:33:26] Sharon: Yeah.

[00:33:27] Katie: There's so many moving parts. There's commissioners, there's funding, there's the evidence, there's research, there's healthcare implementation. The UK's a really amazing place to work in genomic medicine, and I think that's partly because of the amazing collaborations that we have, and the way that we can translate research into healthcare as John's team have done with this amazing study.

[00:33:48] So let's all keep working together, please.

[00:33:52] Sharon: Absolutely. And John, it feels like this is your lifetime's work.

[00:33:58] John: Well, I've become aspirin man, it wasn't intended. But Katie's done fantastic work in her role as chair of the Cancer Genetics Group in the UK, so we've now implemented a,

[00:34:06] we're the first in the world to really make this an absolute directive to the GPs and all, to all doctors to say, "People with Lynch syndrome need to be offered aspirin." And so that's a great step forward. But we also need to get it into the British National Formulary, and I'm working with their team so that the GPs are empowered to do this.

[00:34:24] It's actually part of their care package. But I would just say we've still got a long way to go. We've now got a national list of all the people with Lynch syndrome, like Drew, to make sure we offer them all a colonoscopy, but there are only 14,000 people after several years of really pushing.

[00:34:40] Sharon: Right.

[00:34:40] John: We think in the national population in all ages, it's about 1 in 300. That's a lot of people. That means there's about 150,000 people like Drew in the country, and we've only found 10% of them. So we can't just rely on family history for all the reasons Drew explained. You know, I mean, Drew's dad probably died of Lynch syndrome, but we don't know because we've lost that record.

[00:35:02] So now we're checking every bowel cancer to see if it might be caused by Lynch, and that programme is now kicking in, and we're picking up a lot more gene carriers as a result of that. But there's still a long way to go to get co- get people aware of Lynch syndrome, to think of it when someone presents with a cancer, not just of the bowel, but in the womb, in the kidney, in other parts of the body.

[00:35:23] It's not just the bowel, but that's the most important group.

[00:35:26] Sharon: Yeah.

[00:35:26] John: So there's still a long way to go.

[00:35:28] Sharon: Where you've come to now is still an incredible achievement, even though we've still got a long way to go, and I don't think we should ever lose sight of that. So we're going to wrap it up there. Thank you to our guests, Katie Snape, Professor Sir John Burn, and Drew Hyde, for joining me today as we discuss cancer prevention.

[00:35:48] If you'd like to hear more like this, please subscribe to Behind the Genes on your favourite podcast app, and thank you for listening. I've been your host, Sharon Jones, and Behind the Genes is produced by Deanna Barac, Florence Cornish, Sophie McLachlan, and Dave Howard at Bespoken Media.