Dr. Josep Tabernero is one of the most recognized and prestigious figures in the field of oncology. He is one of the most cited researchers and his healthcare work has earned him recognition as one of the 100 best doctors in Spain. His career has also earned him numerous awards, including the “Premi Nacional de Recerca de la Generalitat de Catalunya” and the “Premio a la Trayectoria Investigadora en los hospitales del ICS”. He is also chairman of the scientific advisory board of GENESIS Biomed. With him we have talked about how the covid-19 pandemic has affected research activity in our country and the lessons we have learned from such extenuating circumstances. We also reviewed where oncology is heading to in the upcoming coming years, how technology transfer is changing in Spain and its value in guaranteeing the sustainability of the healthcare system, and the need to develop new reimbursement models.
We have been immersed in the fight against covid-19 for a year now. To what extent has this situation set to focus on how important research is?
I think in a very important way. We have seen that research in the area of public health and viral infections was underfunded in all aspects at a certain time. And this has been revulsive. It is true that society in general and administrative bodies have reacted positively by seeking funds for covid-19 research. Once the situation improves, I would like such actions not to be taken for granted but to activate discussion forums to assess how far we want to go with research and to reconsider if research is truly a tool to improve the life quality of population and society. On the other hand, it is also a business opportunity. In many environments, including our own, research has never been valued well enough. I hope that after all this, at least in terms of public budgets, we will be able to put our research funding on a par, if not with the best countries like Germany or Holland, at least with the European average. Let us remember that we are well below this average.
The impact of COVID-19 on other pathologies such as cancer is unquestionable, with delayed diagnosis as the main consequence. But in medium and long term, are there other issues that haven’t been assessed yet?
The impact on cancer diagnosis, at least in Catalonia, is well known. The Oncology Master Plan has closed the year 2020 and has made the comparison with 2019. And what we know is that 12.2% less tumours have been diagnosed. This in part may be due to delays in screening programs, especially colorectal cancer and breast cancer. During the first wave, surgical and diagnostic activity was paralyzed, and this led to a delay that we are still catching up on. It is also true that there will be many patients who have died, most of them due to covid-19, and who would have been diagnosed with a tumour that was either in the diagnostic phase or would have clinically manifested during this period. Let us not forget that almost half of those who have died from covid-19 are older people who are more frequently diagnosed with cancer. What we do foresee is that in 2021 there will be a recovery in diagnoses if there are no other major setbacks.
Drawing positive conclusions, it has been possible to achieve effective vaccines in record time by combining efforts and with a great deal of funding. Does this demonstrate the growing importance of multicentred research? Have we learned that together we are better?
In the first place, cooperation is good. We already know this without any doubt. It is true that both public and private efforts have been pooled to launch covid-19 vaccines. It is also true that the American and European administrations have made a titanic funding effort to develop them. If they had gone wrong, it would have been a non-repayable grant. It’s the first time that such an effort has been made, funding this research in an extraordinary way, both with public calls and with private agreements with the pharmaceutical industry, in order to be able to carry out these vaccines that were necessary to tackle the pandemic. I believe that this also calls for a reflection and that in the future more public-private collaborations should be established. Perhaps not on such a large scale as this health and humanitarian emergency, but in any case, it is a good example to encourage this type of collaboration.
Cancer research in recent years has served to give a major boost to approaches such as immunotherapy or targeted therapies. Where do you see cancer research heading over the next decade?
The common umbrella will be precision and personalized medicine. We must increasingly approach each patient’s tumor as a unique entity, with its own properties and characteristics, which need not be the same as those of another patient with the same disease. And on this basis, develop the most appropriate treatment. Whether they are therapies directed at genetic characteristics of the malignant cell, such as mutations, translocations or amplifications, or treatments directed at characteristics of the tumour’s support environment, such as angiogenesis, the importance of inflammation or differentiated metabolism. Within this we also have, as a big area, the response of our immune system to tumours. In some cases, an already educated immune in fighting the disease, but that has been silenced by different mechanisms. In these cases, it would just be a matter of waking it up. But in 75% of tumours this is not enough, because the immune system has not recognized the disease as something to be eliminated. And so here we must educate it. These are especially important areas for future consideration. And then there will also be technologies. To point out one, usage generalisation of massive genetic sequencing in patient’s diagnosis. But it is also important to understand the dynamic heterogeneity of the disease, which is evolutionary. Liquid biopsy will play an important role here. And we must not forget research for prevention and early diagnosis, which is fundamental in cancer. We know that 40% of tumours could either be prevented or diagnosed much earlier, a research field from which emerging branches of research will greatly contribute.
Imaging markers used in radiomics are quite novel at the oncology level, although they have already been used extensively in mental health and neurodegenerative diseases. These raise different challenges than other molecular biomarkers. How do you see these types of technologies?
We cannot yet see the dimension of the use of radiomics and artificial intelligence associated to radiomics, will have. To put this into context, today we use less than 5% of the information acquired by radiological techniques, both MRI and CT, for the conventional diagnosis of diseases and their evolutionary follow-up. Research in this area, looking for the rest of the information that these technologies can give us, will be fundamental for a more functional understanding of the disease. Some studies already suggest that, if we were to repeat a CT or MRI scan 24 hours after an initial treatment, we could already know whether this treatment is going to go well or badly and whether it is going to last longer or shorter. All of this will first require a deep analysis of the data and artificial intelligence algorithms to help us process this data. Perhaps where there may be more of a challenge here is in the business model behind a predictive biomarker based on radiomics.
The possibility of developing oncological vaccines has also been considered. To which extent has this topic been developed?
Vaccines are actually part of a type of immunotherapy, for those patients who have tumours whose immune system has not recognized the disease as abnormal. And vaccines can help indeed to initiate this immunosurveillance, provoking more neoantigens and activating the immune system. In addition, there are also vaccines aimed at preventing viral infections that cause cancer. This is a different type of vaccine, but it is also important.
VHIO has experience in the development of both patents and successful spin-offs, as is the case of Peptomyc. Is the research landscape in Spain changing in any way so that leading centres are more focused on seeking market outlets and not just on academic research?
It is changing, but it should still change more. More and more institutions have transferred departments, but we are still far behind other countries. It is also true that this should be nuanced. I do not aspire our country having a transfer level like America, where a 10% success rate is considered positive. Piecemeal transfer to achieve a 10% success rate is not a sustainable model. It must be a more ethically sustainable transfer, where success rates should be 25% and if I dare to say, 50%. High failure rate means that, in the end, what is transferred becomes awfully expensive, which is not sustainable. An equilibrium should be achieved.
One of the major topics of debate in oncology is the accessibility of new treatments. To what extent do business models such as RSA (risk-sharing agreements), in which reimbursement is conditional on the success of the treatment, help research centres and hospitals to improve the sustainability of the healthcare system?
This is the future. Pay-per-price reimbursement is obsolete and no longer has a place. The future is what is called value-based reimbursement. I would even go further, with geographically adapted value-based reimbursement, because the value is not the same for each country, since, due to economic and model criteria, they may have a different concept of value. Today, having digitalised medical records, we could reimburse patient by patient, depending on what we consider to be of value and what is not of value. But there are still many limitations for payers because they are afraid to introduce models like these that are more complex. However, this complexity is solved with multiple tools. In addition, this also must drive research and transfer in a more sustainable way. If we already know that we are not going to pay marginal benefits of value, then we already know where we are not going to put a lot of effort into approving drugs that have a marginal impact. This will not only be good for improving the sustainability of the healthcare system, but also for refocusing the lines of research and transfer in the future.
Your research and healthcare career has made you a relevant figure in the field of oncology, not only nationally but also internationally, and has led you to chair several scientific advisory boards such as that of GENESIS Biomed. To what extent do you consider it important to pass on the experience you have acquired over the years to new projects and researchers that are emerging now?
Passing on experience is important for everyone. We live in a rapidly evolving world, where experiences from previous models help to better define new models. And here, frankly, we all learn, and I think this is extremely interesting. We have discussed already here above that everything is changing. Reimbursement models, transfer models, target objectives of what is a good target to complete a transfer process or not… All this is changing. Precisely, one of the few positive things about covid-19 is that it has been a revulsive for everyone to think about whether what they are doing makes sense if it is ethically sustainable and whether we should continue this way.