This interview is with Professors Trevor and Ray Powles, for CANCERactive and was originally published in in October 2003 icon
Professor Trevor Powles CBE At A Glance
An authority on breast cancer. Born 20 minutes before his brother, he is slightly taller, with longer hair and wears a white coat at work. Both brothers are Professors at the Institute of Cancer Research. Rack in 1958, both studied at Barts (St Bartholomews), before Trevor went to Hammersmith Hospital to do endocrinology. In 1967. while working as surgeon on HMS City of Durban, he met Penny and they married a year later and have three children. He joined Ray, at The Royal Marsden, in 1971, where his pioneering work on risk and prevention of breast cancer in healthy women included the first Tamoxifen trials.
He has also led the way in reducing the number of
mastectomies
He has also led the way in reducing the number of mastectomies. Trevor retired from the Marsden at the end of March, just after he and Ray received CBEs for their services to cancer patients. Since then he has set up a breast cancer unit at the Parkside Oncology Clinic, where he is lead clinician and chairman of their medical advisory committee. He splits the rest of his week between the Lister Hospital and Barts, where he is involved in several breast cancer prevention trials. Trevor also advises pharmaceutical companies Eli Lilly and Pfizer on clinical trial results and procedures.
Professor Ray Powles CBE At A Glance
Myeloma and leukaemia expert (Professor of haemato-oncology). Slightly younger than Trevor, and more likely to be seen in jeans at work or while supporting his beloved Chelsea FC. Ray has a different birthday to his twin, as he was born just after midnight. He stayed on at Barts to specialise in haematology, joined The Royal Marsden Hospital, in London, in 1966. and moved to Suttons Royal Marsden two years later. Marriage to Louise in 1980 has given him four children, including identical twin sons.
Both Ray and Trevor appeared on TVs This is Your Life, which highlighted Rays pioneering transplantation work: Performing Europes first successful bone marrow transplant in 1973. and, in 1980, the worlds first reverse bone marrow transplant (from a son to a father, whod given his son his bone marrow eight years before). Ray has just retired from the Marsden, after 35 years, and is busy setting up his new haematology unit at the Parkside Oncology Clinic. He is also on two government panels working on the modernisation of the NHS, as well as being director of a Swiss-based pharmaceutical company and an Indian-based clinical research organisation.
The Third In Our Series Of Interviews With Cancer Pioneers
Professor Ray Powles has arrived home in Surrey fresh from doing ward rounds, checking upon his myeloma and leukaemia patients, at Suttons Royal Marsden Hospital. His first stop, after saying hello to his wife, Louise, is the pond, he designed himself three years ago, at the side of the sprawling family home. This landscaped-to-be-naturally-wild spot is where the man who runs one of the worlds biggest haemato-oncology units loves to relax. As he throws in food for the 1,000 goldfish, orf and koi carp, and cuddles his two cats, its easy to see that the Powles caring approach - which both Ray and his identical twin brother Trevor are famed for - is not just for their cancer patients.
Professor Trevor Powles arrives minutes after his brother. He has been busy setting up "a state-of-the-art" breast cancer unit at the new Parkside Oncology Clinic for the last six months. Ray will join him there as head of haemato-oncology this month.
The brothers homes are just two miles apart, and their lives have remained intertwined, not by design but the natural course of things. They studied medicine together and, even though both were drawn to different specialities, their separate career paths brought them to the Royal Marsden. Their pioneering and caring work, with thousands of cancer patients over more than 30 years, led to them being jointly awarded CBEs by the Queen in March.
With such a wealth of knowledge, skill and experience between these two 65-year-old cancer stalwarts, you could forgive the odd flash of arrogance or superiority, but theres not a glimmer of either. Both Trevor and Ray are naturally laidback, witty and effortlessly helpful. As for being identical, there are subtle differences even though people sometimes muddle them. "Hardly a day goes by without someone thinking, Now is the one with shorter hair Ray or Trev?" says, er, Ray.
As for personalities, Trevor volunteers that Ray is the "slightly more extrovert" of the two. But Ray is quick to point out why that may be. "We are genetically the same, so any differences in us must be environmental" he reasons. "I think Trevor is a bit more conservative than me because hes looked after middle aged, middle class women. An important part of my practice has been young adolescents, so Ive tended to have to wear jeans, rather than a white coat and have my hair cropped to be able to communicate with them."
Both are well-used to dealing with teenagers
Both are well-used to dealing with teenagers, having seven children between them - tour of which are in, or studying, the "family business". Trevors two sons, James and Tom, work at Charing Cross Hospital and Barts respectively as an ENT surgical registrar and an oncology medical registrar, while Rays identical twins, Sam and Luke, are in the fourth year of their degrees at Barts.
Its been a year of change for their fathers. "Its a crazy thing that its mandatory to retire from the NHS at 65," says Trevor, "when most of the States and Europe dont.
Its very disruptive and was quite a complex, logistical thing trying to run down some of the breast cancer prevention research programmes Id started at the Marsden.
Ray managed to stall his retirement for six months, "because they hadnt filled my post but admits, "I would have loved to have carried on, because Ive got 100 people in my team, which I started from scratch, and its an enormous wrench to leave. Like Trevor, though, Ive reinvented myself to go to the Parkside. Its an exciting time and pure luck that they should have opened their cancer centre at the exact time that Trevor was retiring. They were very keen to take us on board and we couldnt have imagined anything better"
It still rankles though, and Ray later points out that his equivalent in Americas Mayo Clinic is in his 70s. Many people look to the States for centres of excellence, but is cancer care better there? "I dont think so" says Trevor. It you look at the best places in the States and the best in the UK, the standard of cancer care is about the same - the same with the worst there and here. Weve done direct comparisons with our results from the Marsden breast unit and the units at MD Anderson in Houston (also Milans Instituto Tumore) and there was nothing to tell between them.
"I think the Marsden is as good or better than any major specialist centre in the States, Europe, Australasia or the Far East. So in the cancer Olympics I reckon wed do very well - and I can say that now Im no longer there!"
Its a big centre, with a big critical mass
Ray agrees. "Its a big centre, with a big critical mass. There are 2,600 employees in the two Marsdens, and the Institute of Cancer Research, so by any standards that is an enormous cancer programme..."
Over the last 10 years, Ray has noticed changes in haemato-oncology cancer care around the world. "You can find one or more institutions in places like South East Asia, Japan, India and, obviously, Australia and New Zealand that are absolutely top notch now. Everything is becoming global" he explains. "Ive been involved in training people from more than 60 countries. I get patients from all over the world and most of them could be adequately treated in their own countries now: whereas when I started and, at my peak for private practice on foreign patients, 20 years ago, almost none of them could have been. Were rather proud of that change."
Breast Care
Both have so much to be proud of in their own specialities and each others. "I think Trevors best achievement has been turning breast cancer from a surgical speciality into a medical one," says Ray. "What good surgeons in breast cancer do now is practice both the surgery and the medicine."
"Its all to do with early medical treatment, before surgery, or even before diagnosis," Trevor explains. "Thats where the action is. At one stage breast cancer was going the other way. More and more surgery, but the results werent getting any better, so that was obviously wrong. Now we do less surgery, because about 80 per cent of patients dont need a mastectomy. Those who do will have a reconstruction at the time of surgery, so no one need go out without a breast.
Both have so much to be proud of in their own specialities and each others
And the results have improved from about 50 to 60 per cent relapsed problems at five years, when I started 32 years ago, down to about 20 per cent. So thats 82 per cent free of problems at five years!"
The mortality rate has improved but younger people are being diagnosed with breast cancer. "Theres been a 30 per cent reduction in mortality since 1990. It has gone down from 18,000 to 12,000. but theres been an increase in incidence over the last 20 or 30 years and its effectively 30-40,000 new cases a year. Part of this increase is because of screening. You obviously pick up smaller things you wouldnt have otherwise, but principally I think breast cancer has increased because of environmental reasons (including oestrogens and other agents/chemicals in the food), and intake of hormones like HRT or oral contraceptives.
"HRT has been shown to increase the risk of mortality from breast cancer, but thats still a fairly small risk compared with the one in just getting older With inherited risk factors, there are some genes that are very strong, like BRCA1 and BRCA2, where you have an 80 per cent chance of getting breast cancer in your lifetime. Now you may bring that forward a bit by lifestyle/environmental factors. Theres a lot of research into the interaction between those and inherited factors."
Trevor pioneered Tamoxifen trials at the Marsden, and the work continues. "We know already that a large proportion of breast cancers will be prevented, but were not there yet because we need to identify the risk factors that are oestrogen-dependent - that will be prevented by using an anti-oestrogen. You need to take the population of women and identify the 10 per cent where 30 or 40 per cent of the breast cancers were going to occur. It they were susceptible to using Tamoxifen or Arimidex, it would mean that youd only need to treat 10 per cent of the population to remove 30 or 40 per cent of the disease. So you can imagine once you get down to the genetic nuts and bolts, which is what were researching at the moment, you can identify which strategies to use with each risk factor.
Exciting stuff, and in the meantime Trevor lists the breast cancer drugs that really work as Tamoxifen"theres quite clear evidence it will reduce mortality in women who have breast cancer", Arimidex "looks like it might be as or more effective than Tamoxifen", and another aromitase inhibitor Letrozole. With chemotherapy, "theres definite evidence that a variety of drugs used in combination will improve survival". The most important are the Anthracyclines, especially Adriamycin, Etiadrianycin and the taxanes, of which Taxotere "is important for breast cancer". Another one in a completely different class of drugs is Herceptin, which is an antibody to a growth factor, and "has been shown to prolong survival".
There is evidence that animal fat increases oestrogen levels and that that could be
detrimental
Early in 2004 Trevor is expecting the results on another trial that has been going for two years, where 400 women who dont have breast cancer have been given genistein. "Were just starting to do the analysis now," he says. "Were looking at all the potential effects on bone, breasts and hormone levels because, with naturally occurring sugars like genistein - in soya and red clover - which are phyto-oestrogens (naturally occurring oestrogens or anti-oestrogens) they may act like Tamoxifen. lithe results are negative, it doesnt mean that red clover doesnt work. We might have got the wrong phyto-oestrogen mix, or wrong dose, so we will do further trials because Im sure that there will be natural products that will be very beneficial. I think they will help because in Chinese/Far Eastern diets, where these levels are high, breast cancer incidence is low and the level of osteoporosis is low. So theres something in those diets thats protecting people against both diseases."
Icon has always advised people with breast cancer to stop eating dairy products, and Prof. Powles feels the same. "I agree with Chris Woollams that there is a good argument in reducing animal fat intake, " he says. "There is evidence that animal fat increases oestrogen levels and that that could be detrimental. Were trying to reduce oestrogen with a lot of treatments were doing. Our general advice is to reduce animal fats and take unsaturated fats instead. Theres evidence that a higher fibre diet might be better as well. We also say to take a multivitamin and to increase your calcium, magnesium and vitamin D intake because, if you reduce animal fats, theres an increased risk of osteoporosis."
Both Trevor and Ray declare themselves fans of complementary, "but strong foes of alternative medicine. I know almost nothing that does harm, providing youre also getting the best medical treatment/ says Ray. "Complementary you add on top of state of the art treatment. Alternative, you abandon all other treatment."
"The problem with alternative treatment," adds Trevor, "is that you may be delaying appropriate, accepted medical treatment. It might be that there is none, but, generally, when there is effective medical treatment available to give just carrot juice is definitely not the way forward.
Mammography
Hmm, while were being controversial, does Trevor see a future for the oft-criticised national mammography screening programme? Oh yes he does. "The evidence for mammograms causing cancer to spread is nil," he says emphatically, before qualifying it slightly with "The evidence is very, very scrappy that they can a) increase the risk by a radiation dose and b) increase the risk of spreading the cancer by a compression. The radiation dose is so low that one is not likely to see a measurable effect in any of the big studies. The criticisms of mammography have been mostly based on early data from clinical trials but as the follow up of national and international trials has continued, data from the benefits of screening has got better, and my prediction is that we will see the benefit on mortality in the next five years. Looking at all the data, my estimate is that there will be probably a 10 to 20 per cent reduction in mortality."
There will be probably a 10 to 20 per cent reduction in mortality
At the moment the programme screens women between the ages of SO to 65 every three years. Trevor wants that extended to the over 65s who "still have 25 years of life expectancy", and he wants to see the data build upon the under SOs. The problem with that age group is that the breasts are dense, so its more difficult to pick up the cancers. He feels that the screening programme will also be shown to be a success because "it was a very good basis for the reorganisation of breast cancer services. Women were coming into screening and then being referred to breast units at the time when new advances in breast cancer were being made, so now most people in the country get Tamoxifen and chemotherapy when they should get it; while patients who dont need a mastectomy dont get one."
Myeloma & Leukaemia
Rays spectacular advances in the field of transplantation have been well documented and his brother is full of admiration for his work. "I thought Rays transplantation programme was absolutely incredible," he enthuses. "People have forgotten, but at that stage (1973) to wipe someones bone marrow out and then be able to give it back, and for that person to recover was miraculous to me. "One of the early transplant patients even did a parachute jump for charity...""Oh yes." interrupts Ray. "After all shed been through and survived, she landed in the main road, in front of a fire engine, and nearly killed herself!"
"Its absolutely incredible how many patients are cured," Trevor continues. "When he started there were 100 per cent deaths - and now less than 50 per cent." Ray recalls that when he was a houseman at Barts, the first 1,000 patients that he came across with myeloma and leukaemia all died. "Now you cure 50 per cent across the board, and the remaining 50 per cent will be cured," Ray says with confidence. "In the 1970s myeloma was a slowly progressive, debilitating disease, with increasing loss of quality of life, until death came as a merciful release after two to two and half years. We now put people into complete remission. We did that at the Marsden 20 years ago, using high dose chemotherapy, and have been consolidating that ever since, mostly with biological treatments. Some 30 per cent of myeloma patients now live between 10 to 20 years. and that is probably going up by about 10 per cent every decade. Myeloma is easily the success story, compared with leukaemia, and Im going to Parkside with the intention of making it the best private myeloma unit in Europe.
Ray is certain that more patients are cured because they get better medical care now, "We went through a terrible period, when was a medical student, where you didnt tell patients what was wrong with them," he recalls. Nowadays you dont have to do it in a brutal, or a sensitive, way but you can do it positively. Patients need to be deeply involved in decisions and we need to build their trust, because they have to be totally in charge. Our job is treating, supporting and getting them through the nightmare. Also in a funny sort of way treating them more aggressively, over shorter periods of time, rather than dribbling in here, there and everywhere, just making them sick without doing anything for the disease. The old drugs, that have been around for 30 years, work the best. Weve just got very good at giving them in the best way - usually in very high doses without killing the patient! Things like Melphalan, Cytosine-arabinoside and the Anthracyclines. Weve also learnt how to mix them together, to give multiple drug combinations for both myeloma and leukaemia.
"We got into chemotherapy, very early on, thinking it was the answer to cancer, but the more Ive done the more I realise that biology is the answer. You learn the biology of the disease and the biology of the people. The body has its own devices and regulating systems. Chemotherapy nudges, fudges, pushes and burns, but the healing process - which were just learning about now and the immunology of everything, which is what transplantation is about - is immunotherapy.
Some people say there are too many new drugs in trials, but Ray disagrees. "I went through a period where were no drugs, so now I think the more drugs there are the more selective we can be. The most exciting new ones are the biological modifiers. Theyre stunning! These are substances that either stimulate or mimic the bodys own biological control mechanism in a dynamic way - the actual harnessing of the body in a properly scientific way, which is what complementary medicine is all about. Im so grateful for the FTIs, Glivec...each one of these costs $300 million to get through clinics. You get down on your hands and knees, youre so grateful for drugs like that. There is also a new population of drugs like Thalidomide and Velcade, which has just got a product licence. Velcade interferes with protein metabolism in cells, which is really exciting."
The Way Forward
Trevor acknowledges that the big successes in cancer cure are, and will come, ,in the biotechnology arena. "The way biotechnology has changed in the last 10 years is incredible," he marvels. "That with the computer power we have has led to extraordinary genetic research. The gene work is probably the most important thing thats occurred in all the years Ive been involved with cancer, It has major applications in terms of identifying targets for treatment, in diagnosis and prevention."
Ray agrees that understanding whats happening at a molecular level is crucial. "The human genome project is only the start of that because genes dont work in isolation, but as part of a dynamic system thats 200 million years old. Its nearer to traffic than chemistry," he explains. You close one bridge and everything goes over another.
The way biotechnology has changed in the last 10 years is incredible
Getting your mind around the dynamic of 3,000 gene sites, ar producing proteins and interacting (we know about 10 of them in my field, maybe 15), is a 1OO~ year project. And it may be that the human brain is never powerful enough to be able to grasp the dynamics of that. Its ike asking a London taxi driver to learn every street in every city in the world, and then dropping him anywhere. You would see that the human brain isnt powerful enough to do that, but the base of all this is a strong breakthrough, with so many exciting things still to come. I see the great advances in cancer In about 2020 when we can understand a little bit more about the dynamics of the bodys own regulating systems."
So many research projects underway, and so many lives already saved by both these professors - its hardly surprising they were awarded CBEs earlier this year. But being team players theyre quick to share the praise. It was a very special day," ~ay admits, "because, most of all, I felt like an ambassador for the 1,3 million people doing NHS work. It was their honour really, theyre all heroes. I wasnt doing anything different, just do work love doing and would do for free. I fee! I just got frightfully lucky.
Trevor is just as humble. "I was very honoured by the award. but, for me, the single most important thing is looking alter the patients."
"Yes," agrees Ray. "The best satisfaction is meeting the patients and talking to them. Thats why its so nice to be able to continue with that, because I would have missed that more than the research or anything else. I know it sounds corny, but its the fundamental core of what we do. In life you do what youre used to. Its unthinkable to do anything else."
The Parkside Oncology Clinic is at 49 Parkside,Wimbledon, London SW19 5NB.