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| Back to his roots |
7-Jun-2006 |
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Professor Alan Coates
’
life has revolved around fighting cancer. Now, almost 10 years after heading the Cancer Council Australia, he is returning to his first love
–
clinical research.
By Bianca Nogrady.
PROFESSOR Alan Coates is softly spoken, formal and somewhat reserved — until he starts talking about research. When the subject of his life’s passion comes up, the 62-year-old launches, unstoppably, into lengthy stories of research breakthroughs and treatment mechanisms. He is animated, excited and eager to share his knowledge.
He may have overseen the growth of the Cancer Council into one of Australia’s most powerful medical organisations but, for Professor Coates (pictured above), it has always been about the research.
From the very beginning of his medical career, he was fascinated by cancer. “I guess it’s because it was a tough problem to solve, particularly when we started,” he says. “We had very few tools, whereas in some of the established specialities like cardiology and endocrinology, there were a lot of answers.”
His lifelong pursuit of those answers has earned him a place among oncology’s greats, along with an Order of Australia and a recent award for scientific leadership from the American Society of Clinical Oncology. As his successor at the Cancer Council, Professor Ian Olver — himself a giant in the medical oncology field — notes: “Every time I did something new in my career, Alan had been one of the early people in that field.”
Professor Coates has certainly seen changes over the course of his career, particularly in areas such as breast, skin and cervical cancer, as well as in public health initiatives such as smoking policy.
When he graduated, back in 1966, there was no subspecialty training in oncology in Australia. So, as a young internal medicine specialist with an interest in immunology, he took the sideways approach of starting up his own cancer immunology research laboratory at Melbourne’s Walter and Eliza Hall Institute. “It was quite fashionable to think immunologists were on the brink of curing cancer and there were periodic upswings of enthusiasm for cancer immunology,” he remembers.
The optimism turned out to be prophetic, given the later development of a vaccine against hepatitis B — a leading cause of liver cancer — and more recently an HPV vaccine that has the potential to eradicate cervical cancer.
Ten years after graduating, Professor Coates moved to the US to do his oncology training and further research at the University of Wisconsin. “As an Australian, I was automatically given all the melanoma patients.” While there, he witnessed the introduction of a radical new treatment for metastatic testicular cancer — at that time a death sentence for most young men with the disease.
“In 1976, a guy called Larry Einhorn discovered that if you put three drugs together, including … platinum, you could cure people even if they had widespread metastatic disease.” Professor Coates supervised the introduction of the new treatment at Wisconsin.
“It was tough treatment in those days … Platinum’s a drug that makes you vomit terribly. There weren’t good vomiting drugs in the hospital but we used to send them [the patients] down to State Street to pick up a joint,” he says with a chuckle.
“Those kids would go away cured and they’d come back and show me the children they’d fathered with their remaining testis.”
The ability to cure a patient with widespread metastatic disease was new to oncology at the time, although it still only applies to some types of tumours. But there have been even more significant, although perhaps less dramatic, advances in cancer treatment over the course of Professor Coates’ career, particularly in breast cancer.
In the late 1970s, adjuvant treatment for breast cancer was in its infancy with two major clinical trials under way in the US. These inspired Professor Coates to become involved with the newly formed Australian New Zealand Breast Cancer Trials Group on his return to Australia. The group, now almost 30 years old, will occupy much of Professor Coates’ retirement time, along with the International Breast Cancer Study Group, which he co-chairs.
There’s a lot happening in breast cancer research, and Professor Coates is particularly excited by the new molecular-specific targeted therapies.
“I think the fascinating thing about cancer treatments in the next 5-10 years will be picking the molecular targets. So you label a cancer not as, ‘your cancer started in your breast’, but, ‘your cancer is one which overexpresses this molecule, therefore we need this particular antidote to stop that’.”
He is personally involved in trialling one of the new therapies — herceptin. “Herceptin works brilliantly for those 20% of women who have the overexpression of target,” he says.
The drug is also incredibly expensive — about $50,000 for each of the 2000 Australian women who might benefit from it — leading governments to baulk at the cost of subsidising it.
“But it’s incredibly effective,” Professor Coates says.
“If you do the cost-benefit analysis, it comes out at a reasonable price in most of the jurisdictions that have done that.”
The Therapeutic Goods Administration has approved the drug but the Pharmaceutical Benefits Advisory Committee is yet to rule. “I’ve been putting pressure on as much as others have for accelerated evaluation — I think there is some degree of acceleration but not as much as I’d like to see,” he says.
For some cancers, though, the prognosis has improved little in the past 40 years. Lung and ovarian cancers continue to stymie efforts to find effective early diagnostic tools or treatments. “They’re both frustrating diseases because once you’ve got them, the outlook is not as good as it should be,” Professor Coates says.
The combination of CA125 testing and ultrasound is not very effective at picking up early ovarian cancer, so the search is on for a better early warning sign. The cutting-edge technology of proteomics —high-throughput study of protein structure and function —may offer hope.
In the case of lung cancer screening, there is no formal program and spiral CT is mainly used on an ad hoc basis in high-risk patients — that is, those who continue to smoke. “Maybe you could get more bang for your buck by trying to help them stop smoking than let them keep smoking and trying to find their cancer a little bit earlier,” Professor Coates says.
Australia took the global lead on tobacco control during his time at the Cancer Council. “We’ve seen tremendous provision of smoke-free workplaces but we can’t take all the credit for that,” he says, citing the pressure the insurance industry has placed on employers to protect their staff.
While Australia’s leading role in reducing smoking has recently been usurped by places such as California, Professor Coates is optimistic the national smoking rate can be pushed below 15% from the current 17%.
It’s one example of how dramatically the public health policy landscape has changed in the past decade, due in no small part to Cancer Council efforts. In skin cancer, for example, the council’s successful Slip Slop Slap campaign has helped change the attitudes of younger Australians.
One disappointment is that the long-promised screening program for bowel cancer has still not been rolled out. “We know it works, it saves lives but it isn’t working here yet,” Professor Coates says, with a tinge of impatience.
“It’s more the logistics [holding it up] at this stage, but what frustrates me is that all these logistic problems were utterly predictable five years ago when we first knew that the system worked, and it’s only just when we’re trying to roll it out that people are attempting to tackle them.”
Professor Coates’ influence on cancer policy has not always been well received. His declaration in 2003 that he had chosen not to have a PSA test earned him the wrath of federal politicians, urologists and the Prostate Cancer Foundation of Australia, on whose board he sat at the time.
Mr David Sandoe, a director of the foundation and co-chairman of its support and advocacy committee, says the controversial stand caused enormous confusion.
“The people who couldn’t understand that statement were the people like me for whom early detection has been key,” says Mr Sandoe, himself a prostate cancer survivor.
“The disappointment from survivors that make up the support groups around the country was that he was making a statement as an
individual that was being construed as a statement by the organisation.”
While Mr Sandoe says in all other respects Professor Coates has made “a wonderful contribution” to the field of cancer, “we were very disappointed about that statement”.
So why did Professor Coates make such a personal, and public, statement?
“I think the message was a necessary counterpoint to an overenthusiastic selling of something that is an unproven intervention,” he says.
It was a dramatic step, he knows, and one that had a profound impact on men who had survived the disease. “If you’re a prostate cancer
survivor, one of the hardest things to question is whether your treatment was worth it.”
But he still defends his decision to go public, arguing the evidence speaks for itself.
“On the question of PSA testing, almost all world authorities recommend against routine screening.
“At the moment, there is no evidence of good and there is a lot of evidence of harm.”
As always, for Professor Coates, it comes back to the evidence.
The Cancer Council’s new CEO, Professor Olver, describes his predecessor as having an “encyclopaedic” knowledge of the literature, a knowledge that seems likely to expand as Professor Coates returns to his first love and throws himself back into clinical research.
“Not that I haven’t got
satisfaction out of doing the policy stuff, but a lot of people can do that and I have great confidence it will continue to be done well,” he says.
“While I’ve been doing these other jobs as well I’ve had to limit the time I could give to [breast cancer trials] and that’s frustrating. That’s why I’ve decided I want to focus on that for whatever working time I’ve got left.”
Despite being in ‘retirement’, Professor Coates shows no sign of slowing down — something fellow breast cancer researcher Professor John Forbes is grateful for. “We’re all passionate, but Alan is resolute, and passion plus resoluteness is an unbeatable combination for the good of research.”
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