What is a Fellow?
“A Fellow is typically a doctor, from Canada or abroad, who has completed specialist training in Medical Oncology. All of the Fellows in the BRAS Drug Development Program (BRAS DDP), are already recognized specialists in Canada or their home country. Aside from taking care of oncology patients on a day-to-day basis, a large proportion of Fellows also have had prior experience in clinical trials and research in their home institution.
This particular fellowship to the BRAS DDP, is a 1 to 2 year fellowship for most of our Fellows. By being part of a team, we gain exposure and practical experience, on how early phase clinical trials are conducted. Each of us also has academic projects that run longitudinally throughout our 1- to- 2 year stint at the Princess Margaret Cancer Centre. Supervised by the staff physicians, Fellows are heavily involved in the daily management of patients. In terms of day-to-day contact, it’s really the Fellows as well as the nurses who run the program.”
Why did you become a medical doctor?
“That is a very good question. The last time I was asked this was in my interview for medical school more than 15 years ago! It has to do with some personal experiences, and exposure as a teenager, as well as what medicine really meant to me. I’ve always been interested in science during my secondary school years and my A-Levels. It was all very science based. Yet I was also very involved in the humanities as well, within the school. I thought being a doctor was a good balance between science and humanity. Certainly day-to-day patient contact is very humanitarian, and require certain proficiencies in inter-personal and communication skills. Yet the science behind medicine and health forms the basis of these contacts as well.
On a more personal note, around the time when I was looking for a University placement, my grandmother got sick and was hospitalized, and subsequently died of a stroke. I spent a fair bit of time in the hospital with her during her final days, and realized that medicine is very much a team effort. Patients got better, not only because of the doctor, but everyone in the healthcare team played an essential role. I wanted to be a part of that.”
Why did you chose oncology?
“I think it’s the expansion of the same theme. The balance between science and humanity. I think this is an exciting time for cancer medicine, and the science behind it is fascinating. On completion of my internship, I was deciding between Surgery and Oncology. Whilst both specialities treat patients with cancer, they are also on extreme ends of a spectrum. Surgery is certainly
exciting with a lot of science for sure. Many a times, there is a very early sense of accomplishment as well when things are ‘fixed’ after an operation. However, you do not get the human touch per se. When you see a patient on the operating table, you may see them after the operation for one or two more visits, but that’s pretty much it. There is not much continuity in follow-up. On the other hand, as an Oncologist, patients are under your care throughout their entire cancer treatment journey – during both good and bad times.
Due to obvious historical reasons, we in Hong Kong operate a healthcare system based on how things are done in Britain. Our trainings are accredited by the Royal Colleges in the United Kingdom. Typically, our oncologists are Clinical Oncologists and are trained to give radiation therapy as well as chemotherapy. However, given the complexity and recent advancements in
cancer drugs and treatment, Medical Oncologists are playing a much more pivotal role in cancer care. We are internists who specializes in not only the provision of chemotherapy and systemic treatment, but are often involved in clinical and translational research. We are a relatively young specialty in Hong Kong. I am actually ‘Medical Oncologist No. 27’ on the Hong Kong Medical Council Register. We have a population of 7.5 Million! You can see how small this niche is. All of the fellows at BRAS DDP are Medical Oncologists who are further specializing in Developmental Therapeutics – i.e. the testing and research of new drugs and targeted agents.”
Why is it a good time to be in the cancer field?
“I think it is a good time to be in the cancer field, because we are now finding out more about ‘why’ and ‘how’ cancer develops. We are at a point when we now have the technology to analyze a particular patient’s tumour and to choose the most appropriate drug for them. This would not have been imaginable 10 years ago. I think in the last 5 to 10 years, this technology has really expanded. The costs have come down, and we are making real differences in terms of patient care. For example: As part of IMPACT (Integrated Molecular Profiling in Advanced Cancers Trial) at the Princess Margaret Cancer Centre, we are able to select patients with particular genetic mutations, and match them to specific trials, investigating targeted drugs that act on those specific mutations. We are able to see a lot more responses to treatment, and certainly a lot more patients are able to benefit. This has been a real ‘eye-opener’, and we are in the process of setting up a similar program in Hong Kong.”
Is this what we are calling Personalized Cancer Medicine?
“Yes precisely. And I think this is only the first wave. I am certain there is more coming. As the technology becomes more mature, and more popular, and as we know more about different molecular targets, hopefully this drive will continue.”
“ATTITUE, GRATITUDE, AND HOPE.”
– LEE PETTERSEN
What has inspired you since you’ve been here?
“I think the most inspirational aspect is the team work that goes on at the BRAS DDP. The fact that there are so many roles that people play, and there are so many people within it. The unit works like clockwork. On the surface, we may appear tobe a small team of doctors and nurses, but in actual fact, there is a large group of healthcare professionals including research coordinators, statisticians and administrators, who keep this machine well-oiled and the momentum going. This in itself is quite amazing, and most certainly important. This is the only way this unit would ever function, because of the sheer number of clinical trials we conduct, and the number of patients we see. I think that has been the most inspirational.
Patients themselves are also very inspirational – and their families. The patients here are to a certain degree, similar to the ones that we see in Hong Kong. Yet they are very different. Similar in the sense that everybody is going through a tough time with cancer, yet different. I feel the patients here are more in tune with the whole theme of Personalized Cancer Medicine. Being on a clinical trial has its benefits to the patients, as well as to the science. They are more willing to be a participant in the trial.
Back home this is certainly the trend, but it’s still quite difficult. Maybe it is because as a predominantly Chinese society, we are more conservative. Hopefully this will change. There are opportunities here, and it’s been good. It is out in the public now, that the only way cancer treatment can move forward, is by improving our knowledge, and the only to do that, is having clinical trials, and by being a participant is a good option!”
Why are you here?
“The reason why I am here is, similar to the BRAS DDP, my hospital in Hong Kong has also newly established a Phase 1 Clinical Trials Unit. We shall be performing earlier phase drug testing and clinical trials for cancer patients. The BRAS DDP is a renowned unit in this field, and has a very high position globally. I am quite sure this is the most successful unit in Canada! More importantly, whilst the Princess Margaret Cancer Centre is by no means the biggest cancer centre in North American, nor does it have the most number of patients, this cancer centre and specifically the BRAS DDP, provides a good balance between patient volume and teaching. It is an absolutely great program.”
The BRAS DDP is a renowned unit in this field, and has a very high position globally. I am quite sure this is the most successful unit in Canada!
What are some of the advantages of being a BRAS DDP Fellow?
“One of the biggest advantages of being a BRAS DDP Fellow, is to be able to meet other Fellows. Right now, we have 7 Fellows from all corners of the world: Spain, Italy, Australia, the UK, Ireland, Hong Kong and also Taiwan. There is very good camaraderie. We work with and bounce ideas off each other. There is also a growing BRASS DDP alumni consisting of ‘graduated’
Fellows! Most of them are now established academic oncologists in various premier cancer centres around the world. In 10 to 20 years’ time, these Fellows will be the “movers and shakers” of Oncology. It is important to build up this network. This is an advantage for me to bring home.”
What are the phases? How many are there?
“In the drug development, in the clinical development, when the drug is actually being exposed to humans, we divide the phases into four different phases:
Phase I is the first phase when the drug has been tested in the laboratory, as well as in animals. We then bring it forward to human testing. So most of the time, these are First-In-Human testing where no human patients having been exposed to these drugs before. The main reason why we do these phase 1 trials, is to assess the side effects of these drugs. Although we have tested them in animals, it doesn’t necessarily mean that it will be translated to humans.
The other reason why we do it, is we need to ascertain what the correct dose is in terms of humans. We recruit patients into a trial, and we test the drugs at different doses. We monitor them very closely to make sure there are no particular side effects, and at the end of the trial, we establish what we call a Recommended Phase 2 Dose for subsequent testing.
The next phase of testing would be a Phase 2 trial where the drug, having gone through phase 1, we have established the recommended dose. The main reason we do this trial is to see whether or not there is any clinical efficacy.
The next phase would be a Phase 3 trial, where we compare it with what we have as standard treatment for that particular cancer. That’s the big trial where it requires numbers in the hundreds, and to compare with our standard treatment, to see whether this new drug is any better than what we currently have. Typically, if the phase 3 trial shows an advantage of the new drug over the current treatment. The drug then obtains approval from various health authorities around the World and is entered into the market.
A Phase 4 trial, is a ‘look back’ trial where you look at the data of typically over 1000 patients who have been on the drug, and say: Hey is this drug really working, or has the data before been not very accurate? Are there particular safety or other concerns about this drug that may not have been picked up during the earlier phases of testing, where there were only a small number of patients?
The numbers of patients also grow as you go up in terms of phase. For example: In phase 1 trials, we are dealing with a very small number of patients, but we watch them very carefully. The nature of phase 1 trials, means that they are typically conducted in higher specialized centres with a proven track record, and experience in the field. Trials are typically conducted globally across multiple cancer centres. That is essentially drug development in a nutshell!”
How long does this process take starting at phase 1 and ending at phase 3?
“The time frame we are talking about is 8 to 10 years, for any drug to go through, from laboratory, to phase 1, all the way through to approval, and then to market. Certainly the average time from laboratory to actual approval can vary. Only less than 10% of cancer drugs that are tested in a phase 1 trial, ever becomes registered as a phase 3. Why? Because drugs that may have shown promise in the laboratory, or in animals, may not necessarily perform well in the humans.”
The time frame we are talking about is 8 to 10 years, for any drug to go through, from laboratory, to phase 1, all the way through to approval, and then to market.
What are the advantages of being a participant in a phase 1 trial?
“The advantage of being in a phase 1 trial, is you’re able to receive drugs that would not otherwise be on the market! But there are also uncertainties, given the fact that we are looking at side effects. We are not in full understanding of the side effects of the drugs. Having said that, phase 1 trials are conducted in a manner where patient safety is of paramount importance, and the clinical trials are designed, together with the physicians involved, always err towards the side of caution. Some may argue that being a patient in a phase 1 trial is even safer than a patient on standard treatment, as our patients are monitored very closely, with very frequent (often at least weekly) visits and check-ups.”
Are we making progress in the war on cancer?
“I think so. I think we are certainly heading in the right direction. We have made some significant steps, but there is still a long way to go. There is still a lot of uncertainties, but we certainly are heading in the right direction.”
There is a big banner outside this hospital: “We Will Conquer Cancer in our Lifetime.” In your lifetime, do you believe this will happen?
“I hope so. I believe we are generally better in terms of health care. Not just cancer as a whole, but our life expectancies are also increasing as well. I think we have certainly solved one of the main hurdles for cancer care, and that is the genomics aspect of it. The fact we now know that cancers are due to genetic aberrations, and we now have different methods of targeting them.
The next step is to collect the data. We need more patients to be on trials. We need more trials. We need more doctors to be trained to handle these trials, so that we can collect the information and then move forward.”
Are we at the maximum at the BRAS Drug Development Program for the number of trials we can conduct?
“I think we are at a good number. I think there is certainly room for more, but I think at the same time, there needs to be more staffing as well. We have Fellows coming, but we also have Fellows leaving. We are also recruiting more Staff Physicians as well. So, I think this is a good balance. But to be honest, you don’t want a centre where there are lots and lots of trials. You
want a good balance, because at the end of the day, patient care comes first.”
What makes the Princess Margaret Caner Centre one of the top 5 in the world?
“I think it’s the people. It’s the fact that Princess Margaret is one of the most diversely staffed cancer centres in the World. The diversity is seen in both our training background, as well as our varying cultures, and ethnicities. I don’t think any of the larger cancer centres have such an international perspective. I also think it’s to do with Toronto itself, is a very cosmopolitan and
culturally diverse city.”
When do you head home to Hong Kong?
“I am leaving at the end of December (2013). I will be starting at work in a week’s time. I will take a piece of Princess Margaret Cancer Centre and the Bras Drug Development Program home with me. And certainly there will be more collaborations with my colleagues here, and with my mentors, Drs. Siu, Philippe Bedard, Albiruni Razak, as well as Dr. Amit Oza.”
“Thank you Dr. Loong. Thank you for your contribution to the Princess Margaret Cancer Centre, and the BRAS Drug Development Program, and I wish you the best of luck with your new phase 1 centre in Hong Kong.”
Dr. Herbert Loong has since returned to Hong Kong, and has assumed a staff position, and been appointed as an Assistant Professor in the Department of Clinical Oncology, at The Chinese University of Hong Kong (CUHK). Aside from continuing his work in drug development, he is also involved in setting up, and the administration of the newly-established Phase 1 Clinical Trials Centre at CUHK. One of the projects undertaken by him during his year as a Fellow, include the design and scripting of a patient education video on Cancer Molecular Profiling, allowing patients and their families to have a better understanding of what this process entails.