With this chapter closing, how do you envision your own work evolving?
I am incredibly excited about cancer prevention and want to dedicate the next 10 years to working in this field. By understanding the earliest molecular events that drive tumour initiation, we are beginning to glimpse the possibility of molecular cancer prevention – identifying high-risk clonal expansions or inflammatory states and intervening before invasive disease ever develops.
What has become increasingly clear is that many environmental exposures may not act primarily as mutagens, but as promoters. In a cancer promotion model, selective expansion – where inflammation, metabolic stress, or environmental stimuli create a permissive niche – allows pre-existing mutant clones to expand and acquire further malignant traits. If we can identify and modulate those promoting signals, for example chronic inflammatory pathways or tissue repair programmes that drive progenitor cell plasticity, we may be able to prevent progression even when mutations are already present.
Prevention, in this sense, becomes an evolutionary strategy. Rather than trying to eliminate every mutation, we aim to suppress the ecological conditions that allow dangerous clones to dominate. The ambition is not simply earlier diagnosis, but biological interception: altering the trajectory of cancer evolution before metastatic competence is established.
Looking to the future of oncology more widely, what developments give you the greatest optimism?
The power of discovery research never ceases to amaze and inspire me. Just when you think a particular area of medicine is hopeless, breakthroughs occur that change the way we think about disease.
I have seen this happen multiple times during my oncology career, from targeted therapies hitting HER2 and EGFR through to cancer immune-therapy achieving cures in metastatic melanoma. Then there was the early detection of lung cancer through low dose CT screening, and the development of a better understanding of which patients need – and benefit from – adjuvant therapies.
It really does show the power of investment in discovery research in driving better cancer outcomes.
