Upon Alan Coates’ retirement after eight years as Chief Executive Officer (CEO) of The Cancer Council Australia we have chosen to dedicate this issue of Cancer Forum to an acknowledgement of the achievements and contributions of one of Australia’s foremost figures in cancer research, management and control.
In this Forum, a number of Australia’s leading oncologists and researchers discuss important advances in the prevention, early detection and management of cancer. Many highlight the role Alan Coates has played; others focus on developments that Alan helped facilitate or championed. It is evident that he has directly or indirectly influenced people, perceptions and progress across the whole spectrum of cancer control in Australia and overseas.
Through a mixture of history, clinical practice and science these articles provide a context and description of Alan’s life and work. They highlight the breadth and diversity of his knowledge, clinical experience and interests, as well as the personal qualities, which combined to great benefit in his role at The Cancer Council Australia. As Ray Lowenthal attests, in addition to his apparent knowledge and skills, Alan brought to this role a previously unheralded capacity for leadership, skilful advocacy, networking and organisational management.
While the subjects of these articles vary widely, a number of themes emerge. In references to Alan’s contribution to cancer control, key words and phrases are often repeated: evidence, multidisciplinary care, collaboration, quality of life. Lowenthal describes The Cancer Council’s many achievements under the stewardship of a CEO who was “collaborative rather than antagonistic”. Andrew Coates acknowledges Alan’s “cross-disciplinary vision”. Sue Pendlebury notes his insistence on “evidence of efficacy” and formation of multidisciplinary teams before the term was used in the cancer care context. John Forbes praises his colleague’s “remarkable breadth of scientific knowledge, his humanity and his wise counsel”.
Ian Tannock questions whether the increasing commonness of PSA testing is in fact “progress” in cancer management, apart from effectively curing asymptomatic prostate cancer. Toronto-based Tannock argues that for many men knowledge of their PSA is harmful, creating an anxiety he terms “PSAitis”, and subjecting them to investigations and treatments that adversely affect their quality of life rather than permitting them to live peacefully with asymptomatic prostate cancer.
As has been the case in other countries, the debate about PSA screening has been contentious. In presenting The Cancer Council’s position Alan has endured professional and personal criticism. The Cancer Council does not support population-based screening of asymptomatic men for prostate cancer because there is not yet direct evidence of a net benefit in terms of reduced mortality. Despite claims of the opposite, Alan has in fact done many Australian men a great service by his unswerving espousal of this evidence-based position. He has taken great efforts to explain the value of a patient-centred informed decision-making approach to PSA testing in place of mass screening that could, as Tannock argues, be more harmful than beneficial.
In the next three articles, John Thompson, Andrew Coates and Rick Kefford discuss advances in the management of melanoma: Thompson provides a historical perspective of progress in surgical management; Coates explains how cross-disciplinary collaboration has enhanced “mapping” of melanoma metastases; and Kefford provides an update on developments in the field of experimental therapies. As these authors and others have noted, Alan Coates contributed greatly to improving treatment of melanoma, largely through his long service with the Sydney Melanoma Unit, involvement in clinical trials and commitment as a clinician, researcher and CEO of The Cancer Council to the development of evidence-based management guidelines. Kefford cites some of the pioneering contributions made by Alan in investigating systemic treatment of melanoma. What lay beneath the published literature was a gifted and highly principled unwavering commitment to clinical science and to multidisciplinary care that continues to inspire all those with whom he works and has made him the deeply respected mentor of many Australian oncologists. In a tribute to his father’s “cross-disciplinary vision”, Andrew Coates illustrates the potential benefits to be gained from collaboration of disciplines – in this case, the combination of radiography and geography to challenge commonly held perceptions about draining node fields and consequently improve the information available to surgeons. As Coates notes, the primary lesson is to “step back from the minutiae and look about for others pursuing similar goals”, an ability Alan has demonstrated in his dedication to multidisciplinary care (before the term had entered common parlance) and to increasing alliances and collaboration while at the helm of The Cancer Council.
The articles by Frazer, Forbes and Pendlebury describe world-leading research by Australian clinicians that has improved, or is poised to advance, the prevention and management of cancer. These are appropriate inclusions in a Forum dedicated to a man who has not only personally been at the forefront of cancer research but has, in his various capacities, been a great advocate for and supporter of research, particularly clinical trials.
Frazer outlines the viral aetiology of cervical cancer and the development, and potential, of vaccines based on human papillomaviruses to greatly reduce the cervical cancer burden. Cervical cancer is a particular problem in Aboriginal communities within Australia and in many of our near neighbour countries, where prevention through screening is not currently feasible. Alan has demonstrated, through his work with The Cancer Council Australia and internationally with the International Union Against Cancer, a consistent interest in improving cancer control in the Australian Indigenous community, and has helped over the last few years to develop strategies whereby The Cancer Council can assist with cancer control policies for those countries within the region who seek assistance.
Alan’s emphasis on properly designed clinical trials is renowned. In his article describing the Australia New Zealand Breast Cancer Trials Group’s (ANZ BCTG) contributions to reducing breast cancer mortality John Forbes acknowledges Alan’s leadership in the ANZ BCTG and in the development of “evidence-based medicine” for management of breast cancer. Alan was a member of the group of researchers who formed the Ludwig Breast Cancer Study Group, based in Melbourne. This group evolved into the ANZ BCTG, heralding what Forbes describes as a “new era of clinical trials”. Alan was then, and has remained, one of the profession’s most vocal advocates for clinical trials.
While CEO of The Cancer Council, Alan and former President Ray Lowenthal initiated efforts to increase clinical trial participation (by professionals and patients) and lobbied for increased government funding for infrastructure support for independent trials groups. He has been instrumental in bringing all of the existing cancer cooperative groups together, through the Clinical Oncological Society of Australia (COSA) and The Cancer Council, in response to the Federal Government’s commitment to supporting clinical trials and the successful COSA enabling grant.
Sue Pendlebury discusses Alan’s career in the context of the resurgence of adjuvant radiotherapy for breast cancer. Pendlebury notes that the challenge in managing breast cancer – and the fundamental objective of multidisciplinary care – is to “optimally integrate” all treatment modalities. She acknowledges Alan’s leadership in supporting truly multidisciplinary clinics, developing guidelines and fostering discussion and collaboration.
Forbes also acknowledges Alan’s global leadership with respect to quality of life studies – high on the ANZ Group’s agenda from the beginning – and development of quality of life measurements “as the norm rather than an add-on for many trials”. Alan’s commitment to focusing on patients’ quality of life is also the subject of the final triptych of articles, by three of Australia’s leading oncologists, researchers and advocates for the improvement of cancer management and care: Ian Olver, Martin Tattersall and Martin Stockler.
While Olver details developments in antiemetic therapy regimens intended to reduce distressing side effects of chemotherapy for many cancer patients, Tattersall examines a series of published papers about cancer patients’ perceptions of the burden of chemotherapy. But both note the continuing resonance of a 1983 study by Coates et al that highlighted Alan’s commitment and drew others’ attention to the needs and perceptions of patients with respect to quality of life. As Tattersall notes, this and subsequent papers in the series co-authored by Alan, “illustrate [his] skills in measurement and analysis” and provide insight into Alan’s career-long focus on the needs and concerns of patients.
Martin Stockler also highlights Alan’s quality of life research and published articles that have “had enduring influences on how we think about cancer and manage it”. His article highlights three areas of practice in which Alan’s commitment to thoughtful and well-designed studies have produced counterintuitive conclusions that have shaped oncology practice. Key to each was the notion of incorporating patients’ attitudes and opinions into judgements about treatment, which has proved to be of great benefit to patients in terms of both their treatment outcomes and involvement in decision making.
In summary, this Forum lauds Alan’s major contributions to cancer research, particularly: the management and support of clinical trials; the treatment, care and support of people with cancer – both as a clinician and an advocate; public awareness and understanding of cancer; and enhancing Government funding and commitment to improving cancer control in this country. As Stockler concludes, it is Alan’s contribution to “thinking” as well as practice in oncology that will be his legacy.
We suspect there is more to come.