Focused for Impact: Why We’re Starting with Localised Cancers

[00:00:00] Susannah de Jager: So we've spoken a lot about the breadth of potential application for Raman spectroscopy and SERS, but clearly you can't focus on everything. So what are you choosing to focus on and why?

[00:00:16] Cici Muldoon: We have decided to start with urology, so cancers of the urinary tract. This means bladder cancer, prostate cancer, and kidney cancer. This is partly because they are all close to the area where we gather our samples.

[00:00:31] Susannah de Jager: Makes sense.

[00:00:32] Cici Muldoon: But also because they are disease states where there is a real clinical need, and we see a very clear business case. So when we decide what we focus on, we look at where is there evidence of Raman and machine learning being used to identify this disease? Where is there furthermore evidence of Surface-enhanced Raman spectroscopy and machine learning being used to identify this disease in urine? Where is this of clinical or economic impact? Where is there is a disease state where this makes a difference?

[00:01:11] Susannah de Jager: Yep.

[00:01:12] Cici Muldoon: And then we look at disease states which should be widely tested for. So common diseases.

[00:01:18] Susannah de Jager: So you've got the kind of the efficacy where you know it's going to work, you've got the impact where you know there's a need for it.

[00:01:24] Cici Muldoon: Yes.

[00:01:24] Susannah de Jager: And then as you've already spoken about, you've got access that you can access samples.

[00:01:29] Cici Muldoon: Absolutely, and bladder, prostate and kidney cancer answer all these four areas very well. In the context of bladder cancer, it's the 80% of cystoscopies, which are unnecessary and which we can help reduce. In the case of prostate cancer the 80% of prostate biopsies, which we can help reduce.

Of course there are other disease states and other cancers in specific where there is a huge imperative. We are planning on looking those as well. We are planning to look at various of the women's health cancers. So looking at breast, ovarian, cervical cancer, we are plans to look at UTI where we can speciate bacteria in order to better prescribe antibiotics, but we have to follow a pipeline and we have to follow an order.

[00:02:21] Ben Turney: Urinary tract infections or UTIs are extremely common, particularly in women. About 50% of women get a urinary tract infection at some point, and as a proportion of those, around 10% to 20% get very severe infections, sometimes recurrent.

Current testing means that we need to send a sample off the laboratory. Often it takes around three days for the culture to happen, and for us to know which antibiotics are going to be most effective. A test like this would allow us to measure the patient's urine, at the bedside or in the clinic, and see immediately, hopefully, what bacteria is present at what concentration, and which antibiotic might be most appropriate.

[00:03:01] Susannah de Jager: You and I have spoken in particular about breast cancer and how existing diagnostics are not good for particular cohorts of people and how your testing in urine and the regionalisation that's possible within it would be really impactful. Can you illuminate a little bit more?

[00:03:20] Cici Muldoon: There is evidence that women of South Asian descent have denser breast tissue and mammography is less accurate for denser breast tissue. So this is a great example of a place where a model built with a South Asian population would better serve that population.

[00:03:38] Susannah de Jager: Amazing, and of course a biopsy can be really even more invasive and painful. So you are increasing the probability that anyone going to that step really needs it.

[00:03:47] Cici Muldoon: Yes.

[00:03:48] P.G Roy: So breast cancer unfortunately remains the most common cancer in women across the whole world and the way the figures are going, no matter where you are, if you're a woman you're at very high risk of breast cancer, and that's now one in seven people across the world will develop breast cancer irrespective of a genetic makeup.

Not all women will come forward for those screening mammograms because it's purely voluntary. It's not the most comfortable investigation to have, and there is obviously false positive rate as well. Which we know that a certain number of people will go through unnecessary investigations for what is it supposed to be benign pathology. But you don't know until you actually investigate that fully, which will create a lot of anxiety in patients, and of course the test is not the most comfortable test to have it.

So there's a combination of factors which makes it a case that, we need to find something which is simple to institute. Something that can read as a point of care. Then we do it in the in our comforts of our home, not having to take time off. Something which will give results quicker, more reliable, and which is reproducible of course.

[00:04:55] Susannah de Jager: So it makes a lot of sense that for your focus initially, you are looking at these areas and urology in particular. You spoke earlier about being with clinicians in the John Radcliffe and in other settings internationally. Urology, I presume the clinicians are very familiar with this, so is that part of the reason you chose it as well?

[00:05:16] Cici Muldoon: Yes, a third area that we are very interested in looking at is urinary tract infections. The World Health Organization has put antimicrobial resistance as one of the top six imperatives for the world to look at in terms of healthcare. It's a big problem. People taking wide spectrum antibiotics and they're being oversubscribed. So if you could have a test that can speciate the type of bacteria that is causing your UTI, there is a possibility that you can have a prescription to the right antibiotic on the spot as opposed to being prescribed a widespread antibiotic.

[00:05:53] Susannah de Jager: And previously that would've had to be a culture that would be sent away.

[00:05:56] Cici Muldoon: Indeed, normally it's a culture that goes away and there are some novel techniques out there coming out with faster tests, but nothing quite as fast as a sub 10-minute test.

[00:06:06] Ben Turney: Often when patients have an infection, we have to give them a course of antibiotics, for several days. If we don't know what bacteria is present in the urine, we have to make a best guess. We often overtreat patients with lots of antibiotics or we treat them with the wrong antibiotics because we don't know which one is going to work for that patient. That means patients often get two or three treatment courses of antibiotics over several weeks.

The problem with this is that more antibiotics that are in the community, the more resistance will develop to antibiotics, and we are already aware that globally there's a increasing incidence of resistance to antibiotics, and if we could be more targeted and more appropriate and judicious with our use of antibiotics, it would really help in terms of both maintaining the sensitivity to these antibiotics so that they're really valuable when we need them.

[00:06:54] Susannah de Jager: Obviously a test that can look at three areas is really useful from a clinician and from a patient perspective, but there's also benefit from a paying perspective. Can you tell us a bit more?

[00:07:05] Cici Muldoon: Yeah. you have to understand the incentives of not just the patient, which is the easiest one to understand, but also the payer and the physician, and if you think about the physician, if he can charge to three CPT codes with one test, that is to him, a benefit to him or her a benefit.

You have to think about compressing their workflows and incentivising them to use your technique, because essentially you could be really cynical and say, the urologist wants to perform as many cystoscopies as possible because that keeps them on the golf course. But in reality, if you can negate the need for that first appointment when they book you in because they've been, you know, the patient has been referred directly to cystoscopy from primary care or from urgent care, that actually is an incentive for the urologist to adopt and ultimately the payer, the health insurance company, needs to be incentivised as well and for them, this is the most obvious one because every cystoscopy is a cost to them and if they cannot do the cystoscopies that are not necessary then that's a cost saving.

[00:08:06] Ben Turney: Patients present and have lots of investigations of some of these quite invasive, such as cystoscopy. This has a time implication for the patients having to travel to and from the hospital, but also has a cost implication for healthcare as well. So cystoscopes obviously have a cost, and also staffing costs to run these clinics. A simple point of care test may be able to remove some of these costs by removing the need to do as many of these procedures in the clinic.

[00:08:35] Susannah de Jager: You say it sounds cynical, but to me that just sounds like really good common sense when you're trying to commercialise an idea. Too often you hear about beautiful academic ideas that either don't work outside of the lab or that nobody wants to adopt, and either of those are flawed. So you are answering, it can be taken out of the lab, but also that it's useful to all three people as you've just illuminated upon the physician, the patient, and the payer.

[00:09:01] Cici Muldoon: Indeed and this is probably the number one lesson I learned from VeriVin. We built a fantastic technology platform, great patented hardware, for a client that didn't want it. So market need, business case, is hugely important and it's also about knowing the steps to get there. You need to not just make assumptions along the way, but you have to make sure that you're seeing who's paying for it? Why does someone want it? Would they want to use it? Would they want to adopt it? We come back to the hospital, to the person in the hospital using a point of care test. Is it modular? Do they want to use it because they can test for lots of different things or are they gonna put it on a shelf?

[00:09:39] Susannah de Jager: No. So important, and I think that your point there is so valid about just experience that you've been an entrepreneur before. You've had a learning from that failure because you had this great product and somebody didn't want it, and you now get to take that on and make sure it's front and center of everything you're doing when you design your product. So clearly that's a huge benefit to you and your company.

[00:10:02] Cici Muldoon: Absolutely you have, there's many types of risks in this type of endeavor. There's scientific risk, there's regulatory risk, but the market risk is one that you can afford to get right very easily, and I think a lot of great technologies don't think that one through. They focus on the science. The science is fantastic and they make lots of assumptions about how they're gonna get to market and how long that's gonna take.

[00:10:26] Susannah de Jager: Yeah, it's not a research project, it's a business.

[00:10:28] Cici Muldoon: It is.

[00:10:29] Susannah de Jager: Wonderful, thanks Cici.