Clinical directors can sometimes appear like the uncrowned kings and queens of the NHS. Sat at a significant distance from the great majority of us – they can appear mysterious & unknowable, perhaps even operating in a different dimension to the rest of us.

And although these myths are not generally borne out in reality, as thinker & writer Edward De Bono said, sometimes ‘Perception is real even when it’s not reality.’ However, spending some time with our new Clinical Director, Ali Greystoke, should shift any misperceptions you have.

Image courtesy of the Bobby Robson Foundation

I’d like to start by asking whether medicine is a family affair?

No, I’m the black sheep of the family. I’m one of 6 and all the rest are either lawyers, like my dad, or in business. In fact, I initially wanted to be a vet but, unfortunately, I can’t stand seeing animals suffer.

So, how did you break the family trend & enter medicine?

Well, after putting the vet idea to bed, I decided I wanted to be a scientist, and the one good bit of advice my parents gave me when choosing my A levels was to tell me that if I became a doctor, I could always become a scientist afterwards, but if you become a scientist, it’s hard to become a doctor. So, I went at it that way round.

Where did the interest in science come from?

I’m very curious about why we are like we are, and I think genetics is all about that, you know, about individual differences. I think that’s why I find cancer so fascinating, because every person’s cancer is different. Every case of lung or breast cancer is different because it arises in your genetics with a different background.

Given your new role, how would you like to help shape the future of NEY GMS?

The number one thing to my mind is getting the genomic medicine service for cancer that I would want for my mum or my dad. Testing for everyone in the region that we would regard as, minimum standard. Ideally, even higher than the national test directory. The second part is improving the genomic literacy of the workforce and the public.

What were your first professional steps on the path to NEY GMS?

Well, I escaped London at 18 and went to medical school in Edinburgh. I also got married there, in the botanical gardens. In fact, I met my wife on the medical school open day! The first time I got into cancer was when I was on a Houseman rotation. I worked with a very nice consultant, and she said, “You’re only with us for two months, so you’re going to look after all the patients with small cell lung cancer.” At that age it’s great to have some responsibility and to help manage my own patients. And starting the treatment is great because you give the first treatment and patients generally feel better straight away. Unfortunately for small cell lung cancer, it doesn’t last. But as a junior doctor, you don’t see that. So that really got me into oncology. Then I did a year in Edinburgh, then moved to Newcastle for the first time, working in haematology with Graham Jackson at the old RVI.

When did you return to oncology?

I went down the Royal Marsden for a year in 2003 as a Senior, Senior House Officer, with a wonderful guy who was a real mentor for me, Martin Gore. I did 6 months with him, then an opportunity arose in their drug development unit, with a new consultant, Professor De Bono, who was looking for two new fellows to look after the patient’s own unit. And this was the first time I did drug development – in Portacabins looking after patients and trialling new drugs.

Image courtesy of the Bobby Robson Foundation

What was the appeal of this work?

You get to know the patients really well. You see them once a week, sometimes two or three times a week. But it’s also the curiosity of saying, “well, you know, we’ve got this new drug and it’s worked on this patient, but not on this patient. Can we work out what is special about this patient and their response to the drug?”

Was this where you worked until returning to Newcastle?

No. I got married and went to work in Palmerston North in New Zealand for a year on an extended honeymoon. Then I moved to Manchester and The Christie, where I did my PhD for 8 years. I was working on drug development, and my PhD was jointly funded by Cancer Research UK and Astra Zeneca. The work was looking at using blood tests to try to predict which patients were responding to treatment.

Was Genomics on your radar at this time?

Yes, there had been a couple of things like Herceptin and HER2-positive breast cancer, but not much else. So, some of the work we were doing was giving EFGR inhibitors to patients with lung cancer, and people were trying to work out why some patients responded, and others didn’t. We were also looking at biomarkers in blood tests – in particular with circulating tumour cells.

Could you already see that genomics was a transformative area of development?

Oh, yes, everyone was really interested in circulating tumour cells. That was the real area of excitement, but with circulating free DNA sort of coming on behind. ctDNA is now the leading technology because of technical difficulties in measuring circulating tumour cells and the small numbers that you get in most patients. I could already see that this was a really good way of predicting which patients could respond to treatment, but particularly how useful it was for monitoring.

What brought you back to Newcastle and the North East?

This is where serendipity plays a role, which is always good. Professor Plummer, at Newcastle, was advertising for a job, and my wife and I loved living in Newcastle more than Manchester, so I came up for the interview and got the job. That was in 2013 – so I’ve been here 10 years now. I don’t think many people know how beautiful the Northeast of England is. I always used to love when I was going up to Edinburgh from London, the coast up near Berwick is absolutely beautiful. I also used to be a rugby referee, and I used to go around all the little clubs in the area, so I got to see the region

You used to be a rugby Referee; did you also play?

I used to be a Prop Forward but then damaged my neck so moved to refereeing for 10 years. I even got into the England development squad. But then I was doing my exams and stuff like that, and then I had kids, and so it wasn’t doable anymore particularly with my wife working as well.

Apart from the beauty of the area, what other differences have experienced as part of your move?

The Christie and Marsden are wonderful cancer-only hospitals with big cancer charities associated with them. You can almost feel the cancer focus as you walk in the door. Up here, with some of the newer treatments we’re giving, we need to work more closely with other specialities and that’s easier to do in Newcastle, and I really enjoy that. So, obviously, we work closely with the lung team, but we also work very closely with cardiology, gastroenterology, and intensive care. Plus, the Trials Unit had a reputation for excellence, Professor Plummer and Hilary Calvert were here, and the Bobby Robson Foundation had set up a really nice unit based around patient care. And lots of people at the University and Trust were willing to support me – particularly in those first 4 or 5 years when I was getting established.

How was genomics impacting on your work at this time?

I was already doing lung cancer, and lung cancer already has a lot of links with genetics. Northern Genetics and Angie Silmon were here, and from the very beginning we started to talk about the genetic services, and we were very keen to get the clinicians talking to the scientists to make it work for everyone. So, we used to have a day every year where we’d discuss what’s working well, and what’s not working well. Then we got a grant from Bobby Robson Foundation to start sequencing patients with cancer coming to Newcastle so as to try and get a handle on their genetics and look where we can match them up to early clinical trials.

Image courtesy of the Bobby Robson Foundation

You’ve recently become Clinical Director for Cancer for North East & Yorkshire Genomic Medicine Service (NEY GMS), how did that come about?

I’ve been clinical lead for cancer at NEY Genomic Laboratory Hub (NEY GLH) over the last 5 years, but it’s now been brought together with the NEY Genomic Medicine Service Alliance (NEY GMSA) within the NEY GMS with one tier of leadership. Jackie Cook oversees Rare Disease and I’m in charge of Cancer. Then we’ve got Michael Wright as Medical Director. It’s early days, but I think it’s the right approach, particularly as we are a huge region and we have we have a lot of unique challenges such as high levels of socio-economic deprivation. But we’ve been very good at working together as a region, which is good.

What are you hoping for the foreseeable future?

The one thing I would really love to see is more headspace. We haven’t had any headspace for the last five years and I think it’s very important for people – particularly scientists or clinicians in our case – to have time to just to think about whatever role they’re in, and what they would like to do over the next six months or a year. You always feel like there’s another piece of work that you just have to do now, and you can’t think.

Although achieving that’s going to be challenging, because the demand for clinical work will carry on going up.

And finally, if you were to look 5 years to 10 years from now, what kind of developments do you think we’ll see from genomics?

It’ll be the monitoring and screening using DNA released from the cancer into the blood stream (so called ctDNA). I think is going to change the way we work. We’ve already got trials looking at the potential of cfDNA for screening a healthy population.

We haven’t seen the results of those yet, but we’ve seen ones for patients going to diagnostic centres when their clinicians are worried, they might have cancer, and it works really well in that setting, as you can be very quickly reassured.

Waiting for results from scans and biopsies if you are worried about cancer, is a huge issue. But you know, if you could say, “well, there’s no sign of tumour DNA in your blood now. And I’m going check it every three months to see.” that might help.