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An interview with Dr Toby Maher

Dr Toby Maher has worked at the Royal Brompton & Harefield NHS Trust for 5 years and has been part of the Interstitial Lung Disease consortium within the National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit (BRU) since 2009. 

Interstitial lung disease (ILD) refers to a group of lung diseases affecting the tissue and space around the air sacs of the lungs and includes alveolar epithelium, pulmonary capillary endothelium, basement membrane and perivascular tissues.

Dr Maher is the lead consultant for clinical trials into ILD at the BRU and his particular areas of expertise include idiopathic pulmonary fibrosis (IPF), hypersensitivity pneumonitis, sarcoidosis, Langerhan’s cell histiocytosis and Lymphangeiolyomyomatosis. 

Dr Toby Maher

In 2013 Dr Maher was awarded an NIHR Clinician Scientist Fellowship to look at improving clinical phenotyping of ILD with the ultimate aim of improving diagnosis and disease management.

We had a chat with him to discuss his research.

You trained as a doctor but now you work in research too. What attracted you to a career in research?

One of the challenges in medicine is that as you come to understand individual diseases you rapidly realise that there are a lot of things that we don’t know. These unknowns make it hard to communicate to patients about how a disease may affect them as individuals but it also makes it hard to make decisions about treatments. Added to this there are still many fatal diseases, such as a number of the ILDs, for which there are no effective treatments available. 

So research is an opportunity to try and answer those questions. There’s an excitement to discovering things that people hadn’t known before and being able to communicate that to other people to improve understanding of diseases. In turn I hope that answering these questions will lead to the development of new therapies

What research are you currently working on?

There are three areas to my research.

One is running clinical trials; I work with several pharmaceutical companies who have new drugs that they think might work for particular diseases, such as idiopathic pulmonary fibrosis. So I work with those companies to design clinical trials so they can conduct trials here at the NIHR Respiratory Biomedical Research Unit at Royal Brompton.

At the other end of the spectrum, I do some laboratory research. I supervise research fellows who are doing scientific experiments with samples taken from individual patients. From these experiments we are trying to learn about what causes the development of ILD and pulmonary fibrosis. We are trying to discover what the initial mechanisms are which characterise the development of lung fibrosis. I hope that by better understanding this it will then be possible to come up with better treatments. 

The third element of my research is discovering biomarkers. Biomarkers are measurements that we can make in blood samples, breathe samples, or even things like CT scans or lung function tests which help us diagnose ILD or else which provide information about how the disease might behave in the future or how well it might or has responded to specific therapies. As part of this I’m currently working with a big group of patients all of whom are part of the PROFILE study, collecting samples for the Biobank and looking for particular measures to tell us more about their disease. 

How do you foresee this impacting on patient care?

The hope is that the basic science research leads to changes in our understanding of disease and helps us identify new drugs and biomarkers. In turn I hope that this will lead to better clinical trials and improved treatments. 

The clinical trials will lead to short term benefits for patients; in fact one trial that has just completed here at the Brompton (as well as other centres across the world) has led to the drug Nintedanib* being shown to be effective as a treatment for idiopathic pulmonary fibrosis. It is to be anticipated that Nintedanib will soon be available to prescribe to patients in clinic and so it is gratifying to know that the BRU and patients from the Brompton have contributed to such a tangible development which should benefit all patients with idiopathic pulmonary fibrosis.

The biomarker work will hopefully give us better tests that we can use in clinics in perhaps 5-10 years time. The basic science research is looking at long term benefit, and hopefully will provide results which in 10-15 years time will translate into new drugs and treatments.

Last year you were awarded an NIHR Clinical Scientist Fellowship – tell me a bit more about that? What does it involve? 

The award pays my salary for five years and allows me to focus much more of my day to day work on research. A new Consultant will be taking over a number of my existing clinical duties. I will therefore be able to focus on developing and expanding the research which I’ve just described. I will also now have the time to further develop my own research skills in bioinformatics which will then enable me to utilise novel computer based techniques for integrating the results of basic science experiments together with information on biomarkers together with individual patients outcomes.

And finally; where do you see ILD research heading in the future? More on the management of the disease or on treatment?

ILD research is at an exciting stage at the moment. For many years ILD has lagged behind other diseases in respiratory medicine for example COPD and asthma. We’ve only just started to see clinical trials delivering drugs which can now be used for treating patients in the clinic. Despite the recent trial successes we are still at a stage where we need to develop more effective and better tolerated therapies for a group of lung diseases which have a mortality rate akin to many cancers. 

So I think at the moment the focus is still very much on developing more and better treatments. But as we start to have treatments available the focus will naturally change to focus on how we integrate those treatments into patient lives, how we minimise side effects for drugs and how we go about helping patients live longer with the chronic disease, because ultimately we are not going to cure ILD. But, we will hopefully be able to help patients adapt to living with manageable but ever present respiratory symptoms. As the ILDs become treatable and life expectancy increases the nature of the research conducted in to these disorders will need to change – a process we have seen in many diseases, like HIV and cancer, which were once fatal but which now can generally be controlled with long term medication. 

* Published paper on Nintedanib available here 

July 2014

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