Few people are aware of the plight of head and neck cancer survivors due to irreversible damage to their salivary glands. Radiotherapy is one of the main treatment options to shrink tumours that arise in the mouth and throat. However, in more than 75 per cent of patients it also causes damage to their saliva-producing glands that can lead to chronic dry mouth.
Reduced production of saliva can make it difficult to speak, eat and digest food. It is a serious side effect of head and neck cancer treatment that can severely impair patients’ quality of life, as Dr Elaine Emmerson, RCUK/UKRI Innovation Fellow and Chancellor’s Fellow, knows all too well. Her father, who died in 2005 after being diagnosed with head and neck cancer, has been a major driving force behind her research.
“I was always interested in tissue repair and regeneration, but upon learning about the off-target damage of radiotherapy I took it upon myself to find out more about what was being done to negate or treat these effects,” she says. She found very little, so she decided to pursue this avenue of research. “It is not just a job; the work has personal meaning to me. It is very close to my heart.”
Engaging the public in science
As the Centre’s Academic Lead for Public Engagement, Dr Emmerson has increased awareness of the problems caused by loss of salivary function after radiotherapy and current research into ways to overcome them. “Most public engagement efforts still require the audience to have some interest in science,” she says. “However, this means we aren’t reaching a huge proportion of people who may not feel confident or interested in science. Art is a great way to show a little bit of science in a non-technical manner and bridge this gap.”
When Robin Morton, Science Communication Manager at the Centre for Regenerative Medicine, put her in touch with artist Emily Fong, she embraced the opportunity to work together. “Initially we didn’t know what form the project would take, it was a completely novel experience for both of us,” says Dr Emmerson.
Emily Fong studied Fine Art at the Queensland College of Art, Griffith University in Brisbane, Australia, and the Duncan of Jordanstone College of Art and Design in Dundee, Scotland. She has been exploring life and death, embodiment and emotion through drawing, painting, sculpture and writing. “My interest in observing life and living things naturally brought me to science,” she says.
When she first contacted the University of Edinburgh about potential residency opportunities she wasn’t quite sure what aspect of science she wanted to focus on. But, once Dr Emmerson introduced her to the research being carried out on the salivary gland, the focus quickly sharpened. They decided to map the journey of the gland from the patient to the lab.
Her residency in Dr Emmerson’s lab has been supported by The Throat Cancer Foundation, The Swallows Trust, ASCUS Art & Science, Surgeons’ Hall Museum, and healthcare professionals from NHS Lothian and Greater Glasgow and Clyde
Salivary gland regeneration after radiation injury
Dr Emmerson’s team at the Centre is developing a permanent solution to chronic dry mouth by regenerating salivary glands after radiotherapy. At present, there is no treatment for dry mouth. “Patients rely on oral rinses and mouth washes to keep the mouth lubricated or carry a bottle of water everywhere to alleviate the symptoms,” she explains.
Her team are working on two main strategies to regenerate salivary glands using stem cells, which are found in the organ and that function throughout life to replenish old or damaged cells. Following radiotherapy these stem cells aren’t able to kick-start regeneration. “We are looking for ways to reactivate the remaining ones with a drug or to remove these cells from patients before radiotherapy, and transplant them back once the treatment has finished,” Dr Emmerson says.
This idea of a body part taking on a whole new life immediately inspired Emily. “Seeing someone’s salivary gland in a container was just extraordinary,” she says. “To see this body part having its own experience in the lab aside from the person it belongs to, who is walking around without it, just raised so many questions in me.”
Emily started shadowing people in the lab, seeing what they did on a day-to-day basis and asking questions. “While Emily learnt a lot about what we were doing, we had to learn to communicate in an accessible way why we do certain things and what they mean,” says Dr Emmerson.
Although by her own admission science can be hard to access and pretty intimidating, Emily managed to find a ‘third language’ in between science and art, and feel at home: “The lab felt a bit like a studio, everything is very organised and they are both places for exploration.”
For student Ella Mercer, who is studying a Wellcome Trust four-year PhD programme in Tissue Repair in Dr Emmerson’s lab, working with an artist has been a unique experience. “I didn’t just learn to talk differently, but to think differently and see things from a different perspective,” she says.
Video: VIDEO – the art of science
Innovative Edinburgh scientist Dr Elaine Emmerson gave a talented artist unlimited access to her head and neck cancer research, and the resulting illustrations capture the treatment development journey in an engaging and enlightening way. For two years, Emily Fong has been working as an Artist in Residence to illustrate the research carried out in Dr Elaine Emmerson’s lab at the University’s Centre for Regenerative Medicine. Her drawings document the journey of head and neck cancer patients and provide a behind-the-scenes look at vital research to restore salivary gland function following radiotherapy. Read more: https://www.ed.ac.uk/impact/research/future-health-and-care/the-art-of-science
Towards life-changing therapies
Dr Emmerson’s work has shown that nerves surrounding the salivary gland produce signals that activate stem cells to make saliva-producing cells. Unfortunately, drugs that mimic these signals have an effect on the whole body and affect other organs such as sweat glands, the gut and the heart. Unpleasant side effects such as excessive sweating, diarrhoea and bradycardia make patients reluctant to take these medications.
To overcome this problem, Dr Emmerson is collaborating with the lab of Dr Asier Unciti-Broceta at the MRC Institute of Genetics and Molecular Medicine (IGMM). “By structurally altering a drug so its activation can be triggered at the desired site of action we can avoid off-target effects,” she explains.
Her team is currently testing the technology with various compounds that can stimulate salivary gland stem cells and is planning to examine the effects in mice in the next six to twelve months.
They have also shown that fluorescently labelled salivary gland stem cells from genetically modified mice can be isolated and grown in the laboratory for a couple of months. By working with salivary gland biopsy samples from patients they aim to replicate these findings. “We are in the process of identifying markers of these cells in live human tissue so we can show that we can grow them long term and engraft them initially into a mouse model and into patients further down the line,” explains Dr Emmerson, who is a member of the University’s Animal Welfare and Ethical Review Board.
Beyond the lab
To document how salivary gland biopsies end up in the lab, Emily reached out to Dr Emmerson’s collaborators: surgeons, oncologists, pathologists and radiographers involved in the patient journey from consultation to diagnosis and treatment. Her drawings capture the settings of intense and vulnerable experiences for patients, such as the Neck Lump Clinic, and others that they are unaware of, such as the multidisciplinary team meetings in which the best course of treatment is discussed.
Until working with Emily, Ella, who is investigating how nerve cells interact with immune cells to promote salivary gland regeneration, had never considered communicating research through art instead of words. “It is so much more accessible,” she says. “Emily’s drawings are so relatable, even if you are not a patient, you can feel what it might be like to be in these spaces.”
Emily was able to speak with several patients and show them her work. “I witnessed how they connected with my drawings, they could see what they had gone through from another angle and see what research is going on to help them”. Dr Emmerson agrees that the project has given patients a voice and opened-up new dialogues with patients and between healthcare professionals. As a result of the project, she has been answering a lot of questions from patients about the therapies she is researching. “They keep telling us how life changing these treatments will be, which is really motivating.”
For patient Debi Kirk and partner Sandy MacLean, Emily’s work has added a new level of understanding to their own experience. The illustrations have enabled them to see the journey from the operating theatre to the pathology lab and on to healthcare professional treatment plan meetings. Emily’s drawings also gave Debi and Sandy an unexpected insight into Dr Emmerson’s scientific endeavours: “The final revelation for us, was the research going on in the Emmerson Lab… this has been observed and captured again by Emily through her drawings. It was very moving and inspiring to find out that, in parallel to patients going through surgery and life-saving cancer treatment, there is a whole team working on ways to restore salivary gland function post cancer treatment. This crucial research will ultimately have life-changing effects on patients left with a post-treatment legacy of dry mouths and throats.”
It is no surprise that Dr Emmerson says, “Working with Emily has been a fantastic experience so far.” Thanks to the MRC Public Engagement in Science Activities Seed Fund, and in partnership with ASCUS, a non-profit organisation committed to bridging the gap between art and science, they will continue to build on the project and co-create a series of workshops with patients.
Even though the coronavirus lockdowns at times meant lab-based research work and face-to-face meetings had to be put on pause, Dr Emmerson and Emily have kept up momentum digitally. They were invited to be speakers at the virtual International Head and Neck Cancer Conference held by The Swallows Head and Neck Cancer Support Charity in November 2020, and have attended The Swallows Head and Neck Cancer Support Group’s online meetings.
Dr Emmerson has held virtual meetings with all members of her team on a regular basis to discuss how to continue their projects and check on their general wellbeing. “We resumed our group meetings online in the first lockdown and had a couple of virtual happy hours, complete with a quiz to maintain some sort of normality,” she says.
As the routemap out of the pandemic progresses, she is thrilled to be gradually returning to lab-based work, with government guidelines in place. “I am very proud of the strength and resilience all group members showed throughout this period; we remain determined to continue developing our understanding and expertise of salivary gland regeneration,” she adds.
Exhibiting the illustrations
An exhibition of the sci-art project, G-Lands: An out-of-body experience, was due to appear as part of the 2020 Edinburgh Art Festival. Emily is hoping to exhibit her work and to create a long-term legacy in the form of a book that captures the whole process. “The experience has exceeded all my expectations,” she says. Highlighting the importance of projects that bring together art and science she adds: “Interdisciplinary projects like this one help people to think laterally and help lessen scepticism and fear of science.”