How automating flow cytometry is revolutionising cancer diagnosis and treatment

As the incidence of cancer rises around the world, the demand for faster, more precise diagnoses is also on the rise. This demand will only intensify over time, as the worldwide incidence of cancer is expected to rise 55% between 2022 and 2045, from approximately 20 million cancer cases in 2022 to 32.6 million cases in 2045, according to the World Health Organization’s International Agency for Research on Cancer.

This indicates a significant increase in cancer incidence worldwide over the next two decades.¹ The American Cancer Society anticipated that, in 2024 alone, the United States could surpass 2 million new cancer diagnoses for the first time in history, driven by an increase in diagnoses of six of the 10 most common tumour types: breast, prostate, endometrial, pancreatic, kidney, and melanoma.²

Rapid advancements in technology are driving down cancer mortality rates and enabling early detection, offering hope for improved patient outcomes and increased survival rates. Those advances include the detection of tumour biomarkers that can help oncologists match patients to the treatments that are most likely to be effective, and the ability to monitor treatment success and guide future treatment paths.

To support physicians in treating cancer patients, oncology laboratories can benefit from adopting end-to-end automation of flow cytometry workflows. Rapid advances in automation are improving every step of the flow cytometry process, from sample preparation to data analysis. Laboratories that adopt and implement these tools will be able to process more patient samples – with increased accuracy – often in less time than before, speeding results to clinicians and expanding their capacity to serve more patients. In part, this is because automation can help reduce technical and biological variability in cell population frequencies, enabling researchers to obtain more consistent and reliable results.

Automating each step from sample prep through analysis

The Royal Marsden NHS Foundation Trust in London is a prime example of a treatment centre that has successfully implemented automated flow cytometry, demonstrating its value in cancer diagnosis and treatment. Between 2008 and 2023, its oncology immunophenotyping lab saw the number of requests for flow cytometry increase from 3,000 to 8,500 per year, with samples of different types, which can add to the challenge.

“Our biggest bottlenecks were in the set-up of samples,” said Alan Dunlop, head of immunophenotyping at the Royal Marsden NHS Foundation Trust. “We had individuals who were running three analysers, answering the phone, dealing with timers, and washing cells on a Friday evening. There were times it had gotten overwhelming.”

Starting in 2020, the hospital responded to the rapid increase in demand by automating several steps of its haemato-oncology flow cytometry sample-processing workflow.

The Royal Marsden NHS Foundation Trust is now automating its sample preparation set-up for flow cytometry processes through a system that allows labs to design protocols with easy-to-use and intuitive software. The equipment provides onboard washing and cell lysis capabilities, as well as continuous loading and unloading of samples. Once a sample is completed, it can be unloaded from the instrument and sent for analysis, while the instrument continues to prepare additional samples in the queue.

This streamlined process ensures that samples are available more promptly. Additionally, the equipment offers the capacity for as many as 12 cartridges of 12 panels each of dry reagents, and it employs automated tracking of samples, reagents, and antibodies to ease inventory management, in addition to producing a full audit trail. This has enabled the lab to test multiple samples against multiple parameters simultaneously, enhancing diagnostic capacities. Dry reagents also have certain advantages for this, including that they can simplify assay preparation, making it better for reproducibility and long-term storage.

Dunlop noted that he and the team of scientists can garner more information per testing tube with the use of compact flow cytometers that have 13-colour capability and use avalanche photodiode detectors that improve sensitivity, eventually resulting in better diagnostic accuracy. These cytometers can analyse large cell populations, with up to 50 million data points per file and 30,000 events per second, and they easily connect with other laboratory systems for a seamless data transfer.

Furthermore, the lab has implemented flow cytometry data analysis software that can process multicolour files of up to 3 million events in real time. The software allows for offline and remote analysis – a benefit that proved invaluable during COVID-19 shutdowns, when scientists often needed to work at home. And it has allowed The Royal Marsden NHS Foundation Trust to streamline its quality-control reporting. “The software made it so quick. It was really transformative,” Dunlop said.

Moving beyond diagnosis

By implementing increased automation, then, the example of The Royal Marsden NHS Foundation Trust shows the enhancement it provides the laboratory's capabilities, allowing for more efficient and accurate testing. Instead of just being able to diagnose cancer from the samples it receives, it can more easily detect response in samples from patients who are undergoing treatment, because scientists can add antigens to the flow cytometry workflow.

As a result, in fact, scientists have achieved increased sensitivity and more information in samples for multiple myeloma, B-cell acute lymphoblastic leukaemia, and chronic lymphocytic leukaemia. “Not only are we getting more [tests] out, but we’re getting better information,” Dunlop said.

“With older equipment, the lab had to often run several follow-on tubes. By expanding our panels using all 13 colours available to us, we have been able to add new informative antigens such as TRBC1, which has drastically reduced the number of follow-on panels needed,” Dunlop said. “We also see more consistent results using the automated systems, meaning that analysis and interpretation is easier. With increased sensitivity and automated analysis, labs can get standardised test results with less sample waste, leading to more efficient testing. This has eliminated the need for hundreds of tests per year, which has been an immediate saving for us. It was very useful.”

Dunlop also notes that the shift to automated flow cytometry has eliminated long queues of scientists waiting for their turn to use the instruments. Now, they can load the flow cytometers with a batch of samples, then log in from home to ensure everything is operating properly. This has not only eliminated the need for late nights at the lab, but it has also freed up scientists to spend more time analysing results and completing other high-value tasks.

The transition to end-to-end flow cytometry automation at The Royal Marsden NHS Foundation Trust demonstrates multiple advantages such technology brings both to scientists and the patients they serve. Leveraging new technology in flow cytometry offers oncology labs the opportunity to expand their capabilities beyond diagnosis, giving cancer patients and their physicians precise results throughout the treatment process – and the hope for better outcomes.