Below are written responses to questions posed to me by the China Medical Tribune, a Chinese medical publication similar to our ASCO Daily News.
1. Since tumors with high incidence in China have regional-distributed features, what advantages do you think are there in these local areas for clinical cancer research? Do you think more operable and small-scale clinical trials could make patients benefit earlier in China?
Variation in disease presentation and outcomes are experiments of nature that should be studied and from which we can learn. What can such observations tell us about causation of cancer and drivers of disease? Most likely there are environmental factors at play such as infectious diseases or nutritional factors that may lend themselves to cancer prevention studies or cancer screening for early detection of cancers when they are more successfully treated. There may also be germ-line mutations present in higher proportion within such populations that account for differential cancer incidence.
Looking forward, we anticipate that anatomically defined cancer categories, such as lung cancer, will be recognized as comprised of a myriad of separate entities with unique patterns of molecular drivers of malignant behavior. Small-scale studies of populations who are more precisely identified will allow more nimble trial design and more rapid progress against cancer
2. What collaborated projects between China and other countries have you learned about? Please give us a short introduction to them. What obstacles would be encountered when multicenter research is carried on, how to overcome? What are you willing to do for helping Chinese clinical doctors in their research?
We are learning that cancer causation, natural history and response to therapy differ across populations. On one hand, this may mean that the results of studies done in one part of the world may not be directly applicable to cancer patients elsewhere. However, given the likelihood that environmental risk factors are more often responsible for carcinogenesis than the inherited genome, as globalization leads to adoption of western life styles and cancer risks factors, we can anticipate that cancers themselves will globalize and become more similar.
One implication of this is that we need robust biobanks that can support clinical trials, allowing annotation of bio-specimens to clinical history and response to therapy, so that we can ascertain that the same cancer population was in fact studied.
3. Would you like to talk about your experiences in some specific clinical trials and what aspect do you think should be improved in future? What could Chinese researchers learn from foreign counterparts?
The most frustrating part of our current clinical trials design is the requirement for large numbers of clinical subjects, the resulting slow pace of trial completion and closure of studies for lack of adequate patient accrual. We are starting to look at new trial designs such as adaptive trials and we are beginning to look at what we can learn outside of clinical trials by harvesting knowledge from routine clinical care facilitated by our rapidly developing base of electronic medical records.
4. Would you like to talk about the theme of this annual meeting, “Strengthen cooperation, continue innovation”?
Cooperation and innovation are best served through collaboration. This requires agreement on objectives, values, and processes. The objectives include building an infrastructure of technical and human resources that support cancer prevention, treatment, and research. The values are doing so in an affordable, sustainable manner that can be brought to sufficient scale that all cancer patients benefit. The processes are defined by the cancer professional organizations such as CSCO and ASCO.
5. Would you kindly to introduce whole status of cancer in America? What specific regimens have been set up for cancer patients in your health care system, are there any specific welfare for them?
Over the last 20 years, the five-year survival of cancer patients in America has improved from 50% to 67%. There are two implications to this that to which I would like to draw attention as they are rapidly growing areas within oncology: Survivorship and Palliative Care. Long-term survivors face continuing emotional trauma and increased risk of health problems related to cancer risk and chronic disability caused by side effects of therapy from surgery, radiation, and chemotherapy. There are economic consequences to society from the loss of productive labor and costs of monitoring and treating the medical conditions. ASCO’s Survivorship Committee was formed two years ago in recognition of the urgent need to address these types of issues that are the product of our successful treatment of cancer.
Palliative Care is the other side of the coin. ,For those patients for whom we cannot yet cure, there is the inevitable reality of death. In the United States, our belief is that when the overwhelming probability of further medical treatment of a patient’s cancer will be futile, patients are best served by acknowledgement of that fact and shifting the focus of care to symptom management, alleviating psychological stress, and maximizing quality of life. ASCO has several projects in design or implementation as we begin to explore this very difficult area of cancer care.
6. As the President-Elect of ASCO, would you like to introduce the featured activities in your society? What kind of cooperation will be intended among societies? What are the distinguishing features of cooperation between oncology societies?
ASCO members contribute to our Society through active participation in over 20 standing committees supplemented by a range of Task Forces and Work Groups to deal with ad hoc projects, as well as participating in the editorial boards of the Journal of Clinical Oncology and the Journal of Oncology Practice. ASCO staff, of almost 300, supports the work of our volunteer members. The breadth and depth of activities in cancer research, education, and patient care is extraordinary, pushing the boundaries of emerging topics such as health information technology and precision medicine. One-third of our membership is from outside of the United States, representing over 100 countries across the globe.
Given this, ASCO has the ability to offer a wealth of knowledge and support for oncology societies based in other countries and geographic regions outside of the U.S., and the best way to bring that forth is through ASCO members who are also the leaders of their home countries' oncology societies. This means that ASCO international members need representation on the full range of ASCO committees, so that they understand what ASCO has to offer and its relevance to their situations. I am strongly supportive of having international ASCO members who hold leadership positions in their countries' oncology societies serve on ASCO committees besides the International Committee.
7. Are there collaborated projects between ASCO and CSCO? Will they collaborate in the future? What are the most effective and convenient patterns to realize the cooperation?
ASCO and CSCO interact in several ways, and there is a strong desire on my part to find ways to expand programs that are mutually beneficial to our societies. For a number of years, ASCO and CSCO have presented a Best of ASCO meeting in China, which is now larger than the Best of ASCO meetings in the United States! Of course, China is not only a consumer of research but also a producer of research; we understand that expansion of China’s clinical trials enterprise is a high priority for CSCO, and ASCO continues to support the Advanced Clinical Trials China Workshop. This year Dr. Richard Schilsky, our new ASCO Chief Medical Officer and past Chair of the Cancer and Leukemia Group B, will represent ASCO at ACT China. Research collaborations are further nurtured between Chinese and American investigators through ASCO’s International Development and Education Award, which creates mentee-mentor pairs among ASCO members, and ASCO’s Long-Term International Fellowship (LIFe) Program, which allows mentees to spend a year of fellowship with their mentor in the U.S. or Canada.
I believe that ASCO and CSCO should begin to explore opportunities to advance the understanding and treatment of cancer among Chinese populations, whether they reside in China or in the United States. The U.S. Chinese population continues to grow, especially among our states that are on the Pacific Rim. Yet, because in aggregate, Chinese-Americans comprise only 2% of the U.S. population, we have limited ability to study cancer among U.S. Chinese patients. At the same time, Chinese-American cancer patients can provide a window into what cancer in China will look like as Western lifestyles and their attendant cancer risk becomes more prevalent.
8. Please introduce some training programs on continuing education for doctors and clinical researchers. In your opinion, what's the efficient way of international society cooperation?
I think there are key roles for societies like CSCO and ASCO to play in the area of setting international standards for training and competencies, and in the area of adaptation in order to facilitate implementation in different countries. For example, the Recommendations for a Global Curriculum in Medical Oncology developed by ESMO and ASCO provide an outline of the knowledge and skills that medical oncology training should include. These Recommendations have in turn been consulted and adapted by national societies around the world, including, I believe, CSCO. Similarly, in terms of continuing medical education, there are numerous resources, such as ASCO’s ASCO University, and there is a role for societies like CSCO and ASCO to collaborate in making these resources available, translated if necessary, and adapted to a range of practice settings while maintaining essential practice standards.
9. More and more tumor therapeutic guidelines and consensus have been published by oncology societies, national health authorities, and cancer institutes, so how do you hope to convince the process on personalized and standardization therapy?
I see two central challenges to developing guidelines and these are establishing the evidence base that supports the guidelines and creating new guidelines rapidly enough to address the most pressing questions that face physicians and patients. The two are of course related. To be useful, guidelines need to be specific to a clinical situation, provide actionable recommendations, and lead to improved outcomes that are measurable. Relatively few of our current guidelines meet these qualities, but if they did, it would take little effort to convince physicians to use them. ASCO is re-engineering our guidelines development process so that our guidelines have these attributes and can be readily built into electronic health records.