Jul 15, 2020
The Global Oncology Young Investigator Award (YIA) from ASCO and Conquer Cancer, the ASCO Foundation, provides research funding to early-career investigators to encourage and promote quality research in global oncology and to develop the next generation of researchers to address global health needs. Global oncology refers to the application of the concepts of global health to cancer, and implies an approach to the practice of oncology that acknowledges the reality of limited resources in most parts of the world. Applications for the next grant cycle are now open. Learn more and begin your application.
Two recent recipients of the Global Oncology YIA discuss their supported projects and how the award is helping them improve cancer care in their home countries.
Taking the Groundshot to My Native Ground: Developing a New Model of Cancer Care Delivery in Nepal
By Bishal Gyawali, MD, PhD, 2020 Global Oncology YIA: Implementation Science
I have personally witnessed the vast gulf in cancer care and resources between high-income countries (HICs) and low-and-middle income countries (LMICs). I attended medical school in my native country of Nepal, furthered my oncology education in Japan, went back to work as a medical oncologist for 6 months in Nepal, and am now working as a clinical fellow in medical oncology in Canada. These experiences gave me an insight that addressing the global cancer burden would not require major technologic or drug advances, but simply the focus and ability to implement the things we already know to work. If most patients with cancer in Nepal were dying due to lack of access to curative cancer surgery, it wouldn’t make much sense for me to advocate for access to precision cancer therapies. I coined this concept of prioritization in global oncology as “the cancer groundshot,” which I published in The Lancet Oncology in 2018. However, I didn’t want to just propose the cancer groundshot as a philosophy—I wanted to take the concept to the ground, to actually get involved in doing the type of projects that the cancer groundshot advocates for. One low-hanging fruit in improving cancer care in an LMIC like Nepal, I had come to realize, was to treat patients at their local hospital. This sounds very simple, but it is vitally important.
Nepal is a country where 80% of the population lives in rural areas. This Himalayan country with a population of 33 million has fewer than 20 medical oncologists to treat cancer among the Nepalese people, in whom the incidence and mortality of cancer is increasing steadily. For a Nepalese patient with cancer, this disparity means that access to care is not as simple as going to the local hospital each week for chemotherapy. There are only two public cancer centers in Nepal that offer treatment: one in Kathmandu and the other in Bharatpur. In a country characterized by mountains and variable road conditions, those centers can be difficult to get to. Living expenses in Kathmandu are prohibitive, leaving some patients to travel more than 500 km to get 45 minutes of chemotherapy on a weekly basis. Some patients need to rent an apartment in Kathmandu to complete their chemotherapy or other cancer treatment; some stay in hotels or in the homes of relatives or friends. This is precious time spent away from their own family, or from work. Indeed, it has been my perception that such transportation, accommodation, and food expenses sometimes exceed the actual cost of treatment.
One of my patients was a young man from the far western part of Nepal. He needed chemotherapy every 2 weeks, and it would take him more than 36 hours to come from his home to Kathmandu to receive treatment. This disrupted his job, an additional burden on top of the cancer diagnosis and hassle of travel. The burden is even worse for women, who continue to take on the majority of childcare and household responsibilities (as they do in many countries around the world). Another patient, a woman from rural Nepal, stayed in Kathmandu with her relatives for more than 3 months to complete her chemotherapy. She had two little kids back home who needed her care, but she had to finish her treatment first and a weekly commute of that length was impossible.
The solution to this issue suddenly hit me when I became acquainted with the Canadian cancer care system, which utilizes the expertise of primary care doctors, trains them further in the basics of oncology care, and involves them in the cancer care delivery system as general practitioner oncologists. This has helped Canada deliver chemotherapy services in rural areas in coordination with centralized academic cancer centers. I thought a training program for primary care doctors, which builds their capacity to deliver basic cancer treatment in rural settings, would solve this important puzzle in Nepal as well. Having a similar system in Nepal, where the initial consult would be done at a big cancer center but the chemotherapy regimen would be delivered at a local hospital in continuous collaboration with oncologists in the cancer center, would definitely benefit patients and improve outcomes. A patient who has to deal with the physical, mental, and emotional burden of cancer would not have the extra burden (both time and expense) of travel and accommodation arrangements.
However, I didn’t have the resources to take any concrete steps towards addressing this problem. When I saw that ASCO and Conquer Cancer were offering a Global Oncology YIA specifically in implementation science, I knew I had to apply. I applied with a proposal to develop a curriculum and implement an education model focused on training primary care providers in low-income countries on the basics of chemotherapy, which will allow patients in rural settings to receive care closer to home. I was very excited when I received the news that my proposal was successful and I had been selected for the Global Oncology YIA.
The award will allow me to lay the groundwork for a new model of cancer care in Nepal. It will enable me to perform a needs assessment and collaborate with Nepalese doctors to develop a training curriculum in basic oncology care. The training will be delivered to primary care doctors who practice outside the two main cancer centers in Nepal, thus increasing the capacity of general practitioners throughout the country.
My collaborators and I obviously will not be able to complete the entire project within a year, but receiving the YIA will help us create a strong foundation to successfully launch the program. We have already received the ethics clearance and identified the local site principal investigator. Although the coronavirus pandemic and the accompanying travel restrictions have somewhat delayed our project, we remain motivated. Our ultimate goal is to make cancer care more accessible to patients, regardless of geography, both in Nepal and in countries like it around the world.
We thank ASCO and Conquer Cancer for supporting our project with the Global Oncology YIA. This small support is a giant motivation for early-career researchers like myself.
Dr. Gyawali is a clinical fellow in the Department of Oncology, a scientist in the Division of Cancer, Care and Epidemiology and an assistant professor in the Department of Public Health Sciences, Queen’s University, Canada. He is a member of the JCO Global Oncology editorial board. Follow him on Twitter @oncology_bg.
A Collaborative Effort for a Clear Need: Developing a First-of-its-Kind Hematopoietic Cell Transplantation Outcomes Registry
By Monica M. Rivera-Franco, MD, PhD, 2018 Global Oncology YIA
Although it has been 2 years, the excitement I felt on the afternoon when I received the email notifying me that I had won a Global Oncology YIA from ASCO and Conquer Cancer is still very present. After scrolling down and carefully reading the email, I realized that I had been given a once-in-a-lifetime opportunity. I had just been funded to perform a study that would otherwise be difficult to accomplish: to develop a cloud-based electronic application to investigate the feasibility of collecting and analyzing demographic, clinical, and outcome data on hematopoietic cell transplantation (HCT) recipients at four public Mexican centers. Naturally, my mentor was immediately notified along with the invited centers. It was gratifying to learn that many HCT physicians supported the need for a Mexican HCT outcomes registry, as the existing database managed by the National Transplant Center exclusively reports on solid organ transplantations, and past efforts made by the National Center for Blood Transfusion (CNTS*) to develop a registry have failed due to limited funding and available personnel to collect data at all centers.
As the aim of the study was to assess the feasibility of HCT data collection using an electronic platform at Mexican centers, four of the largest and most prestigious public hospitals participated (Fig. 1): the University Hospital in Nuevo Leon, the National Institute of Cancer (InCan*) in Mexico City, the Mexican Social Security Institute (IMSS*) in Puebla, and the National Institute of Medical Sciences and Nutrition “Salvador Zubiran” in Mexico City, which also functioned as the coordinating center. An electronic platform in Spanish (Fig. 2) was developed by a Mexican information technology enterprise to allow real-time data collection of different demographic, clinical, and outcomes data. Data managers were hired and trained on the fundamentals of HCT and the usage of the electronic platform. Visits took place every other month, completing a total of up to four 5-day visits per center. Data from January 2015 to December 2018 were retro- and prospectively collected during a 10-month period, using electronic and/or paper medical records and, if available, institutional databases.
The results were as follows: 473 HCT procedures were performed in 453 patients (mostly men, 53%); the University Hospital performed the highest number of HCT (39%), and 2017 was the year when most HCT were performed (27%). Autologous HCT recipients had the oldest median age (49 years) compared to allogeneic and haploidentical recipients (34 and 29 years, respectively). Multiple myeloma and acute leukemias were the most common diagnoses for autologous and for both allogeneic and haploidentical HCT, respectively. The median follow-up was 12 months. Neutropenic fever was observed in 60% of patients and toxicity to chemotherapy (grades 3 to 4) was documented in 17%. Median days of engraftment for both platelets and neutrophils were faster in autologous HCT (12 and 11 days, respectively) compared to allogeneic (13 and 14 days, respectively) and haploidentical HCT (18 and 16 days, respectively). Acute and chronic graft-versus-host disease occurred in 20% and 35% of allogeneic HCT and 25% and 36% of haploidentical HCT, respectively. The 2-year disease-free survival was 70% for autologous HCT, 61% for allogenic HCT, and 50% for haploidentical HCT. The 2-year overall survival was 89% for autologous HCT, 55% for allogeneic HCT, and 40% for haploidentical HCT. Disease relapse was the most frequent cause of death among all types of HCT.
In regard to the implementation of a data collection structure at four Mexican centers, the following was observed: all the participating centers provided their data without any restrictions and data managers were well-received and supported, which was very motivating. On the other hand, the main difficulties included limitations within the number of institutional computers to review the electronic medical records and extensive waiting times to obtain paper medical records from the archives; time differences within the data collection at each center were observed due to the varying availability of the collected HCT variables.
A manuscript detailing the results and experience from this study was published in the journal Bone Marrow Transplantation on May 16, 2020.
Finally, I would like to highlight that aside from funding (which is, of course, a key element to conduct any research protocol), this project would not have been feasible without the support of all the participants. Thus, I would like to extend my gratitude and acknowledgment, first of all, to my mentor, Dr. Eucario Leon; to all the physicians at the participating centers, including Dr. David Gomez, Dr. Cesar Gutierrez, Dr. Luis Valero, Dr. Brenda Acosta, Dr. Alejandro Limon, and Dr. Uendy Perez; and to Dr. Jaime de la Garza for his support as a Fellow of ASCO. May this be the first of many successful multicentric studies to come.
* The commonly used Spanish acronyms for these centers.
Dr. Rivera-Franco is a junior clinical researcher in the Hematopoietic Cell Transplantation (HCT) Program at the National Institute of Medical Sciences and Nutrition “Salvador Zubiran” in Mexico City. She is active in the Center for International Blood and Marrow Transplant Research as the primary contact and data manager at her center.