Jan 04, 2018
By Carson Rolleri, ASCO Communications
The quest for worldwide health equity is driven by scientific discoveries from every corner of the globe.
Globally, more people die of cancer than of tuberculosis, malaria, and HIV/AIDS combined.1 This burden is not shouldered solely by high-income countries (HICs) like the United States—60% of the world’s total new cancer cases are diagnosed in low- and middle-income countries (LMICs).2
“Cancer’s death toll is high worldwide, but the burden is tilted more toward these countries that lack resources and infrastructure, which include a shortage of health care professionals trained in research, a lack of funding, and a lack of mechanisms for conducting research,” said Abdul Rahman Jazieh, MD, MPH, current chair-elect of ASCO’s International Affairs Committee.
In this article, ASCO members from around the world—including clinicians, researchers, and Society leaders—share their insights into the unique challenges cancer presents to LMICs, how the discoveries of innovative global scientific and health services research in diverse practice settings are helping to advance the field, and inform how ASCO improves access to cancer care around the world.
Acknowledging the Reality of Limited Resources in Most Parts of the World
LMICs have the highest rates of stomach, liver, esophageal, and cervical cancer, and have a disproportionate burden of infection-related cancers.3 Although these cancer rates are also high in HICs, they are plateauing or decreasing for the most common cancers due to decreases in known risk factors, screening and early detection, and improved treatment.3
Effective cancer control in any setting requires a complex combination of prevention strategies, early detection, and therapeutic and supportive care. This is all made even more complex in LMICs, where limited resources require a careful allocation according to priority needs. And determining the most effective approaches in LMICs is a fertile area for innovative research.
Olufunmilayo I. Olopade, MD, FACP, FASCO, is a breast cancer researcher known globally for her work on genetics, particularly the BRCA1 and BRCA2 genes, and research to close the knowledge gap leading to disparities in cancer outcomes in the United States and abroad. At the 2017 ASCO Annual Meeting, she was honored with ASCO’s Humanitarian Award. She notes that while the majority of patients with cancer live in low-resource settings, cancer treatments are developed for use mostly in high-resource settings, and that patients should not die prematurely from cancer because they do not have access to affordable, lifesaving treatment.
“The disparities in low- and middle-resource countries aren’t there because people don’t show up,” said Dr. Olopade. “It’s because the systems fail them. And the systems of these countries are failing because everyone thinks that people who live in LMICs only get infectious diseases. People in these countries are getting cancer, and there aren’t many people or resources on the ground to treat them.”
While most new cancer cases are diagnosed in LMICs, and the overall burden of all disease is greatest in LMICs, these countries receive a disproportionately low amount of funding for health. The World Health Organization (WHO) reports that sub-Saharan Africa—with 11% of the world’s population and 25% of the global burden of disease—accounts for less than 1% of the world’s financial resources for health. In contrast, the Americas, with 14% of the world’s population and 10% of the global burden of disease, account for more than 50% of the global health expenditure.4
“We really have to accept the responsibility that health is a human right,” said Dr. Olopade. “And as a society of oncology, we cannot look for the most expensive way to treat cancer when the basic way of preventing cancer and treating it has not reached 90% of the world’s population.”
Defining Steps of Progress in Global Research and ASCO’s Role
The first step in addressing cancer’s global impact is to recognize that the disease affects people living in all countries, under all economic conditions. ASCO’s vision reflects this global reality, working to realize “a world where cancer is prevented or cured and every survivor is healthy.” The Society’s diverse membership is also indicative of the global reach of cancer—over 44,000 members working in more than 150 countries. Of the 30,000-plus professional attendees at the 2017 ASCO Annual Meeting, nearly 50% came from outside the United States.
To better understand and address the needs of its members outside the United States, ASCO formed its International Affairs Committee (IAC) in 1997, composed of members from around the world who advise ASCO on its international activities and policies and oversee its portfolio of international programs. These programs, collectively known as ASCO International, leverage ASCO’s network of members and partnerships in order to improve global cancer practice.
“ASCO is a global organization representing nations of every economic level,” said Dinesh Pendharkar, MD, PhD, chair of the International Affairs Committee. “Global oncology is the center of the IAC, and is a focus for many of ASCO’s programs. The committee is working to pull together all other stakeholders in the field to organize global oncology programs.”
In the 20 years since the IAC was formed, ASCO International has steadily grown. Most recently, in 2014, the ASCO Board of Directors appointed a Global Oncology Leadership Task Force to provide recommendations for further expanding ASCO’s international programs and contributions in global oncology. The task force submitted its final recommendations to the Board in 2016, and they were unanimously approved. The full report of its findings was published in the Journal of Global Oncology.
“Cancer has no borders,” said Gabriel N. Hortobagyi, MD, MACP, FASCO, chair of the task force. “What is a problem for us in [the United States] is a problem for everyone around the globe. While the United States is one of the richest countries dedicating lots of resources and energy to cancer research and improving cancer care, we still have a lot to learn from other parts of the world. A little bit of humility injected into our approach to global oncology will be enormously helpful to everyone.”
In its recommendations, the task force articulated an overall global oncology strategy for ASCO that is grounded in three supportive pillars: innovative global oncology research, quality improvement, and professional development. In recommending enhanced support for global oncology research, the task force noted the importance of equal collaboration across borders:
“[There are] opportunities for collaborative efforts around the world to develop optimal solutions to these challenges, which in all cases should be context-specific, taking into account the local environment, resources available, financial considerations, and other factors. ‘Global Oncology’ requires a paradigm shift, from a model of taking knowledge generated in a ‘developed’ location and disseminating it to a ‘less developed’ location, to a multipolar model where solutions are being generated and shared across multiple settings.”5
“We can’t think of ASCO’s role in global oncology as a form of foreign aid,” said Dr. Hortobagyi. “We should think of these efforts as an approach to continuously improve the quality and quantity of both cancer research and cancer care in different parts of the world, including the United States.”
Fueling Global Discoveries
One approach to combating cancer health disparities in LMICs is through investing in research efforts focused in these countries.
“There is a dire need to support research in all practices settings, enabling health care professionals to conduct research projects relevant to their settings and patient populations,” said Dr. Jazieh.
“We have to be in this together,” said Dr. Olopade. “We don’t know where the cures are going to come from. The looming global epidemic of cancer means that all of us in oncology have to come together to make sure anyone and everyone has a chance to survive cancer.”
Understanding the importance of research outside of HICs, the Conquer Cancer Foundation of ASCO established the International Innovation Grant (IIG) in 2013. IIGs are 1-year research grants of up to $20,000, awarded to a nonprofit organization or governmental agency in an LMIC, that fund projects designed to improve cancer care in local communities and that have the potential to be transferable to settings in other resource-constrained countries. Each grant is associated with a principal investigator who is an ASCO member affiliated with the grantee organization, and is a citizen or permanent resident of an LMIC. In the program’s first year, four grants were awarded to support novel research projects in Colombia, Myanmar, Nigeria, and Tanzania. (Read the full account of one IIG recipient’s experience.)
“These grants are very important for non-U.S. members based in LMICs,” said Dr. Hortobagyi. “There are very few resources dedicated to engaging in global oncology in their own countries to assess what is going well, what is missing, how they can improve the level of care, and how they can adapt clinical and translational research to their own environment.”
An inaugural recipient of the IIG, Armando Sardi, MD, FACS, applied for an IIG hoping to use the funds to improve cervical cancer service provision and health outcomes in Colombia using a model telehealth education intervention program. In Colombia, cervical cancer is the second highest cause of cancer mortality and cancer incidence among women.6
“We started making yearly medical mission trips to Cali, Colombia, in 2006 to perform all types of surgeries,” said Dr. Sardi. “And while we were helping a lot of people, we didn’t really make an impact to the system and didn’t know what happened to the patients afterwards.”
Hoping to make a bigger difference, and recognizing the socioeconomic burden of cancer, Dr. Sardi and colleagues formed the Fundación Para la Prevención y Tratamiento del Cáncer to design, develop, and implement a patient-centered high-quality replicable model throughout the continuum of cancer care. The foundation’s expansion is being supported by Susan G. Komen and the American Cancer Society.
“We recognized that the education of primary care physicians and nurses on cancer screenings during their medical training is minimal. If we were going to make a lasting impact, we had to improve their training, as these professionals are the front line of medical care,” he said.
Supported by the IIG, Fundación Para la Prevención y Tratamiento del Cáncer was able to start a monthly teleconference in Spanish to educate primary care physicians and nurses on cervical cancer screening, diagnosis, and treatment.
“The support of Conquer Cancer was essential for us to get where we are today,” Dr. Sardi said. “The program has expanded to other areas, including a monthly program in breast and cervical cancers, which have benefitted over 400 health care professionals.”
In 2015, the second year that IIGs were offered, Yanin Chávarri-Guerra, MD, applied. She hoped it could help fund a breast health educational program to increase breast cancer awareness among adolescents and their female relatives in Mexico through intergenerational learning. The program consisted of culturally adapted breast health education sessions given by medical doctors, educators, and a breast cancer survivor, and aimed to transform young girls into health promoters within their households and communities.
“In Mexico, as in other LMICs, obtaining funding is a huge challenge, and many researchers are often forced to abandon their innovative ideas,” said Dr. Chávarri-Guerra.
Her program was successful—over 96% of participants found the program acceptable and learned something about breast cancer.7 The research team is currently exploring the potential integration of the breast health education program into the educational curriculum of Mexican middle schools.
“Obtaining this grant was instrumental for the successful development and completion of our project,” said Dr. Chávarri-Guerra. “It helped me consolidate my research team, integrating a multidisciplinary group of people from various national and international institutions, and helped me obtain new skills to continue developing research in patients with cancer or at risk of cancer in limited-resource settings.”
Noting the substantial contributions of the IIGs, the Global Oncology Leadership Task Force recommended that ASCO and Conquer Cancer take the next step and support young investigators interested in global oncology research. In response, Conquer Cancer added a Global Oncology Young Investigator Award (YIA) to its portfolio of grants and awards for 2018. The Global Oncology YIAs will serve both as opportunities to tighten the links among ASCO’s U.S. and international membership and to glean insights that can impact care not only in low-resource settings, but in every setting.
The Global Oncology YIA provides research funding to early-career investigators to encourage and promote high-quality research in global oncology and to develop the next generation of researchers to address global health needs. The inaugural recipients of the Global Oncology YIA will be announced later this year.
“There are a number of U.S. members that are absolutely passionate about learning more about global oncology care and research, who began doing projects in LMICs before organizations like ASCO became involved in the effort,” said Dr. Hortobagyi. “By recognizing the importance of global oncology, ASCO and the Conquer Cancer Foundation will provide more of a formal approach to this as an accepted and legitimate area of research.”
Creating a Global Network of Learning
It is well recognized that mentoring is a critical success factor for any early-career investigator, regardless of location. Opportunities for mentorship are often limited in resource-constrained settings, due to the small numbers of senior specialists, time constraints and heavy patient loads, and other factors. In response, ASCO and Conquer Cancer are working to provide carefully designed mentorship opportunities that link members from around the world. And creating these connections is proven to work—at large, mentees in medical training mentorship programs report that their mentor had an important influence on personal development, career guidance, career choice, and research productivity, including publication and grant success.8
ASCO and Conquer Cancer started supporting international mentorship more than 15 years ago with the launch of the International Development and Education Award (IDEA), one of ASCO’s first international programs. IDEA connects young oncologists in LMICs with leading ASCO members in the United States and Canada, who serve as scientific mentors. The award includes a visit to the mentor’s institution in order to enhance the recipient’s skills. IDEA recipients are then expected to impart the knowledge they gained to their peers back home. Another grant offered by ASCO and Conquer Cancer, the Long-term International Fellowship (LIFe) advances the mentor-mentee collaboration by providing mentees with a 1-year fellowship opportunity with an ASCO mentor in the United States, Canada, or the European Union, developing transferrable skills to effect change in the recipient’s home institution. (Visit CONQUER.org to learn more about international grants and awards.)
With the success of the IDEA and LIFe programs in mind, the International Affairs Committee explored novel strategies to scale up the Society’s mentorship offerings and engage more of ASCO’s global membership. The result was a new ASCO International program, ASCO Virtual Mentors. Similar to IDEA, the program pairs early-career ASCO members with a mentor outside of their country or region. Unlike IDEA, travel is not a component of the program, and instead mentors and mentees communicate through email, phone, or video conferencing to help develop the mentee’s clinical and research interests and professional goals.
“ASCO is bringing mentor and mentee together so that they can support each other,” said Dr. Pendharkar. “Because of ASCO’s large membership base, [Virtual Mentors] has the potential to transform careers for oncologists in LMICs.”
Often, early-career oncologists in LMICs are interested in pursuing research, but are unsure of where to start and how to develop essential research skills. To address this need, ASCO International offers International Clinical Trial Workshops (ICTW). The workshop covers research ethics, clinical study methodologies, regulatory issues, and best practices in implementing clinical trials. The program has seen promising results—over 85% of respondents participating in the ICTW said that the program helped them to better understand research regulations. (Read the list of upcoming ASCO International meetings and courses.)
Disseminating Global Research
While the research conducted in one LMIC can be valuable to investigators in many other countries, few publications focus solely on effectively sharing these insights. ASCO’s Journal of Global Oncology (JGO) plays a critical role in disseminating the results of global research, focusing on cancer care, research, and care delivery issues unique to countries and settings with limited and constrained health care resources. Launched in 2015, JGO serves as an example of ASCO’s commitment to quality care in LMICs.
“A journal that aims to be the voice of global oncology has to attract, review, and publish work relating not only to differences in cancer biology resulting from risk factors, pathogenesis, and pharmacology, but also disparities arising from social, cultural, economic, and political resource-constraining issues,” said JGO editor in chief Gilberto de Lima Lopes Jr., MD, MBA, FAMS. “JGO has become the Society’s vehicle for many of our international initiatives, such as the Global Oncology Leadership Task Force and our resource-stratified guidelines.”
ASCO has also expanded channels for disseminating global oncology research at its Annual Meeting. At the 2017 ASCO Annual Meeting, four education sessions explored disparities in cancer care in LMICs and their approaches to care as part of a new Global Health Track. Sessions covered a variety of topics concerning the state of global cancer care equity, including presentations on how to create globally accessible academic paths, strengthening prevention and early detection of cancer, lung cancer in LMICs, and the role that organizations play in partnerships that affect implementing quality cancer care around the world.
The Road Ahead
While confronting cancer’s global impact presents an ambitious road ahead for oncology professionals from LMICs and HICs alike, Dr. Olopade emphasized the importance of working together everywhere and anywhere that there is a patient with cancer.
“ASCO does not only belong to the United States,” said Dr. Olopade. “It’s a global community working to serve all of its members. And we need to continue to use this as a call to action for helping patients with cancer around the globe.”
- American Cancer Society. Global Cancer Facts & Figures. 3rd ed. Atlanta: American Cancer Society; 2015.
- International Agency for Research on Cancer. World Cancer Report 2014. www.who.int/cancer/publications/WRC_2014/en/. Accessed Oct 6, 2017.
- Torre LA, Siegel RL, Ward EM, et al. Cancer Epidemiol Biomarkers Prev. 2012;25:16-27.
- Anyangwe SC, Mtonga C. Int J Environ Res Public Health. 2007;4:93-100.
- International Agency for Research on Cancer. GLOBOCAN 2012: Estimated Cancer Incidence, Morality and Prevalence Worldwide in 2012. globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed Oct 26, 2017.
- Soto-Perez-de-Celis E, Smith DD, Rojo-Castillo MP, et al. Oncologist. 2017;22:1249-56.
- Sambunjak D, Straus SE, Marusić A. JAMA. 2006;296:1103-15.