Jun 01, 2013
Watch an exclusive video of Dr. Swain delivering her Presidential Address at the 49th Meeting of the American Society of Clinical Oncology. The complete transcript is also included.
Thank you, Allen. Welcome everyone to the 49th Annual Meeting of the American Society of Clinical Oncology. I realize that many of you have traveled a long way to get here and I am delighted you can be a part of “Building Bridges to Conquer Cancer.”
For those of you who know me well, you know that I love movies. What may surprise you is that one of my favorites is The Replacements. It’s the story of a football team whose players have very different backgrounds—and how these unlikely players leverage those differences to create a winning team.
During one of the pivotal scenes, someone asks the coach—played by Gene Hackman—"What will it take for this team to win?" His answer was . . . “heart”. . . “You gotta have heart . . . miles and miles of heart.” I have to confess that I’ve seen this movie more than once. And the coach’s message resonates with me every time.
I can draw many parallels to what we, as oncologists, do every day. Like The Replacements, we are people of diverse backgrounds. We draw from different cultures and experiences. But we are all passionate about our work. We have a common goal of conquering cancer. I’m confident that through teamwork, and by sharing knowledge, we will connect the pathways that empower us to deliver the best outcomes for our patients.
This is an extraordinary time—especially in oncology. An explosion of new data comes weekly. The digital age is changing our world at a rapid pace, democratizing both information and education. There has never been more opportunity and there has never been a greater need to collaborate.
In particular, I want to highlight three things. They are: 1) the possibilities and promise of global health equity, 2) the need to strengthen future generations of leaders and practitioners, and 3) the vision for a rapid learning system in oncology. The solutions for all three have at their core the need for connection.
If recent events have taught us nothing else, it is that success is made possible by collective effort, by neighbor helping neighbor, and by learning from those who have gone before us. Nowhere is this truer than in oncology. The promise of science, the power of technology, and the strength of an increasingly global community can be leveraged to produce a world free from the fear of cancer.
One of the pleasures of the year as ASCO president is the ability to bring personal and professional passions and a sense of what really matters into focus for the work of our membership. This year’s meeting theme, “Building Bridges to Conquer Cancer,” reflects my particular interest in outreach to partners and possibilities that lie beyond the work of our daily practices.
What about those bridges? Do we have the capability to build them? Can we strengthen those already in place? Any engineer will tell you the strongest bridge has solid support, high-quality materials, and a good design. ASCO is fortunate to have all three.
To be specific, ASCO’s great support comes from a membership of more than 33,000 professionals in every sector of our field. International membership has surpassed 10,000, and we now have ASCO members in more than 100 countries. Our reach and our ability have never been greater.
ASCO’s materials . . . education, scientific publications, guidelines—and many more high-quality programs—come from dedicated committees, boards, and task forces. I take great pride in the work produced by the ASCO volunteers I’ve worked with this year. Special thanks go to Dr. Doug Yee and Dr. Antoinette Tan, who have prepared an outstanding meeting. A record-breaking 5,306 abstracts were submitted this year, and nearly 2700 faculty members will present cutting-edge science and education programs over the next few days.
Of course, the strongest support and finest quality materials need good design. This is the ASCO mission: to conquer cancer through research, education, prevention, and delivery of high-quality care. ASCO is fortunate to have talented leadership for the more than 143 committees, advisory groups, and task forces whose efforts are aimed at achieving that mission. ASCO volunteers have set a high bar indeed. This year alone, 1,600 volunteers have worked to advance our mission—and I thank each and every one of you for all that you do.
Clearly there is no shortage of challenges deserving our attention. The three issues I mentioned earlier—advancing global health equity, mentoring the next generation of leaders, and the need for a rapid learning system—belong squarely on our personal and professional radar screens.
Before I speak to these, let me briefly review information we know all too well.
Global health equity
Cancer is a global crisis, and we must respond as a global community. It is a leading cause of death today—far more than HIV, TB, and malaria combined. And it is poised to become an even greater crisis if current trends continue. More than 7.6 million people will die from cancer around the world this year—and by 2030, that number will surpass 12 million.
Progress against cancer has been strong in some parts of the world, but there remain daunting challenges in health equity for low and middle-income countries. It is for this reason I highlight the critical need to advance global health equity. To achieve a world free from the fear of cancer, we must address serious gaps in access to care and screening. Cancer’s global threat requires a comprehensive, coordinated response like never before.
As illustrated here [Slide 14], a key predictor of whether or not an adult will survive cancer is income. That is a tragedy. This outcome gap is largely a result of differences in access to care. If current trends continue, we can expect far more suffering and premature death from cancer in the decades to come. We should be alarmed by the projections for cancer—and, we should act.
But income isn’t the only reason why there is an outcome gap for patients with cancer. A recent study shows there are global increases in smoking, heavy alcohol use, and poor diet. All are risk factors for cancer. Such discrepancies—and the inequities they represent—are disturbing. These are serious problems, but we can and must overcome them.
We can do it with people like Dr. Jose Scheliga, who turned his frustration into positive action. In a moving article entitled "Riches of Poverty," he talked about attending our annual meeting, about his excitement in learning of breakthrough therapies and new ideas. The difficulty was returning home to the reality of overwhelming need and few resources. I was inspired by his passion, by his belief that we can overcome barriers—and by his firm conviction that each of us can make a difference.
There are many causes for global health inequity, and I'm sure many of you face them. If we bridge our collective wisdom, leverage limited resources, and use the power of technology to share information, we can support physicians like Dr. Scheliga as they work to bring the best possible care to the people they serve.
For women, cancers of the breast and cervix are the most common causes of cancer deaths worldwide. Breast cancer is the most common cause in 99 countries, and cervical cancer the most common in 55 countries. There have been important advances in vaccines and screening for large populations. But we have been unable to make many of these methods available globally. And even if the cancer is diagnosed, there are wide gaps in the availability of affordable treatments. We will hear plenary presentations tomorrow that address these very important issues.
We can and must do better.
There is some good news. In 2011, an historic United Nations meeting placed cancer—for the first time—on the global health agenda. World leaders joined in signing a declaration that—among other things—calls for adoption of voluntary targets in the prevention and control of cancer. This new global monitoring framework was agreed upon in November 2012 with input from ASCO, UICC, the American Cancer Society, and other organizations. It targets many important metrics for cancer, including time-specific goals for reduction in overall mortality, decreased tobacco use, increased access to palliative care, and establishment of metrics for cervical cancer screening. On May 27th of this year, the UN World Health Assembly adopted these critical targets. We have a long way to go, but this is a very important beginning.
In response to the global cancer crisis, ASCO is doubling its commitment to international programs. Through an ambitious new program called ASCO International, the Society will increase support for existing programs and invest in new programs aimed at global cancer control. One important strategy will be to use the power of digital resources—such as virtual meetings and mentoring—to knit the world closer together. By engaging you, ASCO International can begin to address disparities through new or enhanced programs in education, research and innovation, and professional development.
Education initiatives include Best of ASCO® programs, started in Japan in 2005, where the best science from this meeting is shared. I have been fortunate to attend the Best of ASCO Mexico for the past several years and have seen these vibrant meetings first hand.
Investment in education and training will also extend to areas that can have tremendous impact on patient outcomes and quality of life. Palliative care is one example. You have told us how important these efforts are to your patients—and that they make a difference in day-to-day practice. Whether they happen in Ghana, Mexico, Honduras, Viet Nam, Ethiopia—or anywhere around the world—these programs individually and collectively contribute to closing the equities gap.
Supporting global clinical research—and the next generation of cancer investigators—is another important feature of ASCO International. The globalization of clinical trials is a reality. A strong foundation was established in 2009 with the first International Clinical Trials Workshop, held in Buenos Aires. Led by Dr. Eduardo Cazap, this program set a high standard and paved the way for investigator training that has been held in numerous countries.
ASCO also participated these past two years in the Chinese Advanced Clinical Trials Workshop— or ACT China—which was organized by the Chinese Society of Clinical Oncology and the Society for Translational Oncology. Additionally, ASCO and the Conquer Cancer Foundation will be making available new funding, called International Innovation Grants. These are specifically for research conducted in low- and middle-income countries.
The consequence of failing to reverse trend lines I shared with you earlier will fall, not on my shoulders, nor on those of my generation. It will fall most heavily on future generations. That is why investment in developing leaders is so critical. Now in its 12th year, the ASCO IDEA program will continue to foster new leaders from developing countries. Past program participants are now leading their national societies, creating new organizations, publishing research, and joining ASCO’s leadership ranks. It is through these efforts – linking global talent and initiatives—we will make progress in closing the equity divide.
No country is alone in facing health disparities. Forty eight million uninsured Americans—and those joining the Medicaid rolls—are all part of this picture. They await full implementation of the health reform law. Although the Supreme Court has, in large part upheld it, states have tremendous leeway in implementation. One area of concern is the wide variability in Medicaid programs. Some may be adequate. Others are clearly not.
An uncertain economy and the diversity of state approaches to health reform suggest we will continue to experience turbulence for some time. Issues around health benefits, cost of care, and physician payment reform will be high priorities for the foreseeable future.
On the plus side, a recent study showed that in states where Medicaid programs have been expanded to cover more individuals, there has been a reduction in overall mortality. While this is an encouraging sign for the general population, cancer specific outcomes for patients covered by Medicaid have been associated with no better outcomes than for those who are uninsured. Another outcome gap, which is unbelievable that it occurs in our country. We all have to be engaged, to shape ASCO’s international and national programs in a way that assures every patient gets the care they need.
To keep these issues front and center, ASCO has strengthened its focus on health disparities by transitioning the Health Disparities Advisory Group into a standing committee this year. Paul Farmer quoted Martin Luther King in his latest book: “Of all the forms of inequality: injustice in health care is the most shocking and inhumane.” Our organization will continuously strive to achieve justice for all of our patients with cancer throughout the world.
Many of you are familiar with the story of Henrietta Lacks, chronicled in a book by Rebecca Skloot. This story is at the heart of many of the issues faced today regarding health equity. Henrietta was a poor young African American woman who developed cervical cancer in 1951. The cells from her cancer were the first immortal human cells grown in culture. This now famous HeLa cell line has been used by thousands of researchers worldwide, contributing to more than 60,000 research papers. They were critical to development of the polio vaccine and to progress in cancer research. But HeLa cells were developed and used without consent from Henrietta Lacks.
In stark contrast to the many scientific contributions, this part of Henrietta’s story raised concerns about equity, informed consent, breach of privacy, and use of human tissue in research. Such issues have led to a focus on bioethics. This is especially relevant in today’s age of rapid dissemination and availability of genomic data. The dialogue has continued, most recently with publication of the HeLa genome. Concerned that data could disclose genetic traits of surviving family members, objections were raised, not only by descendants of Henrietta Lacks but also by scientists and bioethicists. The genomic data have now been pulled from public databases.
In a March 23 New York Times article, Dr. Francis Collins, Director of the NIH, commented, “This latest HeLa situation really shows us that our policy is lagging years and maybe decades behind the science. It’s time to catch up.” We all recognize the contribution of genetic information to scientific progress, but we must advocate for clear policies around data sharing and usage. I am sure that our patients would agree, but we need to include them in this discussion and work together on ways to realize the enormous potential for advances.
I want to next highlight one Innovative effort to bridge equity gaps. In the state of Delaware, a forward-looking screening program for colon cancer is now available to every citizen. Through the combined efforts of Delaware Governor Markell, the Delaware Cancer Consortium, Representative Carney, and Dr. Grubbs, the state was able to change the course of colon cancer in ways that not only improved the lives of its citizens, but also reduced cost.
Just to give you a few examples of the program’s success, screening rates in African Americans rose dramatically, from 48 to 74%. The number of African Americans presenting with regional and distant colorectal cancer was lowered by 39%. The disease was diagnosed in its earlier—and more curable—stage. The decline in mortality rates for African Americans was 42%, bringing it closer to that of whites. These are spectacular results! Not only did the program help patients avoid the pain and suffering associated with aggressive treatment of late stage illness, it saved millions of dollars in treatment costs.
This is the kind of result that can be achieved on a global basis with investment in screening, Prevention, and broad access to care.
Inspiring work is also coming out of India. Overcoming great odds and extremely limited resources, Dr. Shastri and his colleagues have successfully educated women with persistent efforts in that country about cervical cancer. Their single-minded attention to results that are cost-effective and feasible—like screening and prevention—have had tremendous impact on the goals we all share. Dr. Shastri’s results are outstanding, and he has become one of my heroes.
Supporting the next generation of leaders and practitioners
Of course, any progress in oncology could not have happened without the strong foundation built by many forward thinking leaders. This brings me to my second point, our need to attract, mentor, and support the next generation. This effort must stay on our radar screens. Are there enough of these young bright minds entering our pipeline today? As we consider the need to nurture future leaders,
I want to honor and take inspiration from several leaders we have lost this last year.
In October, the world bid farewell to Dr. John Durant, ASCO’s first Chief Executive Officer. The 22nd president of ASCO, John Durant was a giant in the field of oncology. His leadership, passion and affection for oncology are legendary and serve as a model for the rest of us.
In April, we lost another great, Dr. Emil “Tom” Frei. Known as the “father of combination chemotherapy,” he was a strong advocate for collaborative research. He was one of the founders of the first cooperative group in the United States, CALGB. Over the course of his career, he directed the training of more than 300 oncologists. Many of those he mentored are leaving their own mark on our field. Dr. Frei inspired a generation of oncologists to pursue the impossible. He will be greatly missed.
ASCO was extremely fortunate to have a woman with great vision as one of its founders. Before clinical cancer research was even a specialty, Dr. Jane Wright recognized the need for like-minded individuals to share their work and their ideas. Dr. Wright—who attended ASCO meetings until just last year—passed away in February. She was an inspiring mentor—and a woman before her time. She was an African American woman physician leader who was strong, committed, and forthright. She was one of the first to perform and publish clinical trials in humans with experimental cancer therapy. In 1957, her landmark paper in the New England Journal of Medicine described groundbreaking work, which tested chemotherapeutic agents on in vitro human tumor cells and correlated response to the clinical setting. The dedication, commitment and energy of Dr. Wright are memorialized in a Young Investigator Award.
In addition to these amazing individuals, I am fortunate to have been surrounded by people who enriched and influenced my professional life. At a time when few women chose medicine, Dr. Donald Jicha encouraged me to pursue that goal. Dr. Nash Collier, who was mentor to countless chemistry students, became a great friend and meant so much to me that I asked him to give me away at my wedding since my father had died years before. And I would not have become an academic oncologist without the support of Dr. Warren Ross who encouraged me to apply for a fellowship at the NCI—a decision that led to great opportunities.
Supporting the next generation of clinical cancer researchers is a top priority for the Conquer Cancer Foundation. It is top on my list, too. The Young Investigator and Career Development Awards programs have given opportunities to nearly 1,000 young investigators. They have received more than $68 million for cancer research. We can’t move to the future without them. We need the energy and curious minds—and so do our patients.
This has been money well spent. Ninety-eight percent of past award recipients are still involved in cancer research, and 95% are publishing in high-impact scientific journals. At a time when the economy is so volatile I don’t think you can show any other investment that has had such high returns!
However, as the economic environment has worsened, the Conquer Cancer Foundation has been faced with a growing number of applicants—which we welcome—but fewer donations to support the program. This is not unique to ASCO. With dwindling federal research dollars, it is more important than ever we provide a future for our young, aspiring researchers. I ask that each one of you right now look down at your badge. Do you have an orange ribbon that says Conquer Cancer Foundation Donor? If you don’t, please join me in supporting the foundation. If you do—thank you!
We will always need more leaders, and toward that end ASCO has continued its successful and popular Leadership Development Program. Of its 110 participants to date, many now participate in ASCO committees and other initiatives. Mentoring is an investment—it takes time—but it brings great joy and is truly one of the most IMPORTANT things we do.
Developing the next generation of leaders is important, but we are facing potential shortfalls in practicing oncologists. Will we be able to meet the projected increase in cancer cases? To better understand and monitor these trends, ASCO has established a Workforce Information System.
Here are some concerning trends: The number of oncologists 64 years of age or older is growing rapidly and outnumbers those who are under the age of 40. And we are not immune from disparities. Only 3% of oncology fellows are African American, and 8% are Hispanic. In order to address the serious disparities in which populations receive access to cancer care, we need to ensure a diverse professional workforce.
A picture is emerging, but it is not complete. Unless we understand who is in practice—and where—we cannot fully assess the impact of today’s environment or—importantly—how payment policy and other health reform efforts will impact our profession.
ASCO launched an effort last year to conduct the first US national census in oncology. Six hundred thirty-two practices responded—more than half of you are affiliated with a community hospital. A big surprise was that over three quarters are using an electronic health record—and nearly two-thirds an advanced system. Since about 65% of patients with cancer in the U.S. have Medicare, not surprisingly,
Medicare patients represent almost half of the typical practice’s patient population.
This was a first effort but we need your help to focus this picture. ASCO needs an accurate picture of the landscape to represent you. The ASCO census will be an annual event and we ask that each and every one of you participate. It is happening right now. Stop by the ASCO booth today. Be heard. And be counted!
Accelerated learning for a data-driven era
This gets me to my third issue. To create a world free from the fear of cancer, we must accelerate our knowledge about the disease, its biology, and its treatment. We must transform day-to-day practice from individual observations to collective insight. We need a rapid learning system in oncology.
ASCO is making this happen. We’re undertaking the most ambitious effort we have ever launched. It’s called CancerLinQ™! This effort was inspired by forward-looking ideas from the Institute of Medicine and Lynn Etheredge, who is credited with advancing the concept of rapid learning systems.
CancerLinQ is a rapid learning system that aims to use real-time information from every patient experience; both to guide day-to-day care and inform our clinical guidelines on a real-time basis. A rapid learning system will transform information that is now locked away in filing cabinets, patient records, lab reports, journals, disconnected electronic records, and inside our overloaded brains into real insight.
We need to be able to use the 97% of patient information that is currently lost.
Let me give you an example: You are seeing a new patient referred for a second opinion. You eventually determine she has a very rare type of tumor—adenoid cystic tumor of the breast—and it’s metastatic. What is best for her? Years ago—the younger generation may not remember this—I had to go to the NIH library stacks, research articles one by one, Xerox them, spend hours studying them, and then come up with a plan. Now, I can do an electronic search, instantly find relevant references, and even a summary on Wikipedia. I can see a reference that says, direct quote, “chemotherapy is considered on a case by case basis, as there are limited trial data on the positive effects of chemotherapy.”
This is a situation we face all the time. We have to treat the patient in front of us with very limited evidence. And, with genomic information, things will get even more complicated because we will have this available for every cancer. We can see a future in which genetic information will inform the care—for every patient we see. There are just too many variations for each question we ask and it is impossible to have randomized data for all the complex scenarios.
This is exactly the kind of problem CancerLinQ can solve. A physician can query CancerLinQ for the situation that I described to you a few minutes ago. She can learn there are 2,000 cases of this in the database. She can see not only how it was treated, but also the outcomes. By stitching together many stories, we can gain understanding of what worked and didn’t for thousands of patients—not just the 3% who may have been in a clinical trial.
Ultimately, understanding patient experiences can guide research questions, bridge the gaps in our knowledge, and provide critical information for situations in which randomized controlled trials are not feasible or possible.
Can it be done? Is it feasible in today’s practice environment? We are now able to answer a definitive “yes.”
We advanced CancerLinQ this year with development of a prototype that used breast cancer cases. The prototype contains de-identified data on more than 130,000 breast cancer patients. By using a combination of open source and other software, we have shown it's possible to obtain and aggregate information from different EHRs. We have incorporated guidelines that can inform decisions at the point of service. We have demonstrated that oncologists are willing and eager to share their clinical data.
CancerLinQ is early in its development, but these first efforts have generated tremendous excitement about its potential. It is inevitable that rapid learning systems will happen. We feel strongly that oncology physicians should lead this effort. ASCO has taken these bold first steps. We need to come together as a community to do this for our patients now—and for those in the future.
We can do it! How do we know we can do it? Because you have paved the way: with over a decade of investment in quality measurement. ASCO’s Quality Oncology Practice Initiative—or QOPI®—has shown that when physicians have greater insight into their practice, they enhance quality.
More than 260,000 charts have been submitted to QOPI since its inception in 2006. You ask, does participation in programs like QOPI make a difference? Again, the answer is “yes!” A recent article described clear improvement among QOPI participants on several measures, especially in those relating to new or emerging information. For example, testing for Kras mutations in colon cancer has shown a 44% improvement over time. My cancer institute has participated and is currently a certified QOPI program. The implementation has been invaluable to us to continuously assess and increase the quality of care.
I’ve discussed three challenges today: First, achieving equity of care and access to care across the globe; second, identifying and mentoring and guiding those who will be our future leaders; and three, creating a rapid learning system so we can access the best treatment data from all, and make it available to every practitioner. While each of these is a huge challenge, they are not the only ones that we face.
What about additional health care challenges that are beginning to demand our attention and our resource allocation?
Each year, the ASCO board devotes time to strategic issues to make sure we are ready for what lies ahead. We work every year to anticipate the needs of our patients and membership. Three on the list this year are the obesity epidemic, defining value in cancer care, and leveraging team-based care to address the workforce shortage.
First, obesity is a significant health risk, not only for cardiac disease and diabetes but also for cancer. Obesity is a major problem in this country and is rapidly becoming a global problem. We must stop this destructive trend.
Second, increasingly limited resources have highlighted the need for us as professionals to define value in cancer care. How should we balance efficacy, toxicity, cost, quality of life, and patient wishes within a value framework? It is our professional responsibility to help patients and physicians select treatment options that achieve a balance between these issues.
Lastly, every member of the oncology team is important and connected to each other. How can we partner to reach the millions of cancer patients and survivors that will depend on us in the coming years? We’ll never outlive our need for more bridges to new partners and new possibilities.
An honor to serve as President
It has been a true honor and joy to serve as president. My deepest gratitude goes to friends and colleagues, and fellow Board members, many of whom are here today. Thank you especially to my medical oncology colleagues at the Washington Cancer Institute, who graciously and unselfishly allowed me to take so much time to work on the many projects with ASCO. Thank you for your support, encouragement and friendship.
None of what ASCO represents today would exist without the tireless efforts of the incredible ASCO team that has been led so effectively and progressively by Dr. Allen Lichter. The Directors and staff of ASCO are incomparable, and I thank each and every one of them for what they contribute.
I would be remiss if I didn’t return to you. ASCO members have been in many ways my professional family for my career. You are the lifeblood of this organization. Our goal is to help you create your own new bridges so that we can build a world free from the fear of cancer. I particularly thank you in advance for your help in: addressing equity issues in our field, nurturing our future leaders, and building CancerLinQ.
And now a few words about the most important connection of all: family. I thank my father, who showed me the value of hard work, humility, and dedication, which he clearly showed in his many years of service in the military. I owe a great debt to my mother, who died six years ago, for encouraging and supporting my education—and for teaching me how to be a good cook!
Thanks to my sister, Elizabeth, who is here today and can be seen in this picture with her husband Tom and daughter Cecelia; she has been a lifelong friend and supporter.
I send heartfelt thanks to my husband, Steve, without whom I would not be standing here today. You are my true inspiration and best friend. I love you.
I have a few final thoughts about medicine as a career. Sometimes the reality of our day-to-day professional life and the frustration of not being able to do enough seem endless and overwhelming. That early career desire to do good—the eager anticipation of making a difference—the energy that comes from making a human connection with our patients—may sometimes fade away in the face of daily problems and seemingly insurmountable barriers.
But we do need to stay connected to those earliest motivations. I am personally honored and humbled that patients are willing to trust and share with me this most difficult journey in their lives. One great example for me is Val. She is a young woman I was privileged to care for more than 25 years ago. I stay connected with her to this day.
Last summer, I mentored a young high school student who, after spending time with me in clinic, Expressed surprise that patients confided their innermost feelings and concerns so openly. Those experiences and relationships are what enrich our lives and our profession. I continue to learn from each and every interaction and hope I always will.
I am excited to be part of this age of discovery, but robots and other technology—as wonderful and important as they are—can never replace the interactions that we as oncologists are so fortunate to have with our patients.
I love this picture that I just saw a couple of weeks ago of a blind doctor using his ear as a stethoscope to listen to a baby’s heart. How much more a symbol of “having heart” could we get? We are part of a wonderful profession!
Whether we’re talking about football and my favorite movie, The Replacements—or about this meeting’s theme of bridges—the core philosophy is the same: We can’t do this alone . . . but we can do it. We can build a world free from the fear of cancer.
I don’t minimize the challenges we face . . . but I also don’t underestimate our collective power to get the job done.
We are a team, we have a goal, and we want to get on the field. Though this certainly is not a game, we are playing to win against cancer. Thank you all for your commitment, enthusiasm, and humanity.
Enjoy the meeting.