“International” Outreach Is in the Eye of the Beholder

“International” Outreach Is in the Eye of the Beholder

Don S. Dizon, MD, FACP

@drdonsdizon
Nov 09, 2015

Originally published in "Discussions with Don S. Dizon" on The Oncologist

One of the many things I appreciate about the MGH Cancer Center is the opportunity to interface with so many leaders within our field—and no one comes to mind as a better mentor and leader than Bruce Chabner, who is not only the Editor-in-Chief of The Oncologist, but also a Professor of Medicine at Harvard Medical School and the Emeritus Director of Clinical Research for the MGH Cancer Center. In addition, Bruce has led efforts to establish a longitudinal collaboration with the Botswana oncology community. I asked him to share with me what motivated him to get involved in global oncology care.

“My motivation to become involved in community outreach and global oncology undoubtedly springs from my experience growing up in a rural town in Illinois, where my father practiced medicine,” Dr. Chabner told me. “He made valiant efforts to keep up with the newest antibiotics and glucocorticoids, which revolutionized the practice of medicine in the post-war U.S.  His bible was the New England Journal of Medicine and the epicenter was Boston. I was privileged to come to Boston for medical school, and for the latter years of my career in oncology, but I have never forgotten the distance between our academic medical centers and the more remote parts of our cities, our states, and the world at large.”

Bruce cites his upbringing as the impetus to improve cancer care on a global scale. My interests are just as granular and stem from where I was born and raised, in the tiny South Pacific Island of Guam. While a part of the U.S., it is so remote that resources available in the continental U.S. are often not as easily accessed. I left home for college and ultimately stayed on the East Coast—mostly because of my ambition to pursue a career in academic medicine rather than private practice. While it meant I could not directly treat those living on my island, I have always tried to give back in other ways, whether by presenting at a conference while I was home or by being accessible for that second opinion for family or friends in need of medical advice. But, truthfully, I had not realized how resource-limited things were on Guam until my friend, Pauline*, got sick.

Pauline had grown up on Guam and was the partner of my childhood friend, Jessie. Pauline had been a lifelong smoker and in 2013, she developed a cough that prompted a work-up and ultimately revealed bilateral lung tumors and bone metastases, consistent with stage IV non-small cell lung cancer. Because of the gravity of the situation, they were sent to the Philippines for a multidisciplinary consultation,  where surgery was not recommended, and she was advised to begin chemotherapy.

After her diagnosis, Jessie reached out to me by email. “Pauline has lung cancer and they want to start chemotherapy. I don’t know what to do.”

I reached out to colleagues here at MGH for advice and with their guidance wrote back soon after. “Has she had genomic testing of her tumor?” Jessie responded soon after with a very short email: “What’s that?”

It turns out no one in Pauline’s clinical team had discussed genomic testing, let alone suggested it. They had not even mentioned the availability of targeted treatments in lung cancer. After our discussion, I told her to request the tumor testing for Pauline, which brought on another set of issues. Although her doctor in Manila had heard of it, the system to actually send out the test was not in place. The institution there had no idea where to send Pauline’s specimen and no idea how long it would take to get it back. Her insurance company (on Guam) had balked at the test itself—it was not considered standard of care and they had no idea how it would inform her treatment plan.

I was shocked to hear that it was not standard of care, and in the end, I helped craft a letter for Pauline to get her tumor tested, arguing that it would have therapeutic implications and may impact her overall prognosis. After much effort on their part, the insurance agreed they could proceed. However, as Jessie told me, “Our insurance company says it needs to be sent to Hawaii and that they expect us to cover half of the cost.”

Her insurance company approved the testing, but as it was a send-out, it took more than 4 months to get the results back. In the meantime, Pauline was getting combination chemotherapy—they could not afford to not do anything while this saga played out. When her results finally came back, Pauline was found to have an EGFR mutation, which meant she was indeed a candidate for an EGFR inhibitor. Chemotherapy was stopped and ultimately, she was started on an EGFR inhibitor.

The experience going through this with Pauline was eye-opening because it shows that being a part of the U.S. does not mean equal access to the best testing and medications for any one type of cancer. Resource-limited settings are indeed found within our borders, whether it be in economically deprived counties in any one state or in a territory located in the South Pacific. Ultimately, it has spurred me on to collaborate more closely with organizations involved in the outreach to communities on my island, like the Guam Cancer Care Alliance.

As oncologists, we should strive to make a difference in cancer care—locally, nationally, and globally. Bruce’s efforts demonstrate that it is possible to strive for better for countries beyond our hemisphere and I cannot stress how important I think this work is. But for those of us who are not involved in global outreach, sometimes the same kind of change can be done within our own cities and states, or in my case, by maintaining a connection to where I grew up. After all, you can take the boy off the island, but the island will always still in the heart of that boy.

*Names have been changed to protect the privacy of the individuals involved.

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