By Khalid El Bairi, MD
On a beautiful morning in early October 2022, I received a WhatsApp message from an enthusiastic young professor of pharmacy, Dr. Faisal Gulzar, who invited me to deliver presentations in a country very far from my home in Morocco—Pakistan! A country that I've never visited and that I mostly know about from listening to the radio during my childhood and watching nature documentaries on the gorgeous mountainous region of Fairy Meadows National Park. I thought it would be an opportunity to strengthen my vision to implement precision medicine and research in oncology in under-resourced settings and join my efforts to share my knowledge in the era of global oncology. Without hesitation, I said, "Yes!"
Program and Presentation Highlights
In December 2022, the Faculty of Pharmacy of the University of Lahore organized its International Summit of Health Professionals (ISHP) with the participation of several international speakers from countries such as Denmark, Morocco, and Azerbaijan, as well as professionals from different universities of Pakistan. Of note, Lahore is a city located in the province of Punjab, where it is the capital and the largest city of this region of Pakistan.
My pre-conference workshop covered an important topic for pharmacy students, "How to Appraise a Meta-analysis of Clinical Trials in Oncology." This lecture started with a global overview of evidence-based medicine in practice, followed by a summary of the steps of reviewing the content of a meta-analysis including quality assessment of systematic reviews, reading forest plots, heterogeneity and publication bias evaluation, and finally a summary of the importance of umbrella systematic reviews. This was a great opportunity to attract young pharmacists and students to the field of routine evidence-based practice for the treatment of patients with cancer.
The conference’s opening ceremony focused on how different stakeholders at the University of Lahore can improve the curriculum for young pharmacists trained in this institution and best prepare them to join the pharmaceutical industry and enhance research and development (R&D) in this region of Pakistan. Next was a rich program of seminars and keynote lectures on various topics relevant to pharmacy and health care.
My plenary conference presentation, "Implementing Precision Oncology Research in Under-Resourced Settings: Some Tips for Early-Career Scientists in Low- and Middle-Income Countries (LMICs)," discussed tips and ideas to effectively conduct clinical and translational research in environments with limited access to adequate materials and methods. This vision of addressing these barriers to innovation by focusing on realistic goals joins the aims of my 2022 article series published in ASCO Connection (available at connection.asco.org/blogs). During this conference, I discussed several affordable, relevant, and emerging cancer research topics that do not require significant funding, sophisticated techniques, or specialized staff. These topics are appropriate for settings with limited resources in LMICs such as Morocco and Pakistan and reflected our experience in the development of inexpensive prognostic biomarkers for ovarian cancer,1,2 and surrogate approaches for PD-L1 testing in triple-negative and HER2-positive breast cancer using tumor-infiltrating lymphocytes.3 Novel insights on how to study gut microbiota in cancer and its correlation with patient outcomes using what is available in resource-constrained laboratories were also discussed. Pakistan is remarkably rich in flora which provides an important source for herbal medicine and drug discovery. Therefore, linking predictive biomarkers and natural compounds to deliver precision therapeutic approaches was also highlighted as a promising research topic for Pakistani pharmacologists.4
Selected abstracts in the field of oncology encompassed various evolving topics such as the use of nanomaterials in tumor targeting and delivery. A group of authors investigated the preclinical efficacy of combination tactics using well-known anticancer drugs such as tamoxifen with other potential molecules including thymol and artesunate to overcome drug resistance. Drug delivery based on coming-of-age approaches was the focus of an important abstract that provided the rationale to develop thermoresponsive hydrogel systems. Indeed, this strategy is of high interest to better control drug release and limit toxicities of effective chemotherapeutics such as topotecan.5 Magnetically modulated drug delivery from nanostructured lipid carriers was the topic of another important abstract that demonstrated a prominent increase in drug release under magnetic field conditions, thus providing a biocompatible system with natural lipids to be used for drug release in the case of 5-FU adjuvant cancer treatments.
Clinical pharmacy practice had a place during this summit through a research abstract that shed light on dosing errors in total parenteral nutrition prescriptions and the important role a clinical pharmacist can play in the management of this issue. The authors of this real-world report showed that medical errors in total parenteral nutrition for cancer care can be prevented by involving clinical pharmacists, and limiting potential complications by correcting inappropriate prescribing, preparation, and administration of both micronutrients and macronutrients.
The genetic epidemiology of breast cancer was discussed, including polymorphisms of the estrogen receptor (ER) alpha and beta genes and the risk of developing breast cancer in the Pakistani population. Rs2228480 and rs3020314 variants were not found to be associated with sporadic breast cancer risk but were modulators of disease severity. Another study on breast cancer highlighted the factors associated with the delayed presentation of advanced breast cancer among women in the region of Punjab. The investigators identified important actionable factors, such as limited knowledge about breast cancer symptoms, socioeconomic status, and illiteracy, which all contribute to unfavorable survival outcomes.
A cross-sectional study that surveyed more than 700 Pakistani women demonstrated that they have limited knowledge of cervical cancer. In addition, the study findings reported major barriers to screening for cervical cancer, including cost of screening, male health workers’ attitudes, fear of diagnosis, and availability of facilities in hospitals. There is an urgent need for information campaigns on the importance of vaccination and screening programs. Cervical cancer burden remains high in many other similar parts of the world and is a serious concern in all LMICs.6
Making Valuable Connections
Remarkably, this whole event was successfully organized by young faculty members, early-career researchers, and students of this institution without the need for a third-party event organizer. This approach is highly anticipated to motivate the future generation of Pakistani leaders to acquire the required soft skills and actively participate in the development of professional medicine in their country—a goal I share and hope to help lead for the next generation of medical professionals in Morocco.
From this perspective, I had the privilege to meet Awais Raoof, the chair of the Board of Governors of the University of Lahore, to discuss his vision to implement effective education in Pakistan and to build universities in neglected settings outside his country. My second meeting was with Dr. Syed Nisar Hussain Shah, the dean of the Faculty of Pharmacy, and Dr. Muhammad Ashraf, the rector of the university, to share ideas and discuss how to achieve significant milestones in higher education. I offered a copy of my latest book, Ovarian Cancer Biomarkers: Mapping to Improve Outcomes, to the library of their institution, and we discussed possible collaboration and exchange to dynamically participate in the development of future Pakistani leaders in the field of research. I also had the occasion to meet Dr. Uzair Nagra, chair of the NAGRA Group, who demonstrated how the local pharmaceutical industry in collaboration with the University of Lahore creates jobs and alleviates access to medications in Pakistan.
In addition to the high number of early-career participants at the summit, which allowed a significant interaction between different disciplines, one other important thing attracted my attention. I was in a scientific committee to evaluate poster presentations for the best poster award and the presence of undergraduates presenting their work was noticeably remarkable. I admired their motivation and passion to defend their research. Involving undergraduates in research projects is unique in this setting and it's a brilliant strategy to attract more students to a career in research after their graduation.
This summit was also a great occasion to share some printed copies of our developed guidance paper, published in JCO Global Oncology, with young health care professionals at the University of Lahore to support their continuous training.7 The guide proposes some basic principles and tools to be used by young researchers in oncology from low-resource countries to enhance their knowledge and boost their careers.
The event enjoyably ended with a gala dinner where I discovered the particular food and dances of different regions of beautiful Pakistan. Undoubtedly, combining science and pleasure is always a good idea to strengthen our love for our daily practice in research and cancer care.
Snapshots from Dr. El Bairi's visit to Pakistan to participate in the International Summit of Health Professionals at the University of Lahore.
Is Pakistan a Good Place for Foreign Researchers?
Before my trip, I realized that I had internalized a number of stereotypes about Pakistan, mostly from the Western press. I hope to break down some of the misconceptions one might have when thinking about Pakistan.
First, Pakistani hospitality is supreme! Upon my arrival at the airport in Lahore, I was greeted with flower packets—an amazing gesture that made me feel like I was at a party. The wonderful people I met during my week-long stay made me feel like I was at home. I felt safe. A simple greeting of "As-Salaam-Alaikum" (“peace be upon you") would turn a stern face into a smiling one. I was surprised when several young students approached me to take a selfie and share their photos on social media. Their energy to connect with people from all over the globe is just incredible. The fact that so many young students and researchers speak English made my experience in Pakistan more enjoyable, as we were able to communicate and exchange oncology research issues. I had a misconception that Pakistan is a country of extreme gender division, but I met many women doctors, pharmacists, teachers, and scientists.
If you are interested in exploring Pakistan, or if you are fortunate to be invited for a professional conference as I was, my advice is to do your research, and then go see it yourself. This wonderful trip took 10,000 miles and two days of flying, and despite the time and distance, I still believe that Pakistan merits a visit. I don't regret taking this journey in my career because I believe that every oncologist and cancer researcher should be a citizen of the world to promote the noble aspects of our profession. That is why, from now on, I chose to travel every time young cancer researchers ask to learn from me, and so that I can learn from others.
Dr. El Bairi is a research associate in the Department of Medical Oncology at Mohammed VI University Hospital, in Oujda, Morocco, and he is preparing for a career in medical oncology. He is a member of the ASCO Trainee & Early Career Advisory Group for the 2022-2023 term. The contents of this paper reflect the author's perspective and not that of his institution of affiliation or of the University of Lahore. Follow Dr. El Bairi on Twitter @elbairikhalid19. Disclosure.
- El Bairi K, Al Jarroudi O, Zaimi A, et al. 52P Affordable cancer research for under-resourced settings to implement precision medicine: The tale of the Moroccan OVANORDEST-1 study. Ann Oncol. 2022;33 (suppl 8):S1399.
- El Bairi K, Al Jarroudi O, Afqir S. Inexpensive Systemic Inflammatory Biomarkers in Ovarian Cancer: An Umbrella Systematic Review of 17 Prognostic Meta-Analyses. Front Oncol. 2021;11:694821.
- El Bairi K, Haynes HR, Blackley E, et al. The tale of TILs in breast cancer: A report from The International Immuno-Oncology Biomarker Working Group. NPJ Breast Cancer. 2021;7:150.
- El Bairi K, Atanasov AG, Amrani M, et al. The arrival of predictive biomarkers for monitoring therapy response to natural compounds in cancer drug discovery. Biomed Pharmacother. 2019;109:2492-8.
- Xing R, Mustapha O, Ali T, et al. Development, Characterization, and Evaluation of SLN-Loaded Thermoresponsive Hydrogel System of Topotecan as Biological Macromolecule for Colorectal Delivery. Biomed Res Int. 2021;2021:9968602.
- El Bairi K. Ovarian Cancer Biomarkers: Mapping to Improve Outcomes. Springer Singapore, 2021.
- El Bairi K, Al Jarroudi O, Afqir S. Practical Tools and Guidelines for Young Oncologists From Resource-Limited Settings to Publish Excellence and Advance Their Career. JCO Glob Oncol. 2021;7:1668-81.