Patrick Loehrer, you’re here representing Indiana University, you’re an oncologist but you’re very interested in Africa. Why are you interested in Africa?
Our interest in Africa dates back about 20-25 years ago when our university got involved in a medical school partnership with Moore University. During that time the AIDS epidemic emerged and through this we developed a model called AMPATH which was the Academic Model for the Prevention and Treatment of HIV/AIDS. It was a unique international partnership that brought in many different academic institutions from North America and Europe together with this university.
And what’s special about cancer in Africa, though, that has brought it to your attention?
Well the unique aspect of cancer in Africa has to do with the causes. In the Western world the biggest cause of cancer is tobacco; in Africa the biggest causes are viruses. So you have HPV which is associated with the cervical cancer, hepatitis which is associated with hepatocellular carcinoma, Epstein-Barr virus which causes Burkitt’s lymphoma and nasal pharyngeal carcinoma. So it is actually a different kind of approach in which we can theoretically prevent cancer in Africa by using vaccines of various different natures.
A different kind of approach but there is an epidemic, so to speak, in Africa.
Absolutely. So the number one cause of death in sub-Saharan Africa is cervical cancer; in the United States 95% of women with cervical cancer are cured because they can be detected early. In Africa it is an epidemic and if we could get the HPV vaccine among the young adolescents in Africa we could prevent the number one cause of death in that country.
Why should Americans and clinicians and ordinary people in other parts of the richer world take an interest in Africa?
This is a global community and this is a moral imperative to help people with cancer wherever they are. This is a place where we can make a big impact with little expense and we should be doing this, it is just the right thing to do.
Now you’re talking here in Lyon about the Eldoret model, could you tell me about that?
Sure. So built on the platform of our experience with HIV/AIDS we developed a model in which the academic institutions work together with the local community. We built on that with oncology and what we’re now doing is a similar model in which we have a number of different academic institutions from North America and from Amsterdam working together with the Kenyans, building up the workforce, having the Kenyans find the solutions with us serving as consultants with this. This model of care leading the way, which is reinforced by education and research, pulls together a dynamic of a team that is now unique among the world, I think.
Now, there is conventionally a big problem with coming in with great ideas, well-meaning ideas, from the outside to a country and imposing them. How are you overcoming that problem?
In my talks one of the things that I emphasised in one of my final points is that Westerners who are going to the developing world need to listen before they listen and then finally you might give advice. So one of the founders of the programme there who spent a year in his first endeavour down in Eldoret said he was there for six months before he offered any kind of advice. It’s so tempting for us to go in to their world and offer advice right away but in reality they’ve been doing quite well without us for many, many years. It’s important for us to see what tools they have, how they’re working, how it’s functioning and then to help them, enlighten them in terms of some of the opportunities.
What’s going wrong with cancer care in African countries? You mentioned Kenya, of course, but we could talk about other countries.
At one end of the spectrum is the United States in terms of the amount of dollars it spends on healthcare, it supersedes any other country in the world. And the far end of the spectrum is in Kenya where they spend just a few dollars per capita on care, total healthcare. So that a cancer vaccine like the HPV vaccine may cost $40 which we think in our country is not worth much but that’s more than what the average per capita expense is in Kenya. So the governments of Kenya need to be involved in thinking about a cohesive public policy to help with cancer care. Our job, and I think what Nancy Brinker and the Pink Ribbon Red Ribbon initiative can do, is using leveraging between what we have done in HIV to show that we can induce anti-retrovirals and have an impact on HIV, similarly we need to be doing the same thing with breast cancer and cervical cancer. Once we’ve shown this I think we can then start attacking other cancers.
And what things do you need to do with breast cancer and cervical cancer?
First is public awareness and for the women in Kenya they really don’t see patients who are surviving cancer. So they believe that once you make that diagnosis it’s an instant death-threat. So we have to have care leading the way so we have to have, and what we have built in Eldoret, is a model in which we do have drugs and treatment and we’ve trained surgeons to treat patients with more advanced disease. Once this becomes knowledgeable, that actually there is a treatment, this then encourages women then to be screened. Four years ago there were basically no women in Eldoret that had been screened for cervical cancer, they didn’t have a word for the cervix, they just called it ‘down under’. We instituted a programme there of screening and we’re now screening over 8,000 women a year now for cervical cancer and we’re diagnosing it early. We’re doing a simple test with acetic acid where we paint the cervix, when we see abnormalities they can get instant treatment and we believe we’re going to have a long-term impact in this disease.
But you need to target your efforts very carefully because some procedures can be afforded and others can’t. You might create a crisis of expectations.
You’re right. So one of the other aspects of it is treatment for most cancer is surgery; if you can catch it early and you can get it resected, that’s the way of treating it. Again, up until a couple of years ago no-one had ever done an abdominal hysterectomy for cancer in this region in western Kenya. So Dr Barry Rosen from Toronto came down there, went through this procedure, taught the surgeons how to do this and now, just in the last two years they’ve done 80 such procedures here. So, again as you said, we can’t raise expectations but we have to face the problems that are there.
And the whole idea of finding cancers which are very advanced which if only they could have been found a little earlier, not necessarily by primary screening, how do you overcome that problem?
Even in the West the model is we have screening and prevention, we have treatment and we have palliative care, which in many Western countries evolved into hospice. So what we have developed is a model palliative care programme in which we have physicians from Indiana University who are working with staff, we are paying for an on-site person involved with palliative care, and again we have now treated thousands of people with palliative care and morphine. So this becomes an important part of our armamentarium, of, one, knowing when to treat, the other aspect is knowing when to give comfort measures.
Where do you put your big effort, though? Is it going to be in screening for cervical cancer which is very cost effective, or is it in trying to detect breast cancer at slightly earlier stages?
At this point in time it’s probably not going to be detecting breast cancer at slightly earlier stages. Cervical cancer we already have a strong momentum working on that. Breast cancer screening, again in the West, is centred around mammography and ultrasound; what we need to do, at least in Kenya right now, is at least educate the women to do self-examinations to try and find smaller masses so that we can do the surgery. We need to train the surgeons on how to do the proper kind of mastectomy. In the West we might do a lumpectomy and then give post-operative radiotherapy, there’s no radiotherapy available in Western Kenya so we have to go back to the treatment like we have done in the ‘70s and ‘80s and most women should get a modified radical mastectomy. Once we get radiation there, which we hope to in the next two years, then we can start looking at earlier kinds of treatments with less invasive procedures.
Is it a question purely of funding or are there issues about talking with governments and setting up infrastructure for doing what you need or a question of attitudes that are big obstacles?
The answer is yes to all of them.
But you can’t afford all of them.
You can’t afford so we have to pick slowly. So through some wonderful philanthropy, and particularly I have to give kudos to Pfizer who supported us and the Levenson Family Foundation, we’ve been able to get chemotherapy and treat those patients who have curable diseases. It’s important to develop a workforce so we have education programmes to train physicians and nurses. Ultimately, again, we need to have the government on board and this is going to take a longer range plan of public policy working with the government. They have written a cancer control plan that we’ve been involved with but ultimately it needs to be a country-wide initiative.
Let’s get down to nuts and bolts. You said radiotherapy isn’t necessarily all that affordable, there’s not a lot of it available. So what are the really cost effective modalities that could be introduced into low resource countries first? Some chemotherapy is quite cheap, isn’t it?
Some chemotherapy is quite inexpensive and other chemotherapy is quite expensive. If we take a look at a litany of some of the commonly used drugs in cancer there are some drugs that have been around since the 1950s and ‘60s that cure many different kinds of cancers. These are relatively inexpensive and can be found in the generic form so this is what we do. We have some monies that are available and we do get generic drugs to help pay for the patients’ medicines. Radiation therapy, the cost of therapy is up-front, is buying the equipment, and our hope is that we can again get a cobalt unit donated to us, hopefully two of them, and with them then I think it’s going to be very effective for us to be able to treat patients with radiation therapy. But ultimately we have to make some choices, we’ve got to decide who we should treat and who we shouldn’t treat. In the West we tend to treat, I would say 90% of the people we see with cancer in the United States are offered some sort of treatment or another. In Kenya we’re going to need to make some tougher choices and it’s probably going to be in patients who come in with advanced incurable disease, most of them probably shouldn’t be going on chemotherapy they should be going to palliative care.
How optimistic are you, as you look at Africa, that things will improve and can improve?
Oh, I’m very optimistic. I am very optimistic. We know what we’ve done in the West and I’m old enough to remember the tragedies of early therapies in the ‘50s and ‘60s with people with cancer and I’ve seen a dramatic change in how we effect care. In Kenya I’m already seeing engaged and enthusiastic clinicians and nurses who get the message, who understand they can make a difference and because they know they can make a difference and they can see past this, we’re going to make progress, I have no doubt in this. I’ve also been very comforted by seeing many of the different industries, many of the different pharmaceutical agencies are very interested in sub-Saharan Africa and they’ve taken the HIV model of delivering drugs down there. As you probably recall, back in the ‘70s and ‘80s HIV was a death sentence, then anti-retrovirals came around and they talked about doing this in sub-Saharan Africa and they said, ‘This is crazy, it’s not going to work. They don’t even have clocks to take medicine, how do they know when to take medicine?’
But it is working.
It is working and the compliance with anti-retrovirals is higher in Africa than it is in the West.
And you can get a ride on that whole platform?
Absolutely, absolutely, we expect to. The Pink Ribbon Red Ribbon initiative, I think, is again trying to leverage what has happened in HIV and make the same thing happen in cancer.
So, finally, how would you sum up what you want people to take home from your message here at the meeting in Lyon?
Cancer is a problem and it’s a global problem, it is not a problem that’s unique to any specific country. In the low to middle income countries this is an epidemic; it’s increasing at a rate far higher than the Western world and we need to do something about it. We can’t stand by idly and not make a difference. I think what we see here from this conference is a community of physicians and caregivers from around the world that are committed to making a difference and particularly for those patients who are most disadvantaged.
Patrick, nice to see you.
Nice to see you, thank you.