The case for a cancer 'groundshot'

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Published: 10 Oct 2017
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Dr Bishal Gyawali - Anticancer Fund, Strombeek-Bever, Belgium

Dr Gyawali speaks with ecancer at the RSM meeting on cancer control about the Cancer Moonshot Initiative, and his position that existing gaps in care offer a more pressing health concern than developing highly specific therapies.

The case for a cancer 'groundshot' has been made before by Dr Gyawali and Dr William Mackillop, and Dr Gyawali shares here how this meeting raised discussion among other care providers from low resource settings.

The title of my talk was ‘Cancer groundshot – going global before going to the moon.’ This was in reference to the cancer moonshot projects that have been somewhat popularised in the scientific community as well as in the media. So the cancer moonshot project, I was not here to criticise the cancer moonshot project, but the focus of my message was if we spend even a fraction of that money on a cancer groundshot then we could be saving more lives. What cancer groundshot actually meant was things that we already know, things that we know that work, and things that are applicable to people living across the world irrespective of their purchasing power or their income. So, for example, this includes things like prevention, for example in the case of cervical cancer, this was one topic that I talked in detail. Cervical cancer is a cancer that we can actually prevent. We know that HPV vaccination helps prevent cervical cancer; we also know that there are effective strategies to screen cervical cancer so that we can detect them earlier and cure them. But still there are a lot of countries in the world where a lot of women die of cervical cancer and actually 85% of the cervical cancer mortality burden is in low and middle income countries so this is unacceptable. While we are talking about cancer moonshots and immunotherapies and precision medicine that are supposed to improve survival by a couple of months we know that cervical cancer is preventable and we can cure it but still we don’t have funds to implement and educate people living across the world about this strategy. We still see women dying of cervical cancer so this is unacceptable. That was my focus of talk. And not only prevention, there are other things that we can do, for example co-development where high income countries and low income countries work together to find appropriate strategies, cheaper strategies that can be applicable globally immediately and more and more cancer patients will benefit from that. One such example is the use of technology, for example the web-based application to report patient reported outcomes which improves survival significantly. So instead of focussing on these types of approaches that are applicable everywhere globally and at a low cost we tend to focus on these big over-hyped projects and we spend a lot of money on that and everybody is spending money on that. The problem is, for example immunotherapy is receiving funds from everywhere, every government is funding that, every billionaire is funding that but nobody is going to fund implementation of the HPV vaccine in Kenya or in Nepal.

So that was my main message in today’s talk. I also gave another example from drug repurposing. Drug repurposing is the use of cheaper drugs that are already approved for other indications and we try to test them, whether they are efficacious in cancer. One good example is, for example, the use of propranolol for angiosarcoma. There is some nice evidence that it could be effective but we need to conduct proper big phase III [?? 3:16] to test these strategies. But the problem is who is going to fund the trials of propranolol or the trials of cimetidine or statins for that matter? Because these are the drugs that won’t give you a good financial reward so there is a lack of interest from the pharmaceutical company. But if we find evidence that, let’s say, propranolol or cimetidine or metformin or any [?? 3:43] drugs are really efficacious in some cancers then this is applicable throughout the world easily. Every person can have access to it compared to showing that ipilimumab is efficacious in small cell lung cancer then nobody in Africa or nobody in my country is able to afford that. So these sorts of discrepancies is what I focussed about in my talk today.

Are you able to touch on issues such as the lack of medicines and personnel?

My talk was more about medical oncology, I didn’t focus on those aspects but other speakers highlighted those issues very well. One particularly impressive talk for me was when they presented about how they used the internet based technologies and smartphone based applications to conduct an online training course for pathologists in Africa from the UK without any funding. This substantially improved the quality of pathological services in Africa so this is an example of a cancer groundshot project. So you don’t need a lot of funds for that, they did it without any funding. These are the things that actually matter to those patients and these are the things that will actually improve outcomes. As Professor Wild said, instead of making a bigger cake we are all trying to grab pieces of the same cake. So we are competing among ourselves for surgery versus radiotherapy or pathology and medical oncology instead of making a bigger cake. So, as you said, we are pouring down money at the top and we are hoping that some of it will trickle down to what actually matters.  But we need to be maybe doing it the other way around.

How do you see the role of clinicians as oncology advocates going forward?

We oncologists have that social responsibility to take steps in this matter and to be proactive and not confine ourselves to only those patients that are in front of our eyes in our clinic but there are many other patients globally who need our help and we need to be advocates for them. If not we then who will do that? As we discussed in our panel discussion, to give you an example of that pathologic training, the speaker said that they actually are lacking funds to train those pathologists by bringing them to the UK for a week’s training, hands-on training. They don’t have the money to do that but we have so many instances in which we are giving off label expensive chemotherapies or immunotherapies for many patients. So if we can avoid this off label or ineffective, harmful use of one expensive drug for one year then that could fund five or ten pathologists to come to a high income country and get training and go back and make use of that training in their own setting.

So there are avenues which can we work together and which don’t require a lot of money but need a strategy and innovative ideas and we need to be collaborating together. So high income countries, this is not a case of high income countries teaching one way to low and middle income countries, it’s a two-way collaboration. There are so many things that a high income country can learn from a low and middle income country and vice versa. There are also things that we can work together so that it fits our common goal. There is a very nice example of the use of arsenic trioxide in cases of M3 acute myeloid leukaemia. This is evidence coming from a low and middle income country but this is the standard of treatment even for high income countries. So it’s not that low and middle income countries are waiting for high income countries to do something for them.

The environmental context, the cultural context is different between low and middle income countries versus high income countries. So low and middle income countries are working to create better outcomes for the patients in their own way, as in the presentation of Dr Shailesh, he showed that in India, in the Tata Cancer Centre, they have been working on pancreatic cancer surgeries and they have improved outcomes substantially, comparable to that of high income countries but the setting is different.

So low and middle income countries should focus on their agenda rather than trying to copy and paste what high income countries are doing. High income countries should also not think of low and middle income countries as a one-way preaching job but a matter of belonging [?] together, co-developing, developing together and addressing a common agenda. There are benefits for both low and middle income countries as well as high income countries with this common co-development project.

What are your final thoughts on cancer treatments in high income countries?

Many patients lack access to these expensive drugs and we have data that shows that many patients living in high income countries such as the US or UK they are suffering financial toxicity as a result of the high expense of these drugs. There is also data showing that these expensive drugs don’t improve survival that much. But if you compare that with the groundshot projects that we are talking about, for example training physicians or surgeons in low and middle income countries, building radiotherapy machines, there was an excellent talk after my talk by Dr Peter about the use of radiotherapy in low and middle income countries. He showed that with the use of the same amount of money for the chemotherapy, I forget the exact figure, but he showed that we could develop a lot of radiotherapy machines in low and middle income countries and that would be saving more lives. But what we need to be clear is we are not competing medical oncology versus other groundshot measures; what we need to be sure of is first we need to make sure that a basic level of services are available to everyone before we are trying to achieve a marginal one or two months of survival gain. So without ensuring that every person has access to basic healthcare, to basic cancer care services, if we are trying to invest the same amount of money so that 5% of patients can live for two months longer then that does not make much sense to me.

The other important point is when we are talking about moonshot, those types of programmes, we need to see if they have actually delivered the success that they are trying to achieve. In my presentation I showed that immunotherapies and precision medicine, some of the important strategies under the moonshot, they haven’t delivered success as much as we had hoped for. Still there is time, maybe they will in future but what we have seen now is the success we have seen is very marginal. Even that success will be available to only a few patients who can afford that treatment, even in high income countries, we are not talking about low and middle income countries. People living in high income countries do not have access to those drugs and those who have access most of them suffer financial toxicity and we have data that shows that financial toxicity in itself can impact survival.

Comparing that with, for example, vaccination coverage, availability of surgical expertise or availability of radiotherapy services is completely different because now we are talking about things that are used for curing cancer, not for incremental gains in survival but for curing cancer. For the early stage of cancer if you don’t have surgery even a stage 1 breast cancer can kill you by progressing. But if you have a stage 4 breast cancer then you are only talking about improving your survival by a number of months. So we have opportunities to cure cancer so that should be our first priority then adding two or three months of survival. Adding two or three months of survival is important, I’m not neglecting that, I’m not trying to disparage that, but at the expense of someone who can be cured of cancer is a different equation and we need to be very careful about that.