Getting high level care to low and middle income countries

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Published: 21 Jun 2019
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Dr Eduardo Cazap, Dr Clifford Hudis

Eduardo Cazap, MD, PhD speaks to Dr Clifford Hudis at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting for ecancer's Global Cancer Leaders initiative.

They begin by discussing a stepwise program to address the increasing demand of Western-level healthcare in low and middle income countries.

Dr Cazap then asks whether ASCO can adapt, or will evolve its methods when moving onto a more global level.

EC: We are today at the 2019 ASCO annual meeting. As part of our series of interviews with global leaders about cancer and global issues we have today with us Dr Clifford Hudis. Dr Hudis has been leading breast cancer research for many years and he was one of the leaders at the Memorial Sloan Kettering Cancer Center. But now he’s in a different position, he’s the position of the CEO of one of the world leading organisations for clinical oncology. So, Dr Hudis, thank you for being with us. With your experience and background how do you envision not only the medical aspects of care and cancer control, how do you envision for the next years the progress or the challenges from a global perspective?

CH: The challenges and opportunities that we face on a global scale are front and centre for us at ASCO. Our strategic plan has four long-term aims for the next five years and one of them is to increase our global impact. Why have we focused, as the American Society of Clinical Oncology, on making a global impact? The answer is pretty simple. One, when we come to Chicago for our annual meeting half of the attendees come from outside the US. When we look at our membership one-third of our nearly 45,000 members are from outside the United States. Now, when we look at the big world there are a couple of interesting points that we have to know. The United States is about 326-327 million people, the world is about 7.6 billion people, more or less. So we are a pretty small minority of all the people on Earth. Two, incomes are rising on a global scale which is actually good news and more and more countries have more and more people entering into middle class. With middle class income there is a guarantee of increased longevity, reduced infant mortality, better control of those diseases that unfortunately shorten life early in life. When we live longer you can be certain that there will be more colon cancer, breast cancer, prostate cancer and because especially of tobacco, but even beyond that, lung cancer. Those four solid tumours almost represent a surrogate indicator of gross domestic product for countries. There have been estimates recently reported of significant increases in the need for conventional chemotherapy around the world in the next few years and then you layer on top of that the exciting kinds of breakthroughs that we hear about at ASCO’s annual meeting every year and you realise that the demand for care, education itself but care beyond that, is going to explode. So I’m sorry for the long introduction but I’m just making the point that we are very aware of the giant challenge and opportunity ahead of us.

In summing that up, I personally believe and our Board believes that there is going to be a massive increase in the number of people around the world who expect Western style care for their diseases. That means European, American, Australia, New Zealand kind of care. So this brings me back, really, to your question – how are we going to do this? The way ASCO can contribute as one of many contributors to solving this problem is through the things we traditionally do best – one, educate. So, indeed, we’re launching a new meeting this year in Bangkok designed to bring forward from Asia innovators and thinkers who are already solving some of these problems in Asia, sometimes using new systems, new care models and so forth, also new technology and even some new drugs and treatments. We want to bring them together and have them teach us what might be possible for us. Of course, taking all the rest of our tools globally, so we establish through our Quality Oncology Practice Initiative, or QOPI, standards not for doctors exactly but for practices, for teams. We have a growing number of practices around the world asking us to come in and help them achieve what we call QOPI certification. Interestingly, they are asking for us to do this using the same standards that we use in the United States. I know this is an interest of yours but it’s fascinating that they seek something more even than the resource adjusted measures that you might have expected; they want to meet the Western ones. Now, for low and middle income countries where they aren’t yet used to this we have a pilot programme we’ve just begun where we teach them how to report because, after all, in order to measure quality they have to report quality. So this will be a stepwise project.

So, I’m sorry, I’ve given you a long answer but really what I’m describing is recognising the problem, educating all of the professionals, deploying quality tools and helping them raise their quality of care over the years ahead. That’s our job.

EC: No, I am grateful for your introduction because it is really not so frequently really understood the complexity of the problem. You mentioned two things, one very important is the issue that actually we need to open the problem of cancer to other stakeholders. This issue of innovation, innovators trying different ideas to our problem because actually this is not a medical problem alone, this is a human development issue. We cannot solve human development things but we or ASCO or others can contribute according with the mandate of the organisations and the possibilities. So it makes sense very well. Another thing that are really crucial, as you said, for the 80% of the world population apart from American or Europe, some parts of Europe and so on, is the problem of new populations that are entering in the sequence of health or migrations, as an example. Countries like now Jordan has more migrants than people from the country. Minorities – the case in Europe or populations in war zones or in crisis. Do you think that our medical organisation, do we have any type of responsibility in this?

CH: Our members are sometimes confronted by exactly what you describe and, I agree, we have a responsibility to support our members. Clearly it is beyond our ability to go into a war zone as ASCO.

EC: No, no, I understand that the objective of ASCO is an objective about research, education, good science, I understand that. My doubt is that if you are moving to the global challenges, the global challenges are also different. So perhaps, I don’t know, when you strategise in this regard the participation for the global efforts of members that are experiencing the same problems could be beneficial. So this meeting that you are organising in Bangkok is planned to fix these types of issues? How do you envision ASCO in that area and how you will interchange?

CH: I think we have to separate a problem here. Around the world for a variety of reasons there are problems of access to high quality cancer care. One of the contributors to that is the migration related to war, which is a big problem. But, in the end, that’ s just one more giant societal problem and societal contribution to a more common issue of access to care. How we make sure that everybody who has cancer has access to care is, in a sense, independent of the reason that they have limits. By the way, we have versions of this problem even, of course, in wealthy countries. We have migration in the United States, we have people who come into the country and don’t have access to health services because they are here illegally and we have people who are in the country legally and are working but have inadequate resources to access the existing healthcare system fully. So there are many versions of the access problem and I think that what you’re calling out is one of them. Our obligation is to help our members address all of them in the most efficient way possible.

EC: Two of these general points, one is guidelines because the classical picture is you have guidelines – ASCO, ESMO, NCCN – but the users of those guidelines are in different parts of the world. I know that ASCO is now doing some stratified guidelines, do you have some comments on this?

CH: I do but it’s actually more profound. Our guidelines are good to read on Sunday afternoon but when you’re in the clinic on Tuesday at three in the afternoon you don’t have time to page through a very detailed academic guideline. You need something that allows you to quickly get to important relevant information. So we are in the process right now of reconsidering how we generate guidelines, how we generate short forms of them to help our members read through them more quickly. We’re very focussed on practical application in the form of metrics and measures. So how we know that a practitioner is going to actually improve their quality of care based on our guidelines is through our measures. Especially in the United States but around the world we need these measures, we need them for payment in the United States but we need them for coping, which I already mentioned, globally. So our focus is getting very practical on guidelines and the derivative measures.

EC: I understand. A final question – you have an incredible experience in research but I think mostly basic or translational or clinical. How do you think that ASCO, or if ASCO is doing really things in other areas of research – epidemiological research, implementation research, social – because many of the problems are not only the therapeutic aspects of research. Do you have some comment on this?

CH: Absolutely. ASCO has three mission pillars – education, quality of care and research. To support the latter in the last few years we’ve established with Dr Richard Schilsky a centre within ASCO, we’ve called it CENTRA, our Centre for Research and Analysis. Within that we provide access to data resources, some of which are contained within ASCO, some of which are accessible through ASCO. They can provide the kind of data you like like population or epidemiologic data and practice data related to the delivery of care and so forth. They also provide access to our CancerLinQ Discovery datasets which are real world evidence curated within the CancerLinQ programme that we have. Finally we can provide guidance and support to people so they make sure they’re asking good questions. Beyond that, and thinking about the global part of this, we fund investigators and training programmes for people who want to do studies not just in the US but around the world. I think that’s the way we’re going to make it possible for more people to participate more fruitfully in the whole research enterprise.

EC: Well, Dr Hudis, I must confess that after this interview I have much more and better updated information about many actions that ASCO is actually ongoing that can benefit our community of members. Thank you very much. Your final words.

CH: Thank you very much for allowing me to participate in this. My goal, fundamentally, along with all of the leadership and staff of ASCO is to educate and connect our members and the rest of the world. Anybody who is interesting in helping us take better care of cancer patients anywhere.

EC: Thank you very much.