ASCO AS A GLOBAL ORGANIZATION

Despite its description as an American oncology society, ASCO is truly a global organization, with one third of its 30,000 members living in more than 100 countries outside of the United States. More than half of the 25,000 plus professionals attending ASCO annual meetings come from outside the continental United States. Journal of Clinical Oncology (JCO) is read by more than 48,000 subscribers worldwide, half of whom receive international editions available in Mandarin Chinese, Czech, French, German, Hungarian, Italian, Japanese, Polish, Romanian, Russian, and Spanish. Furthermore, because many ASCO products are available online, international access continues to increase.

GLOBAL CANCER BURDEN

In 2008, it was estimated that more than 12 million new cases of cancer were diagnosed worldwide, with approximately 7.6 million people dying as a result of this disease.¹ If current trends continue, the global cancer burden will double over the next 20 years, with approximately 26.4 million new cancer cases and 17 million annual deaths as a result of cancer projected to occur worldwide by 2030 (Fig 1). Importantly, 70% of these cases will occur in low- and middle-income countries (LMCs), defined by the World Bank as countries with a gross national income of $11,905 or less. Cancer now kills more people each year in LMCs than AIDS, tuberculosis, and malaria combined.² Although the individual risk of developing cancer in the industrialized world remains higher than that in LMCs, the gap between the two is rapidly closing. People in LMCs are living longer, in part because of advances in the control of infectious diseases; however, some of the maladaptive lifestyles of the West linked to cancer development are becoming increasingly common in these countries. In particular, smoking rates continue to increase in many LMCs. Four of five patients with cancer in LMCs have incurable disease at initial presentation,² contributing to a three-fold higher risk of dying as a result of cancer compared with that of an individual in a wealthier country.² Notably, many cancer cases in LMCs are linked to chronic infection (eg, human papillomavirus, hepatitis B, Epstein-Barr, Helicobacter pylori). Primary prevention of these infections will decrease the incidence of common cancers in LMCs.

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Fig 1.

Projections of cancer mortality.

BARRIERS TO CANCER CONTROL IN LMCs

The rising burden of cancer and scarcity of cancer care resources in LMCs constitute a clarion call for the impending crisis in global health. Examples of barriers to cancer control in LMCs include:

ONGOING GLOBAL CANCER CARE INITIATIVES AND CALLS TO ACTION

Poor outcome of cancer care in LMCs is not a recently recognized problem.^8,9 In fact, multiple international organizations, including the Union for International Cancer Control, International Atomic Energy Agency (and its Programme of Action for Cancer Therapy), International Network for Cancer Treatment and Research, American Cancer Society, ASCO, and others, together with hundreds of governmental and nongovernmental entities in LMCs, have been actively working on this problem for years.

In the last decade, the magnitude of this ongoing crisis began to peak broad international interest, as reflected in a call to action.^10–14 The WHO 58th World Health Assembly approved a resolution on cancer prevention and control in 2005, stressing partnership with member states to develop resource-appropriate strategies.¹⁴ This was followed by the World Cancer Declaration, initiated by the Union for International Cancer Control in 2006 and updated in 2008, which mandates a reduction of the global cancer burden by 2020.¹⁰ With more than 200,000 signatories to date, the World Cancer Declaration covers the spectrum of cancer control from prevention to treatment to palliation, with targets that include ensuring that effective cancer control programs are available in all countries, decreasing global tobacco consumption, and covering populations affected by human papillomavirus and hepatitis B with universal vaccination programs. The 2009 LIVESTRONG Global Cancer Campaign and Summit endorsed the World Cancer Declaration and proposed that every government develop a coordinated strategy for addressing the cancer burden within its borders.¹² Important contributions to raising the awareness of the health community have also included the London Declaration on Cancer Control in Africa (2007), led by the African Oxford Cancer Foundation, and reports published by CanTreat International, a consortium of international cancer organizations concerned about cancer care in LMCs.¹³

Forceful awareness campaigns have made progress in the last year toward putting the global threat of cancer and other noncommunicable diseases on the global health agenda. In September 2011, the United Nations (UN) General Assembly will convene a summit on the issue of prevention and control of noncommunicable diseases.¹⁵ In its 65-year history, the UN has convened only one other special session on a health topic, which resulted in the creation of the Global Fund for AIDS, Tuberculosis, and Malaria in 2002. Although one cannot predict the outcome of the upcoming UN summit on noncommunicable diseases, this event indisputably presents a unique opportunity for the cancer community to identify and highlight proven models for cancer control in LMCs to dispel the misconception that nothing can be done. By building on the existing infrastructure for treatment of infectious diseases, cancer control programs are certainly feasible.¹⁶

Farmer et al^17,18 of Partners in Health have demonstrated the feasibility of treating multidrug-resistant tuberculosis and HIV in resource-limited settings.¹⁹ Although no oncologists are available at the health centers and hospitals that Partners in Health helps to operate in rural Haiti, Rwanda, and Malawi, primary health care providers at these sites have begun to deliver chemotherapy to patients with a variety of treatable malignancies with support and training from Harvard-based faculty.²⁰ These efforts demonstrate the feasibility of cancer care delivery through onsite and telemedicine collaborations in resource-poor settings.²⁰ Another example is the AIDS Malignancy Consortium, which recently identified four sites in sub-Saharan Africa to conduct therapeutic trials in non-Hodgkin's lymphoma, cervical cancer, and Kaposi's sarcoma. Each site in Africa partners with a North American institution. Additional programs building on these pilot efforts are urgently needed, along with concerted support from the global community, local governments, and primary health care providers.

ROLE OF ASCO IN OVERCOMING GLOBAL DISPARITIES IN CANCER CONTROL

The ASCO International Affairs Committee, composed of members from around the world, the charter of which includes promoting the “development of the field of oncology in less-developed countries,” has worked with ASCO staff to develop a series of programs designed to address the needs of the international oncology community. Included in these programs are initiatives focused specifically on cancer control in LMCs (Table 2). For example, the Multidisciplinary Cancer Management Course partners with national and regional oncology societies in LMCs to promote a multidisciplinary approach to cancer treatment. The course is designed for physicians practicing in countries in which cancer is generally managed by nonspecialists. Since 2004, more than 2,000 clinicians have participated in locations including Bolivia, Nigeria, Kenya, and Peru. The International Cancer Corps, which pairs ASCO volunteers with health centers in LMCs with the aim of improving cancer care through clinical instruction, has been successfully piloted in Honduras and is expanding to Ethiopia. The International Development and Education Award grant supports early-career oncologists in LMCs by establishing a strong relationship with leading ASCO members who serve as scientific mentors. The Long-Term International Fellowship Program enables these individuals to extend their collaborations through research fellowships at the mentors' institutions. Although the scope and goals of these ASCO programs vary, each serves to nurture relationships between ASCO volunteers in high-resource countries and ASCO members in LMCs to facilitate international mentoring, knowledge exchange, and education.

Although several diverse groups are calling for improved cancer control in LMCs and developing strategic goals and targets to achieve improvement, ASCO has many unique strengths, including a proven track record in promoting cancer awareness and education, improving clinical practice by identifying and removing barriers to delivery of quality cancer care, and fostering innovation to initiate novel solutions to complex problems. Furthermore, because of the large membership of ASCO and its commitment to the entire spectrum of cancer care from prevention to palliative care, ASCO is in a unique position to serve as a leader in pulling together disparate activities in private and government sectors. Capitalizing on these strengths, we have outlined potential action items in each of these categories to help inform a sustainable and highly impactful cancer control strategy in LMCs moving forward (Table 3).

AWARENESS

Awareness is central to addressing global cancer control disparities, because those in a position to offer assistance must be cognizant of the ongoing crisis to provide financial, infrastructural, and educational resources. ASCO can play a key role in fostering education (eg, local symposia, online communications) among those involved: health care providers, government officials, patients, and the general public. Highlighting the cancer control crisis in LMCs through ASCO publications and special sessions at the ASCO annual meetings would provide an opportunity to promote awareness while fostering dialogue and collaboration among ASCO members practicing in a variety of settings. A peer-reviewed publication consisting of articles relevant to the practice and dynamics of LMCs is one such possibility. To jumpstart these efforts, the 2011 ASCO Annual Meeting will have a session entitled, “Innovation in Delivering Quality Care in Low-Resource Scenarios.” This session will highlight the challenges and innovative approaches that can be used in delivering cancer care in low-resource settings and promote interaction and crosstalk between ASCO members who practice in high- and low-resource settings.

In addition to professional education, ASCO should partner with local health care providers, organizations, and government agencies to launch public education campaigns focused on destigmatizing cancer. These efforts should highlight that many cancers are preventable, potentially curable, and/or well palliated with existing approaches and should emphasize the importance of screening and early detection.

PRACTICE

Raising awareness of the growing importance of cancer as a significant cause of morbidity and mortality in LMCs is only the first step. Significant efforts must focus on delivery of care throughout the spectrum of oncologic practice, including prevention, early detection, treatment, and palliation. Although the well-established, evidence-based guidelines that are currently available to optimize cancer management are generally well suited for high-resource countries, implementation of such recommendations is often not feasible in settings lacking adequate resources and infrastructure, appropriately trained manpower, and consistent drug availability. Therefore, resource-appropriate guidelines would allow for the definition of best practices for countries of varying means. Programs such as the Breast Global Health Initiative have strived to elucidate “evidence-based, economically feasible, and culturally appropriate guidelines that can be used in nations with substantial resource constraints to improve breast health outcomes.”²¹ The Breast Global Health Initiative guidelines identify four tiers of resources, ranging from a basic level, at which only fundamental services can be provided, to a maximal level, present in most high-resource countries. This stratification allows for incremental improvements in cancer care based on changing local conditions. Given the expertise of ASCO in clinical guideline development, the organization is well positioned to play a leadership role in the development of a series of resource-appropriate guidelines for the management of a variety of cancers commonly encountered in LMCs. Indeed, interaction between the ASCO Clinical Practice Guidelines Committee and International Affairs Committee may provide the synergy necessary for the rapid development of such resources. Such a task force is already being formed with members of these two committees. Furthermore, ASCO may leverage its journals (ie, JCO and Journal of Oncology Practice), the ASCO Web site, annual meetings, and multiple educational programs focused on LMCs (Table 2) for dissemination of these guidelines.

Although guidelines to direct appropriate care are valuable, sufficient providers to deliver care are ultimately necessary for successful implementation. Whereas the WHO minimum standard is 20 physicians per population of 100,000, countries like Malawi meet a tenth of this minimum standard. Much of the cancer care in LMCs is provided by midlevel providers. ASCO already has programs devoted to the education of midlevel and nonspecialist providers, training opportunities for early-career oncologists in LMCs, and onsite mentoring by experienced ASCO volunteers. In addition, advances in telecommunications and technology have allowed for information exchange to occur at an ever-increasing pace. Teleconferencing and telemedicine can facilitate communication and collaboration worldwide.² These efforts should be expanded to help address the critical workforce shortage in LMCs.

A number of low-cost, low-technology endeavors exist that could be potentially administered by nonspecialists and have a significant impact on cancer control in LMCs. For example, visual inspection and cryotherapy for precancerous cervical lesions can be carried out by trained nurses in even the most basic settings; it was found to be feasible and effective in a recent trial in India.²² ASCO can use existing programs, such as the Multidisciplinary Cancer Management Course and International Cancer Corps, to train health care providers in LMCs in screening approaches for prevalent cancers.

INNOVATION

ASCO should also provide leadership in research innovation to improve cancer control in LMCs. ASCO should provide seed funding, implementation platforms, and collaborative expertise to allow innovative ideas to come to fruition. ASCO currently has a number of initiatives that are operational in LMCs, including the International Development and Education Award. ASCO should also support efforts to conduct practical clinical research in LMCs. Areas of study that would be particularly well positioned in LMCs include health services and delivery research, epidemiologic research, pharmacoeconomic research, and therapeutic trials investigating lower-cost drugs.

ASCO should consider establishing a grant mechanism specifically targeting innovation in cancer control in LMCs. Through these grants, health care providers in LMCs (with or without partners in other countries) could apply for funding to initiate projects that would produce sustainable results in reducing the cancer burden in their local communities without competing with academic investigators from countries with high resources. Novel approaches and clinical trial designs outside what would be considered standard practice in resource-rich countries would undoubtedly be required. For example, the Africa Oxford Cancer Foundation is planning a trial of nurse-dispensed tamoxifen for Ghanaian women 50 years of age or older who have a clinically suspicious breast mass on physical examination.²³

Partnerships with industry for the availability of affordable generic agents must be established. Periodic and limited donations of drugs are of marginal value, because patients may begin therapy, but supplies may not permit sustained dosages as recommended per guidelines. Innovative use of electronic medical records and telemedicine using mobile telephone technology may obviate the large capital expenditure typically associated with health information technology. The creation of a research infrastructure may allow the conduct of clinical trials in resource-poor settings, but such trials would need to be designed with practical clinical end points that take into account the limited resources available to patients and health care professionals in LMCs.

Innovation in the environment outside of medicine is critical. This includes economic development and nutritional interventions that build the sustainability of the LMC medical home. An example of a working model addressing these facets of care is the Academic Model Providing Access to Healthcare Program for HIV care in western Kenya.²⁴

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Employment or Leadership Position: None Consultant or Advisory Role: Matthew D. Galsky, Bristol-Myers Squibb (C), Amgen (C), Pfizer (C), GlaxoSmithKline (C) Stock Ownership: None Honoraria: None Research Funding: Matthew D. Galsky, Celgene, Pfizer, Viatar Expert Testimony: None Other Remuneration: Patrick J. Loehrer Sr, Pfizer

AUTHOR CONTRIBUTIONS

Provision of study materials or patients: Doug Pyle

Manuscript writing: All authors

Final approval of manuscript: All authors