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World Cancer Day 2024: A Live Panel Discussion

In honor of World Cancer Day on February 4, members of the Oncology Data Advisor Fellows Forum and Editorial Board joined forces for a thought-provoking discussion about improving cancer care on a global scale, including treatment access, molecular testing, clinical trial diversity, and patient advocacy worldwide.  

Oncology Data Advisor: All right, everyone, thank you so much for tuning into today's World Cancer Day panel featuring our Fellows Forum and Editorial Board members. We have a really thoughtful discussion planned for today on ways to improve cancer care on a global scale, including access to treatments in low-and-middle–income countries and barriers to molecular testing. Without further ado, I will turn it over to our panelists to introduce themselves and then dive into the conversation, so Dr. Kareff, I will let you take it away.

Samuel Kareff, MD, MPH: Good afternoon, everyone. Good afternoon to all of our viewers. Thanks so much for tuning in for this panel on World Cancer Day. My name is Dr. Samuel Kareff. I'm the Chief Fellow at the University of Miami Sylvester Comprehensive Cancer Center, and I'm happy to be here with this awesome panel today.

Waqas Haque, MD, MPH: Thanks for having us today. I'm Dr. Haque. I'm a third-year Internal Medicine Resident at New York University (NYU) in a Clinical Investigator Track, and I'm an incoming Oncology Fellow at the University of Chicago, which I'll be starting this summer. I have a public health research background and I'm originally from Pakistan, so this is a really important topic to me.

Matthew Hadfield, DO: I can go next. I'm Matt Hadfield. I'm a third-year Hematology/Oncology Fellow at Brown University in Providence, Rhode Island, and I'll be staying on there as a faculty member specializing in early-phase clinical trials and melanoma.

Joseph Kalis, PharmD, BCOP: I'm Joe Kalis. I'm an Oncology Pharmacist with the University of Colorado Health in Colorado Springs, Colorado.

Richa Thakur, MD: Hi, I'm Richa Thakur. I'm a second-year Hematology/Medical Oncology Fellow at Northwell Health.

Dr. Kareff: Awesome, thank you, panelists for introducing yourselves. Let's dive right into it on this very significant day in the oncology and global health community. I think it's a really timely start to our panel because we had a breathtaking report that was released by the World Health Organization (WHO) research agency, the International Agency for Research on Cancer (IARC), just a couple of days ago. In that report, we learned that there were at least 20 million cancer cases and 9.7 million cancer deaths estimated, according to the most recent data, in 2022.

What's really surprising is that five cancer types—breast, colorectal, liver, prostate, and stomach—together comprised about 50% of the new cases and deaths globally in 2022. We confirmed that lung cancer was indeed, again, the most common tumor worldwide and was the top cause of cancer deaths.

These numbers have not changed recently, despite efforts for tobacco cessation and control throughout the globe. And what was very interesting was that the report noted "global inequities in cancer services, with most countries failing to adequately finance priority cancer and palliative care services as part of universal health coverage."

With that background and striking findings, I was hoping to posit to the panelists our first theme here, talking about access to treatments in low-and-middle–income countries. Are there any trends or developments that you would like to share either from patients you've served, projects you've served on, or countries that you have worked with?

Dr. Kalis: I'll kick us off as the pharmacist member on the panel member. I can speak a little bit to the patients we serve here in the US and then the levels of difficulty with that and how that might apply to folks in lower-or-middle–income countries. I think universal health care is an important piece of it. We've got different health systems in different countries that are available. Here in the US, we've got resources through drug companies, foundations, and grants, but I see many patients who are still struggling to have that access to care from a financial perspective. I can only imagine how much more challenging that is in countries at different socioeconomic levels.

Dr. Hadfield: I think it's such an important topic, and as we start thinking more about novel therapies that we can bring to our patients, you have to wonder about how you can bring them out on a wide-scale platform. One really encouraging development that I've seen recently, and just worked on a project related to, is subcutaneous checkpoint inhibitors. There have been several clinical trials looking at the development of subcutaneous checkpoint inhibitors. This followed previous clinical development pathways such as rituximab, which is used in multiple hematological malignancies, and there's actually now an atezolizumab-received approval in the United Kingdom for a subcutaneous version of atezolizumab. I think being able to give something that's much less logistically challenging could really help expand the usage of checkpoint inhibitors in low-to-middle–income countries. Developments like this could really help bring cancer care all around the world, where right now it does tend to be siloed with some of our newer therapies.

Dr. Haque: Dr. Kareff, you alluded to trends in developments. I think what's interesting is that a lot of times for low-and-middle–income countries, we often don't have information to what those trends and developments are just because they haven't been surveyed and thought out. In my health management class I took a few years ago, one of the adages we learned is that what can't be measured can't be managed. I think one of the key aspects to addressing lack of access to treatment is lack of access to data. Thankfully, at least in Pakistan where I'm from, there has been an improvement in epidemiological data. There have been some reviews of patients with breast cancer and diffuse large B-cell lymphoma (DLBCL), for example, showing that in marginalized patients, there's actually a lack of patients who complete the basic chemotherapy for breast cancer or DLBCL. A lot of the time, patients won't actually complete all of their rounds of treatment as well. I think there are some interesting trends there that we can think about.

Dr. Thakur: You guys have brought up some really interesting points. Insurance creates a really great buffer for a lot of our patients. Usually with copays, at least in the US, patients are still able to afford their chemotherapy regimens, but even in a country like ours, there's a significant portion that can't afford the rest of the cost. In India where I'm from, there's really not a big system of insurance, whether it's universal or private. Usually when patients need cancer treatments, they see an oncologist or go to a cancer center, which requires significant travel, and then all of the cost for the chemotherapy is still out of pocket. Just to give a rough idea, I heard about a case of a patient with triple-negative breast cancer that had relapsed, and the treatment for just the initial portion, about three months, was about $75,000 out of pocket. That's just for three months. Who can afford $75,000 in a low-income country, let alone in a high-income country?

Dr. Kareff: Thank you all for your perspectives on this piece. We brought up multiple levels of issues here. We talked about the individual level, the payer level, and even the national level. Our group here is actually working on producing data that could be measured, thankfully, to show access to things like immunotherapy in stage III and IV non–small cell lung cancer, the most common malignancy worldwide. The goal with that type of research is, of course, to make sure that cost isn't a barrier to equity and access. That's our contribution to this conversation, and I've certainly appreciated hearing your thoughts on this as well.

Dr. Thakur: Another really good point that Matt and Waqas brought up too is that oftentimes, here, we go for intravenous (IV) formulations or subcutaneous formulations for whatever the treatments are. These really require a lot more infrastructure and resources on behalf of the patients and the cancer center to administer. Trends in research really would change this landscape. Focusing on either dosing frequency, dose intensities, or even switching formulations to something like oral would really help improve access to care.

Dr. Hadfield: Another thing that I often think about is as we start to give more and more novel therapeutics—we have checkpoint inhibitors, and we're starting to give chimeric antigen receptor (CAR) T-cell therapies, invariant natural killer (NK)–cell treatments by specific antibodies that require cytokine release syndrome (CRS) monitoring—the toxicities are getting much, much more complicated than giving run-of-the-mill cytotoxic chemotherapy. While we have the logistical challenges of giving these therapies to patients worldwide, they also need to have the necessary infrastructure to have follow-up and be seen by people who are specialized in these therapies enough. Unfortunately, the complexity of these treatments is really accelerating at a pace that's much, much faster than it has been in previous decades. We need to be educating practitioners around the world to be able to administer these therapies and give them, in addition to just making them logistically available to everybody.

Dr. Haque: Dr. Hadfield and Dr. Thakur, you both talked about toxicities and dose optimization, and I think we all know the basics of pharmacology is that it's the dose that makes the poison. When we're thinking about optimizing a dose, usually in phase 1 trials, you aim for the MTD, the maximum tolerated dose. That's the one you go with to phase 2, phase 3, then eventually to when a drug is approved. Often, we don't think, once we have that maximum tolerated dose, is there a lower dose that we can give to patients that would cost less in order for them to afford that drug but still have similar outcomes? There have been studies that, for example, that show you can give abiraterone at a fourth of the dose and get similar outcomes for certain cancers. I think that's something else to think about.

Dr. Hadfield: That's a great point.

Dr. Kalis: Absolutely. Getting the drug to a patient, sure, is priority number one, but there are levels of complexity to follow. If subsequent drugs are needed to have on hand, like tocilizumab for CRS, it does create some additional barriers that need to be overcome.

Dr. Thakur: Absolutely. I think another principle of pharmacological clinical trials is that no matter what the standard of care is, usually you add the next-line treatment to it. No one's going to do a doublet therapy in multiple myeloma when triplets are already standard, and we're pushing towards quadruplet regimens. This is also much harder to implement in other countries where oftentimes the best drugs and the best combinations really do require decreasing your doses, decreasing the amount of drugs, and decreasing the frequency, and it's really not in the best interest of clinical trials and pharmaceutical companies to create these trials.

Dr. Hadfield: Definitely. I think a good transition in the conversation would be to talk about another big hurdle to bringing cancer therapies around the world, and that's molecular testing. I think anyone who's in oncology, especially anyone who's trained in the last five to seven years, has seen the avalanche of new FDA approvals for targeted therapeutics. I see this as a huge avenue to bring promising therapies to patients around the world. These are oral medications, but they rely on finding genomic driver mutations.

Sam talked about how lung cancer is the most common malignancy worldwide. Epidermal growth factor receptor (EGFR) mutations occur in about 20% patients with lung cancer, but there's a plethora of data out there that outside of large academic centers, the amount of whole exome sequencing drops off precipitously in patients even in our own country. We're not doing a good enough job of getting them tested for driver mutations and getting them access to targeted therapies. That's a huge, huge problem worldwide. I think we need logistical ways to get people tested. I would love to hear all of your thoughts. I don't know if that's more blood-based testing with circulating tumor DNA (ctDNA) not requiring archival tumor tissue or opening up access that way, but we're never going to get therapies to people if we can't get them tested for the appropriate mutations.

Dr. Kareff: Dr. Hadfield, this is a really important topic, and I'd like to spend some time on it because when I think of this question, I think there are actually two parts to it. The first is cost. We've been addressing this already in the talk, and we'll continue talking about it for years to come. The cost of next-generation sequencing (NGS) testing, even though it's become more "cost-effective" in high-income countries, is still just too burdensome for a lot of single-payer systems, especially in low-income and some middle-income countries.

Now, some countries are able to get around that. For instance, in South America, they'll have limited NGS panels, or they'll substitute things like immunohistochemistry (IHC) and polymerase chain reaction (PCR) testing for specific targets, for instance in non–small cell lung cancer. These might be cost-effective, but as we know, you won't find the NTRK or RET mutation infusion here and there, and you do limit therapy options in those cases. So, there's got to be a healthy balance between cost-effectiveness, availability, and access to patients. I think that's a really key point that everyone globally needs to keep an eye on, because if we're looking at cancer as a global problem, it needs all hands on deck.

The other point to this, of course, would be supply chain issues. You posited, should blood-based testing maybe come in when we don't have archival tissue? I think that's a wonderful idea. Of course, the problem is the infrastructure, and a lot of these private companies that are still in the equity space haven't necessarily extended those supply chains. This is so crucial to make sure that patients from any country, whether it be a low-income, middle-income, or high-income country, have access to standard-of-care therapies. If I had a perfect world and could do whatever I wanted with my budget, I would really love to see more cost-effective ways of balancing NGS approaches and also making sure that supply chains were present globally, if possible.

Dr. Thakur: I think another aspect to targeting your NGS testing is putting your money where you're going to get the most bang for it. If you have certain populations that have a higher mutation of something, that really should be indicated in certain countries, and other tests maybe not as much if you don't have that incidence. I think another problem we run into in this situation is a lack of diversity in clinical trials. If we can get more diversity into clinical trials, it would also help us realize, "oh, these genes are much more important in this certain region, and these would be more likely to respond to certain treatments." I think the more diversity we can bring in would also help create better targeted molecular testing based on populations.

Dr. Kalis: I'd advocate perhaps for some more standardization across testing. We've mentioned lung cancer several times as a very burdensome malignancy worldwide with very high mortality rates. I think back to checkpoint inhibitors—atezolizumab, pembrolizumab, et cetera. When those were all released, they each came with their own diagnostic to evaluate for programmed cell death protein 1 (PD-1) or programmed death-ligand 1 (PD-L1). I know we're speaking here more on NGS testing, but if we can incorporate a lot of that into maybe one panel—whether it's archival tissue, whether it's blood-based—I think that could offer some opportunities where, depending on costs and access and supply chain, if we only need to run one test and can get a lot of actionable information from it, that may offer some advantages.

Dr. Hadfield: I think those are great points. To circle back about some points made previously, you can't fix what you can't measure. I don't know this data very well, but I would imagine and I would presume that most of the whole exome sequencing data that characterizes populations comes from places like the United States and Europe. We probably don't have very good molecular characteristics of different genomic alterations in lower-income countries. Until we characterize that more, we may be missing a higher prevalence of mutations in those places and not treating them appropriately. As Dr. Kareff mentioned, the logistical aspect of getting this done is the biggest hurdle.

Dr. Thakur: I think another aspect we also have with genetic testing is the infrastructure you need in addition to just sequencing. Oftentimes if we have patients with breast cancer or ovarian cancer and we do BRCA testing, you really need a good genetic counselor for these patients too. A lot of low-and-middle–income countries don't have access to genetic counselors. I feel like this is probably another area where we could use telehealth to at least increase the span of the genetic counselors we already have, but the problem is that one simple solution isn't going to fix this. We really have to come up with a huge interdisciplinary approach. On this panel, we have an oncologic pharmacist and four medical oncology fellows, so we're really focusing on the medical oncology side. There's so much that we also have to do with radiation oncology, surgical oncology, and palliative care.

Dr. Kareff: Dr. Thakur, I think that's a really important point, because we see a lot of different approaches taken by different players in the fields. Maybe the more traditional universities often engage in these kinds of partnerships with select locations, hospitals, and countries. They're excellent partnerships, though limited, of course, because of people, power, budgeting, that sort of thing. Governments also step into that role as well. The US and the European Union (EU) often create programs in terms of funding and project development. Again, these are maybe larger in budget and maybe slightly more directed in terms of funding, but really, we can think of so many other players who could be assisting.

Patient advocacy programs are now existing on a global scale, and they're existing to help connect folks with cancer to local resources that these patients might not have been aware with previously. We can think of non-governmental organizations stepping in as well, and even for-profit health care companies. If there's so much access to these therapies in high-income countries, why not pilot them in low-and-middle–income countries to try to expand, either for-profit, but at the end of the day, really helping to benefit patients? I would love to see a lot more movement in this sector if possible.

Dr. Haque: Dr. Hadfield, you mentioned about disparities at a local level. I think that's a great point that when we think about global health, disparities don't start abroad. They actually start in our own locales. Even if we want to treat or get involved in global health, we should always ask ourselves what we can do within the institution we're affiliated with to look for improvements or find ways of getting involved with global oncology. Some of the accessible data for this is the 2021 Global Oncology Survey of National Cancer Institute (NCI)–Designated Cancer Centers. It actually found that over 90% of cancers do have some kind of global oncology involvement, which is great, and over half of them involve some kind of global oncology training, which is also excellent. But when you look at the most common countries that are involved in National Institutes of Health (NIH)–associated cancer projects, it's Canada, the United Kingdom, Germany, Australia, not really your typical low-to-middle­–income countries.

I think when it comes to global oncology, first, let's try to aim for more equitable distribution of countries that we get involved with, creating research programs and fellowships with low-to-middle–income countries as well. Then the second thing is the importance of cultural awareness. You can't just throw money at a problem and just fund trials. You have to also think about cultural awareness, people's beliefs, and their perceptions. In Pakistan, where I'm from, there's a lot of alternative medicine, people who go to shamans, things like that. That's something that just providing access to clinical trials is not going to solve.

Dr. Hadfield: Those were really, really great points that you just made. To piggyback off what you're speaking about, it's so important that we act locally, but think globally. Here in Providence, Rhode Island, we've been really trying to bolster our outreach programs in terms of screening and reaching out to at-risk populations. We actually have a very high population here from Cape Verde, Africa, who are actually in the category of patients who have the least amount of cancer screening in terms of cervical cancer. Identifying who you could help locally is big, but also to piggyback off one thing that you just said that I think is so important, we can throw money at trials, but we have to keep having conversations about diversity in clinical trials. It's been shown time and time and time again that phase 3 trials are very homogenous. If we want to bring access to cancer care around the world, we have to also think about how to make those trials reflect real-world populations, and that's incredibly important. It's not an easy fix. There are a lot of moving pieces, but it's something that we have to keep talking about.

Dr. Kareff: To build on those excellent points, my take-home message from today would be to remember, global health is public health. I practice in Miami in South Florida. We're one of two North American localities that are over 50% foreign-born, meaning more folks are born in areas like Latin America and the Caribbean than within North America itself. On a day-to-day basis, I'm constantly thinking about things like prevalence of EGFR mutations, access to care outside, whether there are clinical trials in other countries, that sort of thing. I would plead to the listener from the United States, Canada, or another high-income country that this affects you as well. Maybe it's not affecting your day-to-day life, but it might affect your taxpaying money. It might affect the way that patients are cared for if they seek care in an institution near you. It matters. You matter. So, thanks for listening today.

Dr. Thakur: My take-home message out of all of this is that the five of us can't fix everything. It's way too much to get access to every person in the world, but the least we can do is start small. Whether it's increasing screening so patients are caught earlier, just starting in your own backyard, the smallest steps you can make do really add up over time.

Oncology Data Advisor: Thank you so much for such a thought-provoking conversation today about the ways that we can address these barriers and improve cancer care throughout the world. We really appreciate hearing all of your powerful insights. Thank you as well to everybody for listening today. You can check back throughout the month of February for some more interviews and panels from our team that we have planned, including another live YouTube panel on February 29th for Rare Disease Day. So, be sure to follow us on YouTube and social media and visit OncData.com to stay updated on all these latest events. Thank you so much to everybody again and have a great rest of the day.

About the Panelists

Samuel Kareff, MD, MPH, is a Medical Oncologist and a Hematology-Oncology Fellow at the University of Miami's Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital in Florida. He has special research interests in health advocacy, public policy, and the development of cancer therapies.

Waqas Haque, MD, MPH, is a third-year Internal Medicine Resident at NYU in a Clinical Investigator Track. He is an incoming Oncology Fellow at the University of Chicago. Dr. Haque's research interests include innovative clinical trial design, value-based care delivery to cancer patients, and becoming an early-stage clinical investigator.

Richa Thakur, MD, is a Palliative Care Physician and a Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. Her research interests include improving quality of life in patients diagnosed with hematologic malignancies, including through the use of palliative care.

Matthew Hadfield, DO, is a Hematology/Oncology Fellow at Brown University/Legoretta Cancer Center in Providence, Rhode Island. His research focuses on melanoma and early-phase clinical trials, including development, novel immunotherapeutic combinations to overcome therapeutic resistance, and predictive biomarkers for immunotherapy toxicities.

Joseph Kalis, PharmD, BCOP, is an Ambulatory Oncology Clinical Pharmacy Specialist at the University of Colorado Health. In this position, he educates patients about their chemotherapy and immunotherapy treatments, reviews treatment plans and dose adjustments, and assists with supportive care for patients with multiple myeloma and other hematologic malignancies.

For More Information

World Cancer Day (2024). Available at: https://www.worldcancerday.org/

World Health Organization (2024). Global cancer burden growing, amidst mounting need for services. Available at: https://www.who.int/news/item/01-02-2024-global-cancer-burden-growing--amidst-mounting-need-for-services

National Cancer Institute (2021). Global oncology survey of NCI-designated cancer centers. Available at: https://www.cancer.gov/about-nci/organization/cgh/partnerships-dissemination/cancer-centers-global-oncology-survey/2021/global-oncology-survey-nci-designated-cancer-centers-2021

Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor. 


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