Podcasts about international cancer control

Dr Yannick Romero (Union for International Cancer Control) discusses his Policy Review on the changing landscape of the national cancer control plans and his work with the international cancer control partnership.Tell us what you thought about this episodeContinue this conversation on social!Follow us today at...https://twitter.com/thelancet & https://Twitter.com/TheLancetOncolhttps://instagram.com/thelancetgrouphttps://facebook.com/thelancetmedicaljournalhttps://linkedIn.com/company/the-lancethttps://youtube.com/thelancettv

Drs. Lillian Siu and Melvin Chua discuss scientific innovations, disruptive technologies, and novel ways to practice oncology that were featured at the 2023 ASCO Breakthrough meeting in Yokohama, Japan, including CRISPR and gene editing, CAR T-cell and adoptive cell therapies, as well as emerging AI applications that are poised to revolutionize cancer care.   TRANSCRIPT Dr. Melvin Chua: Hello, I'm Dr. Melvin Chua, your guest host of the ASCO Daily News Podcast today. I'm a radiation oncologist and I currently practice in the Division of Radiation Oncology at the National Cancer Center in Singapore. I also served as the chair-elect of the ASCO Breakthrough Program Committee, and, on today's episode, we'll be discussing key takeaways from this year's Breakthrough meeting. The global meeting in Yokohama, Japan, brought together world-renowned experts, clinicians, med-tech, pioneers, and novel drug developers to discuss scientific innovations and disruptive technologies that are transforming cancer care today. I'm joined by Dr. Lillian Siu, the chair of the Breakthrough Program Committee. Dr. Siu is a senior medical oncologist at the Princess Margaret Cancer Centre and a professor of medicine at the University of Toronto.     You'll find our full disclosures in the transcript of this episode, and disclosures of all guests on the podcast are available at asco.org/DNpod.    Lillian, it's great to be speaking with you today.    Dr. Lillian Siu: Thanks, Dr. Chua. I'm happy to be here.    Dr. Melvin Chua: We were just at ASCO Breakthrough, and it showcased some incredible scientific innovations, and really showed us how technology innovations in precision oncology, biotech, and artificial intelligence are transforming cancer care. What are your thoughts?    Dr. Lillian Siu: Yeah, it was a really exciting meeting, Melvin. The theme of this year's Breakthrough meeting was “Shining a Light on Advances in Cancer Care.” And our Opening Session featured an illuminating keynote address by the renowned thought leader and tech trailblazer, Dr. Hiroshi or “Mickey” Mikitani, the founder and CEO of Rakuten and Rakuten Medical. In his address that was titled, “Innovative Technology and Oncology,” he spoke so passionately about innovation and really seeing around the corner to predict what is coming and taking risks. And I think that's what medicine is about, not just what we have in front of us, but to predict and forecast what's coming. I totally was inspired by his address, and I think a lot of the audience felt the same way. He also spoke to us a bit about his company's development in photoimmunotherapy using novel technology and light therapy in head and neck cancer. And I think that's also an area of new technology that we should watch in the next few years.    Dr. Melvin Chua: I totally agree with you, Lillian. And one of the quotes that he spoke about really spoke to my heart. He spoke about the 2 choices: whether to do or not to do and not to do is not an option. So, I think that was a very compelling message to a lot of our audience at the meeting.    So, on this same note, innovation is a driving force in oncology, and we saw countless examples of this throughout the Breakthrough meeting. Were there any sessions that really stood out for you?    Dr. Lillian Siu: There were so many exciting sessions. First of all, there is the “Drugging the Undruggable” session. This is a really important session because in the past we felt that certain cancer targets such as KRAS, MYC, etc., are not druggable. KRAS G12C is the poster child in this area. So, during this session we heard about many ways that we are now looking to target these so-called undruggable molecules in the cancer cell. And we talked about molecular glues, we talked about degraders, and really novel ways that are not yet reaching the clinic, called “cyclic peptides” were discussed by one of the speakers.     The other session that is very interesting also is CRISPR and gene editing. Obviously, we all know a little bit about gene editing, really trying to change or knock in some genes that are important perhaps to change the function. And one of the sessions talked about trail targeted induced mesenchymal stem cells, and perhaps this is a way to, again, deliver novel therapies and novel treatments to our patients. There were many examples of how CRISPR and gene editing can be ultimately going to the clinic to benefit our patients in terms of therapeutics.     I want to highlight another session, which is the CAR T-cell and Adoptive Cell Therapies. I think everybody knows about CAR T-cells, but in this session we talk about non CAR T-cells or newer things such as off the shelf NK cells, Natural Killer cells from cord blood. So, this way it is allogeneics, in other words, we don't have to rely on only a patient's donation of their samples, but actually get it from off the shelf from other donors. There are other ways to really use human induced pluripotent stem cells that we can armor them by transgenes and also CRISPR out any unwanted genes, for example, to enhance an effective function of T-cells. So many, many exciting ways to bring these cell therapies to the patients.     And last but not least, I want to highlight Dr. Chris Abbosh, who is one of our keynote speakers, talking about molecular and minimal residual disease and early cancer detection using circulating tumor DNA or liquid biopsy. He talked passionately about the TRACERx study, which he is instrumental in terms of leading together with Charlie Swanson in the UK. This is a study that really has uncovered a lot of science about cancer heterogeneity. And in that study, he also studied circulating tumor DNA and really shed a lot of light about clonal and subclonal dynamics over time that changes.     Dr. Melvin Chua: And just to touch on that point about innovation and how that translates to cancer care, I think it was great that we had those case-based applications in lung cancer, in breast cancer, and the virus-associated cancers. And I like how the speakers were able to bring in the Ying and the Yang, bring the West and the Eastern perspectives in these interactive sessions. I particularly enjoyed all of them. But the session on the lung case discussion where we know that there were this EGFR mutant lung cancers that are prevalent in this part of the world in Asia. I thought the interaction between the speakers was fantastic.     On the same note about therapies and we heard about novel therapeutics at this meeting as well. I wonder what your thoughts are about some of the sessions, and do you think some of these technologies were able to be brought into practice? And your thoughts on the novel therapeutic session that happened at Breakthrough, do you think this will actually impact clinical care?    Dr. Lillian Siu: Oh, for sure, Melvin. The 5 areas that were covered during the Novel Therapeutics session are really drugs already in the clinic. And for example, the first one was about antibody drug conjugates. We know there are now at least 12 antibody drug conjugates already approved by the FDA and many more likely to be approved in the near future. And the session really talked about what's next, how to improve upon ADC, for example, using better drug antibody ratio, talking about new payloads and really new formats that make perhaps ADCs even more potent in the future.     There was a session on oral immunotherapeutics. It was really how to target the innate immunity. And I think novel oral immunotherapeutics is very important because we all know PD-1, PD-L1 inhibitors have been the backbone, but we need another Breakthrough. And having oral immunotherapeutics will make it very attractive for patients because they don't have to come to the cancer center to receive the drugs.     Another part of that session was about T-cell engagers and bispecifics, really how to bring molecules to the T-cell, to the effective cells so that they are able to be phytotoxic to the tumor. We talked about also oncolytic viruses, how are the new ways to utilize this kind of natural agent to target the cancer cells. And lastly, we also talked about personalized cancer vaccine, which is obviously very timely. We all know a lot about vaccine now after the COVID pandemic and how do we use cancer vaccines to be a good therapeutic drug? I think especially important in the earlier disease stages as adjuvant therapy. Some exciting data, for example, in pancreatic cancer, as adjuvant really is groundbreaking for this whole topic of cancer vaccination.    Dr. Melvin Chua: That's great. And for me as a radiation oncologist who's not so deep in drug development, hearing all the talks at ASCO Breakthrough was really informative for me and I learned a lot. In particular, you spoke about the whole session there was oncolytic therapy and the results in glioblastoma multiforme, we know it's a deadly disease, was certainly very impressive. And so, it speaks to the whole notion that in fact, some of this stuff is in fact reaching the clinic and making a difference in deadly diseases. I think there's a lot to take in from there.    Dr. Lillian Siu: Melvin, you're so humble. I know you're a big expert in artificial intelligence and I think the whole session about AI applications in precision medicine really was not just in that session, but a whole theme that went throughout the entire meeting. So, I'm very interested to know what you think about some of the presentations around AI and disruptive technologies in precision medicine, such as next-generation multiomics, etc. What are your thoughts?    Dr. Melvin Chua: Absolutely, I agree with you. And there was so much material within the AI session, the multiomic session, as well as the keynote [address] by Dr. Maryellen Giger, which basically speaks about some of the pre-existing or historical work on artificial intelligence in radiology. And I'd like to first talk about the keynote by Dr. Maryellen Giger. It was very nice that she elegantly showed how AI was in fact already in practice in radiology, where it helped to fulfill or address a need for radiologists. Almost 20 years ago, they were able to show that using computer vision, you were able to basically facilitate the calling of abnormal mammograms. And it was inspiring to see how these early thoughts have now basically accelerated a lot of the advances that we see that are in practice today.     The other thing that was also was to see this global collaboration, the need for global collaboration in the artificial intelligence space and the radiologists are clearly leading the way. And I think part of the impetus for this effort came from an opportunity that arose during the COVID pandemic that clearly affected all facets of healthcare. That was a nice segue to the very sort of dense 1 hour session we had on precision oncology care with artificial intelligence. I think when we designed this session, we were very deliberate that we wanted to address all aspects of how AI could be applied. From real-world clinical data, we saw examples of how having good, well-annotated data sets could actually help to accelerate and facilitate liver cancer screening in Hong Kong. Then we also saw a very simple, practical application of AI in pathology, where apart from just having this tool to be able to extract features that could potentially predict outcomes of patients and predict drug responses, we saw a very practical example that applying AI in digital pathology could actually homogenize or harmonize the ways the pathologists review their cases. And so, I thought that was very neat and could speak to all our clinicians across both developed and developing countries.     We also saw very exciting stuff on the use of AI in terms of calling out mutations because we know that next-generation sequencing is pretty much a cornerstone of how we practice in oncology today. And yet we know that there are prohibitive costs that preclude this technology in certain parts of the world. And it was nice to see how AI could actually lower the cost of some of these sequencing technologies like being used in liquid biopsy.     And then finally, there was some fancy science as well that was showcased in the spectrum when we saw how industry as well as academics are thinking about integrating multiomic data sets to then be able to accelerate drug discovery, help define patients better, and so that we can think about how to look at precision oncology using targeted treatments for specific patient phenotypes. So I think this was a very nice transition to the Next-Generation Multiomic Technology session, where, again, some of these topics were touched on, ranging from liquid biopsies, and this was already covered in Dr. Abbosh's talk, which you spoke about, and as well as the preceding day session where we heard snippets of it. And it was again reinforced by the speakers when it showcased liquid biopsies. We have heard so much about it in the last decade and we see it made approved now for use in the clinic, but yet so much remains unknown, like the discrepancies between assays, addressing the cost of assays and, importantly, how we deal with the information. So, I think we are just at the tip of the iceberg here. A lot of the clinical evidence needs to be generated in due course to address some of these questions.     At the same time, it was also nice to see some of the new technologies being applied in discovery science. So, we know that immunotherapy is a major player in oncology today, and the Breakthrough represents a forum whereby we're able to bring translational scientists to showcase their work. And we saw examples of that at this meeting where single cell technology, digital spatial technology, being able to apply that in pathology specimens and how the two are integrated to be able to review more novel science to us, to show us how immunotherapy works or doesn't work in some patients. Both of us have touched on so much content that was showcased at the Breakthrough, and I think this speaks to the impact, the learning experience we've had from Breakthrough and I think that's the intended purpose of this meeting.    Dr. Lillian Siu: Yeah, I agree. It truly was a very exciting 3 days. And I particularly like the multiomics session where we see that the technology is so advanced just in a really short period of time. Over the last few years, we've been now able to go into single cell resolution where in the past I don't think we would ever dream of being able to do that. In fact, I recall in the single cell session, we can even see messenger RNA on the slide, which I thought was fascinating, something that I cannot imagine we can see by the naked eye. It really is an exciting time in oncology, Melvin, and the field is advancing with these new innovations and therapies, but at the same time, I think it's important that we do live globally and we need to work really also to help improve access to quality-assured cancer medicines and diagnostics in the low and middle income countries. What do you think about that part? Did we do a good job in addressing that in the meeting?    Dr. Melvin Chua: Absolutely, Lillian. We had a special session that was chaired by Dr. Peter Yu and the lecture was delivered by Dr. Gilberto Lopes from the University of Miami. And we know that he's a strong advocate for this. And the session title spoke to this topic very pointedly, “How Science, Technology, and Practice Can Be Enabled in Lower- and Middle-Resource Settings.” And I thought that the work that he highlighted, the whole ATOM coalition, was important. ATOM basically stands for Access to Oncology Medicines, and it was established last year by the UICC, the Union for International Cancer Control, along with global partners to improve access to anti-cancer drugs and to develop processes for ensuring quality delivery, as well as the optimal utilization of medicines in middle- and low-resource settings. And I think there's a lot more work to be done.     Some of the information they showed was very compelling to me from this part of the world. But we know that Asia isn't very heterogeneous in terms of the resources, in terms of the culture. And I thought that the drug pricing, for example, how that should be addressed across the different countries is an important topic to pick up. And I hope his lecture only invigorates this conversation going forward.     Dr. Lillian Siu: Yeah. Thanks, Melvin. I totally agree. That was very inspiring. Breakthrough is such a one of a kind, international gathering that we are not only able to network while we're there; we also have a session to really allow attendees to leverage international cancer networks, to learn a bit about them, all the way from, for example, some of the North American groups to Asia Pacific groups to even global groups, and how we interact between pharma and academia, really transcending boundaries. And I think it is really, really important for us to now have these networks address issues such as equity and cancer care innovation, novel approaches and so much more. And I think, I am sure you're going to do a good job in making sure that gets into the agenda in our next year's meeting in 2024. Ultimately, we hope that these collaborations in cancer research will help to improve the outcomes for our patients with cancer.    Dr. Melvin Chua: Thank you again for sharing the great highlights of ASCO Breakthrough, and I'm really appreciative of your work, and your commitment to build a really robust program for this year. So, thank you.    Dr. Lillian Siu: And thank you, Dr. Chua. And you can bet that I will not miss Breakthrough 2024 in Yokohama in August next year. I will be there.    Dr. Melvin Chua: Okay, I'll hold you to that.     And thank you to our listeners for your time today. You'll find links to all of the sessions discussed today in the transcript of this episode. And finally, if you value the insights that you hear on the podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Thank you again.    Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    Find out more about today's speakers: Dr. Lilian Siu  @lillian_siu  Dr. Melvin Chua  @DrMLChua    Follow ASCO on social media:   @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn      Disclosures:   Dr. Lillian Siu:  Leadership (Immediate family member): Treadwell Therapeutics  Stock and Other Ownership Interests (Immediate family member): Agios    Consulting or Advisory Role: Merck, AstraZeneca/MedImmune, Roche, Voronoi Inc., Oncorus, GSK, Seattle Genetics, Arvinas, Navire, Janpix, Relay Therapeutics, Daiichi Sankyo/UCB Japan, Janssen, Research Funding (Institution): Bristol-Myers Squibb, Genentech/Roche, GlaxoSmithKline, Merck, Novartis, Pfizer, AstraZeneca, Boehringer Ingelheim, Bayer, Amgen, Astellas Pharma, Shattuck Labs, Symphogen, Avid, Mirati Therapeutics, Karyopharm Therapeutics, Amgen    Dr. Melvin Chua:  Leadership, Stock and Other Ownership Interests: Digital Life Line  Honoraria: Janssen Oncology, Varian  Consulting or Advisory Role: Janssen Oncology, Merck Sharp & Dohme, ImmunoSCAPE, Telix Pharmaceuticals, IQVIA, BeiGene  Speakers' Bureau: AstraZeneca, Bayer, Pfizer, Janssen   Research Funding: PVmed, Decipher Biosciences, EVYD Technology, MVision, BeiGene, EVYD Technology, MVision, BeiGene  Patents, Royalties, Other Intellectual Property: High Sensitivity Lateral Flow Immunoassay for Detection of Analyte in Samples (10202107837T), Singapore. (Danny Jian Hang Tng, Chua Lee Kiang Melvin, Zhang Yong, Jenny Low, Ooi Eng Eong, Soo Khee Chee)       

"Various places on the globe lack the proper knowledge, infrastructure and workforce to adequately treat cancer. In Africa, one doctor is focusing her efforts to change all that. This ASCO Education podcast spotlights Dr. Miriam Mutebi, the first female breast surgeon in Kenya. One of Dr. Mutebi's goals is to improve women's health and cancer care in Africa and includes attaining her pilot's license to reach remote areas of the continent. Dr. Mutebi reflects on her life growing up in Kenya (1:21) and her inspiration for getting into medicine and pursuing what was at the time a male-dominated specialty (5:07). She also details how cancer care has improved in Kenya in the last decade (12:49) while there are ongoing challenges of working in low-resource settings (23:25). Speaker Disclosures Dr. Miriam Mutebi: None Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Resources: ASCO Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 1) ASCO Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 2) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Pat Loehrer: Welcome to Oncology, Etc. an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson: And I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. Pat, we have a terrific guest today that ties in very nicely with your interest in global health. I'd love for you to introduce her. Pat Loehrer: Thanks, Dave. Battling cancer is truly a global effort, both in research and in treatment. However, there are various degrees of quality in these fields, depending on the economic health of a particular region. Our next guest is trying to optimize cancer care in Africa. We're very excited to talk to her. Dr. Miriam Mutebi is one of the most prominent cancer doctors in Africa. Dr. Mutebi is the first female breast surgeon in Kenya, and she's currently assistant professor in the Department of Surgery at the Aga Khan University in Nairobi, Kenya. She's on the board of directors for the Union of the International Cancer Control. She has trained and studied at top hospitals in New York and South Africa. Dr. Mutebi is so focused on increasing women's health in Africa that she's trained to be an airplane pilot in order to connect with hard-to-reach areas. Disclosures for this podcast are listed on the podcast page. Thank you so much, Dr. Mutebi, for joining us from Kenya. Can you start off by telling us a little bit about what it was like growing up there? Dr. Miriam Mutebi: I grew up in Nairobi, which is a pretty urban setting to grow up in. So, most of my childhood was spent…I think it was probably a much simpler time where, you know, you would play in the street, go off to somebody's house, spend the rest of the day there and come back at the end of the day. But in terms of growing up, I think I was one of those super nerdy kids, for want of a better word. One of the sorts of things that got me interested in reading and learning and challenging myself was actually my dad. Because what would happen was we had to go to school, I would say almost about 30 kilometers bus ride, and my dad would be like, “Well, if you're on the bus for that long, you can as well, you know, carry a book and made it nice and exciting.” So I remember sort of discovering the library at my primary school and going like, “My word!” Because you get access to all these different experiences and worlds. I mean, you're going in and reading, you know, The Chronicles of Narnia, you're reading about Enid Blyton and different experiences, you're reading all these different worlds and getting to, you know, identify to some extent with the core values that exist. It doesn't matter where the books were centered. And so that for me was an almost, I would say, idyllic growing up, because for me it was like, “Yes, books, check; running around, check.” That's, I think, what I remember most about my childhood. Dave Johnson: It sounds like your father was a powerful influence in your youth. Can you tell us more about your father? Dr. Miriam Mutebi: Sure. My dad, how old is he now? He's going to turn 74. One of the things that he always says, “It costs you nothing to be kind.” And so he would generally– Sorry, I'm just going to stop a little bit. I'm getting weepy. Dave Johnson: I'm sorry. Dr. Miriam Mutebi: It's okay, it's okay. Shame. Dave, you pushed the button. Dave Johnson: It's not our intent to push a button. It sounds like your dad's a wonderful person. Dr. Miriam Mutebi: No, it's fine. Pat Loehrer: Both Dave and I have daughters, and we feel the same way. So as weepy as you're getting, I can guarantee you that he's going to feel the same way on the other end. Dr. Miriam Mutebi: No, it's just that he hasn't been well recently, so it's just– Dave Johnson: Oh, I'm sorry. Dr. Miriam Mutebi: Yeah. Okay, cool. Let me see if I can stop getting a little weepy. Yeah. So one of the things that he frequently says is that it costs you nothing to be kind, and I think that's one of the things that he sort of instilled in us that you need to think beyond yourself. You always need to sort of think about what is the other person going through and how can I help to make it better. Now, my dad, he has a really interesting sense of humor. I think it's where I get my cheesy humor from as well. But he always talks about what we call the 11th commandment, which is, don't take yourself too seriously. And so I think that was part of the grounding steps that he sort of helped to instill in us because he was working– I mean, sort of looking back, our parents, I would say, got married at a very young age and had several kids that they were raising. And sort of looking back, you're thinking they were probably just doing the best that they can, right? But I think he did a fairly decent job, I hope. Dave Johnson: So, Miriam, when did your interest in medicine begin, and who was the inspiration for that? Or if there was someone that inspired that? Dr. Miriam Mutebi: At the end of high school, I remember I wanted to do five or, rather, was it six different things. And so I wanted to do medicine, I wanted to write, I wanted to do architecture, I wanted to do law, I even forget what the other things were. There was like two other things on my to-do list. And I think part of the genesis of that was because, as part of the high school training that we go through, we had to do the international sort of baccalaureate, and what that entails is we have to do components of creativity, action, and service. And so at the end, I'm like holding back to father dearest, and I'm like, “Dad, I have six different things I want to do, and I don't really know about.” And he was like, “So why don't you spend a bit of time, sort of just going through each of those, like shadowing these different specialties?” And so we managed to track down his lawyer friend, spent time in the hospital, spent time in the pharmacy, just shadowing the pharmacist. I actually went to work briefly for a publication house. Eventually– Oh, yes, in architecture as well. So then I managed to narrow it down to, “Yes, okay, I want to do medicine, and I want to write.” And so I went back to my dad and said, “Dad, okay, I have two things I want to do.” And my dad was like, “Well, if you do medicine, you can write. But if you write, then you might not necessarily be able to do medicine.” So that's how I sort of wandered into medicine. Although I still say there's still the great African novel waiting to get out. But again, with medicine, I think I'm guilty of what we call ‘end of rotationitis', where at the end of the day, you finish a rotation, and you're like, “I can do this. I can do this.” So I think going through different rotations– I think for me, the drive– Well, the slow narrowing down to surgery was really around, unfortunately, the time when we were doing our rotations, and this was just really at the start of the 2000s in Kenya. And the challenge around that time was we're really just at the tail end of the HIV epidemic, and not everyone had access to antiretrovirals. And it was an incredibly harrowing time, I would say, for the healthcare profession, just because there was still a lot of stigma around HIV. And what was happening was that we would go to the wards and find patients had been abandoned. And there was a general sort of pervasive sense of hopelessness because people didn't have access to the medication, they'd been abandoned, and unfortunately, not much was being done in terms of active management to patients. Whereas then that was like on the 7th floor, and then you would go four floors down to the surgical ward where patients come in, they're bleeding; you take them to OR, they get better, you send them home. And so, for me, the timing was like, “I need to do this. At least I could see where I was making an impact.” And so that's sort of how I wandered into surgery. And I'm sure, as I said, with, of course, the developments now, the experience, of course, for medical rotations, they're entirely different, but that's how I sort of ended up in surgery. But then, how I sort of found myself in breast surgery was actually because– for me, what stood out about my breast rotation was really looking at what we were reading in the textbooks, which was breast cancers, the disease of the sixth and seventh decade and a “poster child” for this is the elderly nun who's never had any children, who's had this prolonged [inaudible]. And I'm sitting there and looking at the clinic, and I'm like, “These patients are in their 30's and 40's. All of these traditionally protected factors, like having multiple children, having breastfed, ticking all the boxes, but they're still coming in with these kinds of cancers.” And so just thinking this is totally different from what the textbook is saying, and somebody needs to get to the bottom of this, and that's how I found myself going in along breast cancer surgery and also research into women's cancers and things. Pat Loehrer: My sense is that Kenya and many African nations were male-dominated. I don't know what it was like for you going to medical school, but particularly in surgery, it tends to be a male-dominated field. What was that like as a woman? In many ways, I think you were breaking some glass ceilings. I'm sure other women are doing similar things, but tell me a little bit about that experience. Dr. Miriam Mutebi: I would say bewildering for both parties. Because we had to do several interviews just in different institutions before getting into a surgical residency, and I remember these senior professors sort of peering down their glasses and looking frankly bewildered and asking the most bizarre of questions, which I don't think anyone would sort of get away with in this day and age. I remember somebody asked me, and this one always stands out in my mind because somebody asked me on the interview route, “So what happens if you get a patient in ICU and you start to cry?” I'm like, “Well, first of all, I'm guessing that I am crying because I'm having a bit of empathy for the patient. And I think that actually probably makes me a better clinician because I am really truly seeing the patient rather than bed X with diagnosis Z. This is like Mary, mother of one, two, three, and whatever.” But it was really bizarre. Then somebody asked me as well, “Okay, so what happens when you're on call, and you have to breastfeed?” And I'm like, “Well, let's see. This is a tough one.” You could tell as well that they were really out of their depth. So,  eventually I settled on the Aga Khan just because, in terms of the faculty and the interviews, I got a sense that they were a little more open to the idea. And that's because I think one of my earlier mentors, Prof. Raja, who is our former chair of surgery, had come in from the Aga Khan in Pakistan. And for him, it wasn't anything unusual to see women in surgery. So, like, “Yeah, come along. We'll train you and stuff.” And he was also pretty inspiring in terms of the decision to get into surgery because, for him, their approach to at least surgical training– and we always tease him and say, we all drunk the Kool-Aid because we kind of came back. Because it wasn't about just training surgeons for surgery's sake, it's about how do we become leaders, how do you impact care in your region. And so it was never about just learning surgery; it's how do you use the tools that you have in order to improve the health of those around you. In the Aga Khan, you're sort of, one would say, in a position of privilege. Just the backstory to those listening who might not know about the Aga Khan, it's a private university hospital. But I mean, as a private center, then, of course, I would say there isn't any difference, one would say, between the Aga Khan and most of the international hospitals anywhere in the world. But it was always sort of driven into us that this is a privilege that you're having. And how do you use this privilege to elevate the communities around you? Pat Loehrer: Let's talk about breast cancer, if you will, in Kenya. You mentioned it that when you first went into it, patients were coming in with advanced disease, they still do. But how has the field of medicine changed in Kenya during your professional lifetime as it pertains to breast cancer? Dr. Miriam Mutebi: While we still have the majority of patients diagnosed with advanced disease, the scenario ten years ago was that patients would get diagnosed with advanced disease and frequently would not complete their care. And if we did a deeper dive into the reasons behind this, we saw a constellation of factors. One being the fact that patients were having to pay out of pocket, resulting in financial toxicity, catastrophic health expenditure. And then the other major barrier was the health system itself. And again, to some extent, that still exists where we know, at least on average in sub-Saharan Africa, patients are going to see 4 to 6 healthcare providers before a definitive diagnosis of their cancer is made, which of course, again, translates into delays in ultimate treatment. Another area that we frequently don't necessarily talk about as much are the social-cultural barriers that exist and, to some extent, are still pervasive in some communities. What we see is, one, there's a lot of use of alternative therapies. There is still quite a bit of stigma around cancers. There is what we call collectivism, where we always say in Africa, ‘our community is our strength'. But sometimes, that sense of community is a double-edged sword because then, if the patient is losing agency, then that becomes a real concern. Because what we find, for instance– I'll give you an example, I'll have a patient come in and discuss, and maybe she has early cancer, and discuss the options of having breast conservation versus a mastectomy. And then you will find maybe she goes home to have a think, and then a couple of days or whatever later, there's a community gathering, and the clan elder is saying, “We have decided.” And I'm like, “Who's we? That's not your breast coming off. Like, what right do you have to decide on patient decision-making?” But you see, as much as we would like to sort of say have the patients have autonomy over the decision-making, it's really a question of equity and access to care. Because even if you're giving the patient autonomy, and she's saying at the end of the day, “Well, they're the ones paying for the treatment so let them decide what it is I'm going to have”, then we haven't really adequately empowered our women. And so those are some of the challenges that existed, I would say, about ten years ago. We're definitely seeing an improvement. One in the patient's ability to pay, and this, I think, has been a concerted effort by the government to come up with a National Health Insurance Fund, which initially wasn't covering cancer care but has definitely helped to ensure that the number of patients who actually complete their care or going through their entire cancer journey are probably more.   I remember when I was doing my internship, there were like truly heartbreaking because, as interns, we would have the medical internists sometimes– and because there weren't that many medical oncologists– prescribe the chemotherapy and as interns, we were the ones who would administer the chemotherapy. And so, you would have a patient come in and it involves– Basically, we give the prescriptions like chemotherapy, but they'll also have to buy their own saline, the IV line, and everything else,,, and then they get the first cycle, and they just disappear. And then those were the times when mobile phones weren't that common. They literally just disappear. But then they come back six months later, and they're like super excited, and they're like, “Doc, we've raised enough money for the next cycle.” And we're like, “Well, it doesn't quite work like that.” So, with the National Hospital Insurance Fund, it's not perfect, but we definitely see more patients going through the entire care continuum, which is gratifying. I'm sort of putting on my  [inadudible] hat as the chair of Kenya Society for Hematology and Oncology, and we've been working closely with the National Cancer Control Program, really to advise the National Hospital Insurance Fund on maybe getting more comprehensive covers. Because what was happening initially was, for instance, they would cover maybe four cycles of chemotherapy. Then the patient has to come up with the remaining four, for instance, and sometimes if they're not able to afford that, then you're sort of giving them the side effects without the therapeutic benefits of some of these. So they are currently in the process of really looking more at treatment plans, and that's also been, at least, a truly– And the fact that they are willing to listen has also at least been a huge stride. And then, of course, in terms of the real efforts, I would say by the National Cancer Control Program to ensure some of the decentralization of cancer services. Initially, we had only one radiotherapy center at the tertiary referral hospital in Nairobi that was having patients traveling from across the country, 400 kilometers or more, coming in. And you come in from a rural area, you come into Kenyatta and somebody tells you have to live there for a month, you have no family, nowhere to stay. People say, “You know what? I don't need to have this stage or rather have this additional treatment.” And so with the deliberate development of or decentralization of the radiotherapy services, we now have at least regional centers in planning and so really looking at how do we bring the services closer to people. And so, we now have, in addition to the tertiary referral centers, we now have two regional centers in Mombasa and in– Pat Loehrer: Eldoret. Dr. Miriam Mutebi: Yes. I think beyond Nairobi, Eldoret, we now have a comprehensive center in Mombasa. Nakuru's just launched a comprehensive center and Garissa as well, so really looking at enhancing our capability to bring these services closer. And there has also been the development of the chemotherapy units across the country that have at least tried to ensure that these services are more readily accessible to populations. And really just underpinning that with the support from the National Hospital Insurance Fund has helped to basically have more patients completing their care. One of the other things that I think deserves particular mention is really the grassroots advocacy that has really tried to increase awareness around cancers. And as a result, we definitely are seeing, as much as we are saying the majority of patients are still diagnosed with advanced disease, we are definitely seeing the entire continuum all the way from screen-detected tumors, early stage I, stage II cancers to more advanced tumors. So with that, it also really shows that there is a continuing consciousness that's really sort of driving these education efforts and awareness in the community. Of course, we definitely do need to do more because we still see that the advocacy's efforts sometimes tend to center largely around urban areas. And also, the question is how do we then sort of percolate that down to more rural areas? It's definitely something that's improved in the last ten years. And then, of course, we've also seen an expansion in the cancer workforce. And that, I think, has also been largely driven by the fact that we're having in-country training for clinical oncology, medical oncology, gyne-oncology, so we're really thinking about how to expand the workforce but– Of course, we are still looking at the patient-to-population ratios, those are still pretty low and we still recognize that there are deficits along the care continuum. But we're now having pharmaco-oncologists, we are having psycho-oncologists, increase in palliative care specialists. So there's definitely been an exponential growth of all the cadres of healthcare providers, whether it's oncology nurses and things. We've had an oncology nursing chapter now that's been developed. We really see the rise of the professional societies like the Kenya Society of Hematology and Oncology, and there is a lot of crosstalk between the academic institutions that are running the oncology training programs. So it's really a positive move in the right direction, but I think what needs to happen is, as I would say, more deliberate investment in the workforce. Because, again, even as we increase the spectrum of the oncology workforce, there's really a need to carry along the primary care providers because they invariably are the gatekeepers to access. And so unless the primary care providers are empowered and knowledgeable to facilitate early and timely diagnosis and referrals to the appropriate pathways, then it doesn't matter how many people or how much of a workforce you have on top of the pyramid. It just means you're invariably going to be still getting patients diagnosed at later stages. And so there's also been efforts around that to come up with, from healthcare provider courses to educating common signs and symptoms. This is something that the Kenya Society of Hematology and Oncology has been doing in collaboration with the National Cancer Control Program. There's a deliberate effort to come up with an online platform that are actually able to give real-time information to primary care providers. And so, I would say there are definitely steps in the right direction, but there definitely needs to be more investment in the entire spectrum of care. Dave Johnson: Miriam, what you've done is astonishing. What you've just described is an amazing infrastructure in a relatively short period of time. What you're talking about took us in the United States half a century. You're trying to do that in a matter of five to ten years. You've trained in both Kenya and in the United States. I wonder if you might just take a few moments to compare and contrast those experiences. Dr. Miriam Mutebi: In terms of working in different spaces and sort of working in the US, working in South Africa, working in Kenya, what you realize is perhaps a very different patient profile. Whereas in countries like the US, where you have vibrant screening programs, and you're definitely having a lot more discussions around 4-millimeter, 5-millimeter tumors that you are doing an MRI-guided biopsy for and maybe a lot more screen-detected tumors. Whereas working in settings, especially when you get out of the urban areas, whether it's in Kenya or South Africa, you find that you tend to have a lot more diagnoses of patients coming in with fungating tumors and advanced disease, and so it's really that spectrum. And that's what I'm saying in terms of the current state of flux that we're in. We're now, as clinicians, at least working in Nairobi, you're sort of seeing the entire spectrum and much less and less of the sort of fungating tumors. So I think in terms of the principles, and the good thing is that irrespective of where you are, principles do not change. But I think you sort of have to rapidly innovate and iterate in settings where you may not necessarily have a say, MRI to do an MRI-guided biopsy, but you also sort of look at what makes sense for the patient. Working in lower-resource settings, I think, is actually a good thing because it challenges you to constantly think about value-based care. People talk about value-based care as a concept, but you're doing it on a day-to-day basis, even between different patients in clinic, because you have to think about the cost and you have to think about how do I deliver care that's still of good quality, that's not necessarily going to break the bank. And so these are some of, I think, more challenging or at least questions that we have to think about deliberately. Whereas in the US, if you have insurance, then it's pretty much carte blanche, for want of a better word. Which we did realize, especially with COVID - and I'm sure Pat and Dave you can bear testament to this - these disparities exist globally. And so you'll find that in your patients who have no insurance or are underinsured, they're still coming in with the same, sort of, challenges. I was talking to my colleague at NYU who works at Bellevue. When she was giving me the profile of her patients, it was interesting to see that there wasn't really– and these are patients who don't necessarily have insurance, there really wasn't any difference in the images we are seeing from patient they're seeing and the patients we're seeing. So really it's an opportunity for us to sort of rethink collectively our approach to care and really thinking about how do we provide quality care. Pat Loehrer: I was in Washington this week, and President Biden had a three-day African US summit, and at the end of this, he basically pledged to spend $55 billion in Africa to help relations with them. We also had a discussion about the Moonshot 2.0, in which President Biden wants to end cancer as we know it, with a particular emphasis, I think, and now, in linking with LMICs. Briefly, what would you tell President Biden in terms of what would be very helpful for the United States to help with the cancer problem in sub-Saharan Africa? What would you say in a sentence or two? Dr. Miriam Mutebi: As we say, perhaps have the Moonshot, but stay grounded in the sense that– even before we think about complex molecules, we are still struggling as a continent with the basics of care. And so, investing in health systems and the basics will ultimately give more or improve outcomes rather than sort of focusing on specific molecules. So if we have the basics in place to deliver the basics of care, then that would go a long way toward shifting outcomes. The other bit that does need to happen is, again, with research because there is a paucity of cancer research. We did a recent bibliometric analysis and found that as a continent, we are only contributing to less than 8% of all sort of cancer research globally. And we do know that one, we have, I would say, the breadth of diversity in terms of genetic diversity. We do know that the responses to care and treatments are different. We do know that we do need to think about implementation science and what structures we can put into place, and what strategies. What works in different settings might not necessarily work in ours, and it does need to be backed by evidence. So there are opportunities to expand care and strengthen systems, but really do this in an evidence-based, pragmatic way that ultimately [inaudible] its own outcomes and outputs for the patient. Dave Johnson: Thank you for that, Miriam. Pat Loehrer: Well said. Thank you. Dave Johnson: Great advice. I hope the President is listening. Pat Loehrer: Dr. Mutebi, what was the first book that you remember that you really loved? Dr. Miriam Mutebi: I think it was actually The Lion, the Witch, and the Wardrobe. It was just the whole sort of just stepping into a different world. And then, of course, we all had crushes on Aslan, the lion, but it was more because he was like this sort of guy who would swoop in and was morally just and get to mediate the world. And so I went through the whole series, I just gobbled it down, and I think that's one of the things that really stands out for me as one of the books that I sort of remember early on. Pat Loehrer: It's such a great pleasure today. I'm really excited. We're typically talking about books. And here's a book, Dave, I know that you have not read; it's entitled 101 Things I've Learned in Engineering School. It was an interesting book. As you know, I'm an engineer background, but there were a few quotes in here that I– Dave Johnson: Pat, I live on Purdue Avenue, so I have some engineering background. Pat Loehrer: Oh, that's true. Good for you. So you might like this one, Dave. One of the quotes I have is: "Inventing is a mixing of brains and materials. The more brains you use, the less materials you need." And another one - do you know the difference between accuracy and precision? They're really different things. And so, the best example that came from the book, which I thought was interesting, was pi, so pi is what? Dave Johnson: Round. Pat Loehrer: Okay, this is going to be painful. Pi is 3.14. Right? So that's accurate. But if you say pi is 3.1415926535, that's accurate and precise. And if you said pi is 3.98, that's just inaccurate and imprecise. As I think about engineering as we move forward, I'm thinking about the Lung Pragmatic trial that has just been announced, where we're trying to do trials a lot more simply in which I think we can be accurate, but perhaps not as precise as we always deem to be important. And I think we're really excited about that and that project. Dave Johnson: Well, that's really all the time we have for today. And we really want to thank you, Miriam, for a wonderful interview. And knowing that you're up very late at home makes it all the more special. We also want to thank our listeners to Oncology, Etc. This is an ASCO educational podcast where Pat and I will talk about just about anything. If you have an idea for a topic or a guest you'd like us to interview, please email us at education@asco.org. Thanks again. Pat, I have an important question for you before we leave. What do you call a snail that's not moving? Pat Loehrer: You got me, man. Dave Johnson: Escarstay. Pat Loehrer: I love it. Miriam, Asante sana. Dr. Miriam Mutebi: Nime Shukuru. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.      

Antimicrobial resistance - or drug resistance - is one of the most serious health threats facing humanity. It could cause 10 million deaths per year and cost overall USD 100 trillion to the global economy by 2050. Dr Cary Adams, CEO of the Union for International Cancer Control and Kevin Outterson, Professor of Law at Boston University and Executive Director at CarbX discuss this rising global health risk. Hosted on Acast. See acast.com/privacy for more information.

Most people will have heard of cancer stages 1,2,3 and 4 but may not know exactly what they mean or where they come from. These terms form the basis of the international TNM Classification system, which describe how advanced a cancer is when it is diagnosed. This system has proven to be groundbreaking in healthcare, as it allows doctors to explain the cancer to their patients, prescribe the appropriate treatment plan, and improve information sharing and research across populations and regions. The Union for International Cancer Control has pioneered the TNM Classification for the past 50 years. With us for this next episode of Let's Talk Cancer is Dr Mary Gospodarowicz, UICC Past-president and Co-chair of the UICC TNM Project. Hosted on Acast. See acast.com/privacy for more information.

Today we are bringing you a round up of three stories from around the world. We will start at the 2021 World Cancer Leader's Summit, then move onto a story on how radiotherapy can cut late gastrointestinal toxicity for cervical cancer patients, and finish with lessons on what COVID has taught us about cancer care. All interviews are brought to you by journalist Peter Goodwin. First up, we hear from radiation oncologist Stephen Hahn, MD, who was the U.S. Food and Drug Administration's Commissioner from 2019 to 2021—where he oversaw all manner of regulations concerning COVID-19 vaccines and therapeutics. In his 2021 address at the World Cancer Leaders' Summit, Hahn discussed "What can we learn from the development of COVID-19 vaccines." During the summit, leading cancer decision-makers from about a hundred countries met online to assess whether innovations generated during the pandemic of COVID-19 could be harnessed to improve cancer treatment and prevention. Journalist Peter Goodwin was curious to know about decision-making at the FDA during this crucial period of American history.Next, from Mumbai, India—there's news that the new adjuvant radiotherapy standard of care for cervical cancer—image-guided intensity-modulated radiotherapy (IG-IMRT)—should cut late gastrointestinal (GI) toxicity rates by 50 percent. This according to mature results from the Phase III, randomized Postoperative Adjuvant Radiation in Cervical Cancer (PARCER) study.Although IG-IMRT is a newer—more costly—form of radiotherapy that has already been shown to reduce early toxicity rates to some extent when compared with conventional three-dimensional conformal radiation therapy (3D-CRT), up until now it had not been shown to outperform the older technique either in terms of medium-term toxicity or anti-cancer activity.The PARCER findings, however, demonstrate clear superiority for long term GI toxicity. They confirm equivalent anti-neoplastic efficacy.Peter Goodwin interviewed first author Supriya Chopra MD, DNB, from the Tata Memorial Centre's Homi Bhabha National Institute in Kharghar near Mumbai, India. She discusses the strong mandate that the study has brought for choosing IG-IMRT adjuvant radiotherapy for patients with early cervical cancer in whom surgery is needed.Lastly, The COVID-19 pandemic has taught us a lot about cancer care—according to one of India's most prominent oncologists, C.S. Pramesh, MS FRCS, Director of the Tata Memorial Centre in Mumbai, India. He also spoke at the 2021 World Cancer Leaders' Summit, organized by the Union for International Cancer Control, and hosted virtually by the American Society for Clinical Pathology. After the meeting OncTimes Talk reporter Peter Goodwin caught up with him to ask for his take on the impact the pandemic has had on cancer medicine, and about his views on how to improve medical practice and cope better with future crises.

February 4 is World Cancer Day, an international initiative focused on raising awareness of the importance of preventing, detecting, and treating cancer. World Cancer Day is led by the Union for International Cancer Control to support the goals of the World Cancer Declaration. This year, the focus is on Closing the Gap. In this CAPcast interview, CAP President Emily Volk, MD, FCAP, talks with Joseph Khoury, MD, FCAP, who is chair of the CAP's Cancer Committee and Mary Edgerton, MD, PhD, FCAP, Chair of the CAP's Pathology Electronic Reporting Committee about how the CAP and pathologists are working to improve access to quality care. For more information on CAP Protocols, please visit the Protocols & Guidelines section of CAP.org: https://www.cap.org/protocols-and-guidelines.

Hi friends, this is Dr. Michael Williams and welcome back to another episode of the diversify in path podcast. This podcast explores how investing in diversity can lead to a high return of investment in pathology and laboratory medicine by learning from the knowledge and experiences of diverse voices within our field.My next guest is Dr. Dan MilnerDr. Milner completed his MD at the University of Alabama School of Medicine in 2000 and his residency/fellowship in Anatomic Pathology/Clinical Pathology/Microbiology at the Brigham and Women's Hospital in 2005. His masters of science in epidemiology is from the Harvard T. H. Chan School of Public Health were he remains an adjunct professor. He completed his masters in business administration from the UAB Collat School of Business. Dr. Milner began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In parallel with this, he has been heavily involved in pathology capacity building in many countries and, most notably, led the team that built an anatomic pathology laboratory in Rwanda and Haiti for advance cancer diagnostics. Before joining ASCP in 2016, Dr. Milner spent 11 years at the Brigham and Women's Hospital/Harvard Medical School where he taught pathology, microbiology, and infectious disease; was the primary lead for infectious disease consultations in AP/CP; and was the recipient of numerous research grants in the areas of malaria and HIV. Dr. Milner is the author of over 150 publications and has presented national and internationally on his work in more than 25 countries. At ASCP, Dr. Milner is responsible for medical oversight of all organizational activities. He provides vision, direction, and execution of ASCP's Center for Global Health programs including communicable and non-communicable diseases. Dr. Milner and the CGH manage over 80 active collaborations with governments, NGOs, industry, academic centers, and international organizations with activity in more than 30 countries. Dr. Milner's leadership roles/experience with global efforts is extensive and he serves as a direct collaborative consultant in the area of diagnostic pathology for global health to Partners in Health, Mount Sinai, Memorial Sloan Kettering, Clinton Health Access Initiative, American Cancer Society, BIO Ventures for Global Health, Bristol-Myers Squibb, World Health Organization, World Economic Forum, World Child Cancer, Perkin-Elmer, International Collaboration for Cancer Reporting, International Cancer Control Partnership, City Cancer Challenge, and the Union for International Cancer Control.Twitter: @damilnermdInstagram: danmilnermdInstagram: ASCP_CMOPodcast: ‎Inside the Lab on Apple Podcasts This episode is also in memoriam to Dr. Felix M. BrownFelix M. Brown, M.D. '93, a pathologist and associate director of surgical pathology at Brigham and Women's Hospital, died of cancer on May 27 at his home in Dedham, Mass., at the age of 36. In his honor, the Department of Pathology at Harvard has created an annual award to be presented to pathologists-in-training whose qualities of humanity, generosity and dedication complement their talent as physicians.https://medicine.yale.edu/news/yale-medicine-magazine/in-memoriam-62080/

The downstream impact of COVID-19 on related outcomes in the diagnosis and treatment of noncommunicable diseases, such as cancer, will likely be felt for years to come. Since the early days of the pandemic, hospitals and health systems around the world have seen a steady decline in preventative health screenings and treatment, particularly among those living with cancer. For many, this has been driven by fear of contracting COVID-19, while others faced access issues due to lack of funding and low resources, further exacerbating the disparities in care. What does this mean for cancer diagnosis and treatment? What are the biggest lessons stemming from this pandemic? What can be – or is already – being done to get back on track? To learn more about “COVID-19: The Path Forward,” visit: www.webershandwick.com/podcast/.

As the world battles against the worst pandemic in a hundred years, cancer didn't just go away. In 2020, over 19 million people worldwide were affected by cancer, and almost ten million people died.Cancer doesn't wait for anyone. Not even a pandemic.  Where early detection had to be delayed... where medical care was affected or simply overwhelmed in it's struggle to cope with rising Covid-19 numbers... or continuing treatment became more remote and more difficult, cancer carried on regardless and unperturbed.  According to the World Health Organization, over 50 percent of all countries partially or totally interrupted cancer care services to respond to the Covid-19 emergency.Welcome to a new episode of Voices for Health. In acknowledgement of World Cancer Day, we spoke with Gilberto Lopes about the initiatives of the Union for International Cancer Control, UICC, to provide continuity of care for cancer during this pandemic. We discussed the importance of promoting cancer prevention, detection, and treatment as a public health priority, facing the growth of Non-Communicable-Diseases and their impact on health systems.

This Podcast features Ritu Bhatia, Dr Pooja Ramakant, Dr Lopamudra Das Roy and Bret and Peggy Miller, who share their insights on "Reality check on preventing breast cancer and averting untimely deaths." They were keynote speakers for the Sustainable Development e-Talks (#SDGtalks) - a special series, co-hosted by CNS and Indian Institute of Management (IIM) Indore from World Health Day (7 April 2020) to World Environment Day (5 June 2020).Be welcome to listen on Apple Podcasts, Google Podcasts, Spotify, Stitcher, TuneIn, aCast, Podtail, BluBrry, and other podcast streaming platforms. Ritu Bhatia, senior journalist who specializes in medical and health journalism (and a breast cancer patient)Dr Pooja Ramakant, noted breast cancer surgeon and researcher; Additional Professor, Department of Endocrine Surgery, King George's Medical University (KGMU); Vice Dean of Innovations, KGMU; and former part of Editorial Board of Indian Association of Endocrine Surgeons (IAES); recipient of 2015 Fellowship of UICC (Union for International Cancer Control) in Geneva.Dr Lopamudra Das Roy, founded Breast Cancer Hub (BCH), has over 18 years of experience in research, training and mentoring UG and PhD candidates in the field of genetics and breast and pancreatic cancer. She has been a Research Professor, University of North Carolina at Charlotte. Her original research work on discovering the signaling pathway between breast cancer metastasis and arthritis, is attributed with numerous high impact factor publications and citations with global recognition from American Association of Cancer Research. She received the coveted Award of Excellence for Humanitarian service, at Male Breast Cancer Coalition Conference, 2019 Bret Miller and Peggy Miller from Male Breast Cancer Coalition (MBCC). When diagnosed with breast cancer at age 24, Bret promised his surgeon no man would ever feel alone when hearing the words, "You have breast cancer." Teaming up with others dedicated to end the stigma and feelings of abandonment associated with a male breast cancer diagnosis, Bret and his team members formed Male Breast Cancer Coalition in 2014. Breast cancer does not discriminate and we want everyone to know "Men Have Breasts Too", says MBCC team.They were in conversation with CNS Managing Editor and Executive Director Shobha Shukla, who is also the coordinator of Asia Pacific media network to end TB & tobacco, and prevent NCDs (APCAT Media). For more information, be welcome to visit www.bit.ly/sdgtalks ThanksCNS team

Today marks the 20th anniversary of World Cancer Day - a global initiative led by the Union for International Cancer Control, aimed at supporting the cancer community and ensuring that cancer continues to be a priority in the world health and development agenda. This as 8.2 million people die from cancer world wide each year, out of which 4 million are considered premature deaths with ages 30 to 69 years.

Plugged In with Greta Van Susteren examines the global cancer crisis and the search for a cure. Insights from Dr. J. Leonard Lichtenfeld, Chief Medical and Scientific Officer for the American Cancer Society; Cary Adams, CEO of the Union for International Cancer Control; and Dr. Otis Brawley, Bloomberg Distinguished Professor of Oncology & Epidemiology at Johns Hopkins University. VOA's Mil Arcega anchors the show for Greta.

Deborah James and Lauren Mahon are joined by Saima Thompson, a restauranteur who was diagnosed with Stage 4 lung cancer, to explore how different cultures view cancer. They talk to Cary Adams the Chief Executive Officer at the Union for International Cancer Control. Plus, Errol McKellar, a former car mechanic who now dedicates his life to encouraging men to get tested for prostate cancer, shares his incredible story. You can suggest future topics and join in the conversation on social media by using #youmebigc

Dr. Jim Cleary talks with Dr. Pennell about this new resource-stratified guideline, which provides guidance to clinicians and policymakers on implementing palliative care in resource-constrained settings.   Welcome back, everyone, to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. Now over the last decade or so, there has been a major change in our approach to the care of advanced cancer patients with the recognition of the importance of palliative care. There have been a number of trials now showing that integrating palliative care into cancer patients' care can make a major impact on their quality of life and possibly even their survival. And as a result, the involvement of palliative medicine has become part of treatment guidelines. However, much like cutting edge biomarker testing or expensive drugs, specialist-driven palliative care also takes a fair amount of resources that are not available everywhere. So joining me today to talk about this is Dr. Jim Cleary, who just moved from the University of Wisconsin Carbone Cancer Center, where he started the palliative care program in 1996 and for the last seven years, has led the Pain and Policy Studies Group, a WHO collaborating center for pain policy and palliative care. He's now been recruited to the Indiana University School of Medicine in Indianapolis, where he'll be the professor of medicine and Walther's senior chair in support of oncology and director of the supportive oncology program at the IU Simon Cancer Center. He's going to focus on building a program focusing on global supportive care and palliative care, which makes him the perfect person today for us to talk to about the recommendations of an expert panel that's going to be published this month in the JOP titled, Palliative Care in the Global Setting ASCO Resource-Stratified Practice Guideline Summary. Jim, thanks so much for joining us. Why, thank you very much for having me-- a real honor. So can you start out a little bit by telling us about the progression of the role of palliative care in oncology, and what has led to the impetus for forming the panel that you were a part of? So if we look back historically to the introduction of palliative care throughout medicine, it's actually been primarily in cancer care. If we go back to the original WHO guidelines in the 80s, it was all focused on cancer patients. And it's interesting if one looks at the very definition of palliative care from the word go, they said all the principles of palliative care can be applied upstream, earlier in the course of patients' illnesses from the-- even from the 80s. But as we look at it historically, and particularly in the US, with the introduction of the Hospice Benefit, palliative care really became brink of death care. So that you didn't get hospice or pallative care involved until someone was actively dying. So we were missing out on that very principle of-- let's address all the issues, the skills that palliative care provides early on. Let's address these earlier on in the course of people's illness, particularly when it comes to people with advanced disease. And it doesn't just have to be advanced disease to be including the skill set. So people who are getting chemotherapy, some may support it or call it supportive oncology, but really, it's the same principle-- supportive oncology, palliative care. It's total person care of patients with cancer and dealing with cancer. So as we look at those, the studies have been coming out saying it improves quality of life. You mentioned the survival benefit that's been suggested or hypothesized. And while that may be there, for me, that's not the primary reason for doing this. It's the right thing to be doing-- to be addressing quality of life. And even trying to get us to move beyond what seems to be that magic mark of survival-- length of survival or time of survival may not be the only important thing. Quality of life is becoming increasingly important as we address many of these issues. ASCO has recognized this, and in 2016, they actually published a paper-- again, a guideline-- the integration of palliative care into standard oncology care. And that was released in 2016, and it was based on what we would call research that was done in maximal resource institutions, largely in the high income countries. The United States, Canada, Western Europe, Australia-- those sorts of countries. What the situation is in the world is that probably 80% of the cancers are now being diagnosed in low and middle income countries. And in those countries, most people are actually being diagnosed with advanced disease. And this comes from the paucity of person power in terms of diagnosis, the lack of surgeons, the remoteness that these people-- where they live. They're really presenting in different ways. So as ASCO looked at this, and they've done this as well with cervical cancer, they said, let's get a guideline that is resource-stratified. So let's look at the issues that low and middle income countries face in getting this integration of palliative care and supportive oncology across the board. And that's what we aim to do in this setting. No, that sounds like a very important intervention. I have a soft spot in my heart for this topic. Because when I was a fellow at Mass General Hospital, that was when Jennifer Temel was running her initial trial of head of care that led to this possible survival benefit, which was just suggested retrospectively, or at least post hoc, in that analysis, but I remember when this was greeted with a lot of skepticism-- that palliative care was that important in cancer care. And of course, now people broadly accept how important it is. So I'm great to see that this is going to be extended outside of just academic centers in the United States. So one of the questions I have for you before we kind of delve into your paper, and this is a conversation I've had with Dr. Temel, as well. Most of the data is not just in maximized resource centers and countries, but also seems to focus on specialists trained in palliative medicine. Do we understand the aspects of palliative medicine, and what leads to quality of life benefits, enough to be able to extract those different pieces out and then extend them out beyond palliative care trained physicians? I don't think we do yet. And we need to do more research on this. And I know that Jennifer currently has a query study that is looking at the role of telemedicine. At about the same time that Jennifer was doing the study in Boston, we actually did a similar study out of the University of Wisconsin, which looked at an internet intervention through CHESS-- Comprehensive Health Enhancement Support System-- and the service was integrating palliative care information, internet support for both patient and caregiver. And we actually found a survival benefit that mirrored this-- the Temel effect-- for people who use the internet system. So I don't think we have a very good start understanding at all. I think Charles von Gunten has equally identified that there is this difference between primary, secondary, and tertiary palliative care. And primary palliative care is what all clinicians should be able to do. In Charles' papers that he's written on this, he's talked about oncologists should have a secondary level of palliative care knowledge and experience and be able to do this. And then really you need the tertiary level, or the specialty team, involved in palliative care for the difficult cases. I'm not convinced, still to this day, that I need to see every cancer patient with advanced disease. What we need to do in palliative care teams is actually fill in the holes when the current treating oncology team is not able to provide them. And if you have an oncologist who is excellently trained in symptom management, communication-- together with good nurses and social workers, pastoral care, spiritual care, who can come in and help with this-- the role of the palliative care physician may actually go on the palliative care team. Maybe a little moot in most settings, but really, it's filling in the holes and coming in and making sure that patients are getting the appropriate level of care. That appropriate level of care really does become tough in resource poor-- resource challenged settings. And that's probably true even in the United States, as well as in low and middle income countries. If the only health care center within 100 miles is actually with a primary health worker with minimal training, how do you get appropriate oncology care, let alone an appropriate palliative care integrated into that? And I think one of the challenges that some of our panelists from low and middle income countries had was, well, how do you actually define good cancer care in our country? And that continues to be a country many people-- and I'll come back to remind listeners that hepatocellular cancer is actually one of the most common cancers in the world. And many of these people who have, and end up dying of, hepatocellular cancer never actually see an oncologist. Now I agree that that makes sense in so many places-- just even in our own country here, patients struggle to reach specialist oncology care. And so I think the idea of Jennifer's, of trying to be able to do palliative medicine consults with telemedicine, is certainly an interesting potential solution for that. So let's just dig into the panel's recommendations here, shall we? The guidelines are divided into different sections. And each section is very nicely broken down into what you term as basic, limited, enhanced, and maximal sections, depending on the available resources. So maybe we could go through them one at a time, and you can talk a little bit about them. So I think the first section is called, "Palliative Care Models." Can you talk a little bit about that? So what we were doing with the palliative care model with the [? gain, ?] if you think about some of these basic, limited, enhanced, and maximal, we were saying, hey, basic is the primary health care center which I mentioned. It may be a community health worker, or a clinical officer as they are commonly called. It may not be a physician. There may be a nurse, but they may not even be a nurse in some of those settings. So the recommendation is that we should be training and addressing these people to actually even start thinking about palliative care needs in this setting. So it's saying throughout the whole system, we need to be building in palliative care needs. Particularly in advanced cancer, one of the issues that comes up significantly, and is under Item 7, is ensuring that we have access to opioids for pain relief. And this becomes very difficult if you're talking about a rural community-- no one with a physician license or a nurse license. How do we actually get appropriate pain relief to these people, who may never see an oncologist, as they're dealing with advanced cancer needs? So we've gone through and actually looking at the strength of evidence saying, yes, this has to be integrated throughout the whole health care system. And there are evidence from different models as we look at places like Kenya and Malawi as they've introduced palliative care throughout these settings. It's quite possible. Uganda actually has nurses out in many of the districts in Uganda, who are now licensed because of their special training, to actually dispense morphine. And that's a real change. We go to other countries, which have a shortage of physicians interested in palliative care and doing this, and there are physician groups who actually say, there's no way nurses are ever going to be able to do that. Professional protectivism, if you want to look at it-- boundary protecting. No right answers, but I think these need to be considered. And we need to think outside the box with the models of care that we're providing to ensure the appropriate people are getting them. I visited a hospital in Zambia-- the Children's Hospital in Lusaka-- where each child with leukemia had a small bottle of morphine on the top of their locker, which the parents were administering to the children for appropriate pain relief because of their leukemia. Really quite incredible to watch this going on in a resource poor setting, and this was entrusted to the parents to do with appropriate education. Because they're the ones who are most concerned and available to do this sort of work. I've actually been to hospitals in other parts of Africa where the drug cupboard has actually been empty and the lock broken, and it takes 15 to 20 minutes to go to central pharmacy to actually get some morphine. So when someone is complaining of pain, that's not a good situation. So we need to make sure that all of these things actually fall into place and develop good care models. And that's really what recommendation number one does. Recommendation number two goes to look and talks about timing. And this comes up as a critical-- when should you get palliative care needs addressed? And as I said with the primary, secondary, and tertiary, really, they should be addressed from the point of diagnosis, if not even before diagnosis if you suspect someone has advanced disease. And so you're really saying, hey, let's consider this from the word go with everyone in the course of the illness-- a palliative care team, not just the needs of the patient. But a team, in the basic and limited settings, should probably get involved with overwhelming symptoms, particularly metastatic disease. And if a decision not to go for life prolonging therapy is made, that's when I think we need to be engaging teams at that stage. And really, it's coming in with the maximal. And if you've got the appropriate resources, it's saying everyone. And this comes from the 2016 guidelines as well. We should have this integration early in the diagnosis and ideally within eight weeks of diagnosis. The palliative care team should actually be involved at that stage. Oh, that makes perfect sense. I certainly remember when this idea of early palliative care started coming out. And it's so much easier for the patients when they are plugged in and connected with the palliative medicine team earlier in their disease, rather than trying to call them in late. And it's much more jarring and disturbing to them, and they don't get nearly as much of the benefit of the care, I think, at that point. And often pain control is a way I get involved early on. Other symptom management-- how can we help you through chemotherapy? Some of the issues go on. It does actually open up opportunities. Yes, I can maybe spend some more time there than the oncologist. Many nurse practitioners-- advanced practice nurses-- are actually doing this on their own. But it's coming in and helping the oncologist. It's building up that team. And as the disease transitions, that jarring nature of all this-- this guy who's now coming to meet you because I've run out of options. No, you're part of the team from the word go and will continue to stay involved. Yeah, absolutely. I think that has been my experience, that that makes the best sense. So the third section of the guideline addresses the workforce knowledge and skills. And how does that vary from the various resource levels. So this comes up, the resource levels and if you even go back to the WHO definitions of palliative care, we use the term interdisciplinary. It's very hard to be interdisciplinary when you're a single person. Although I often joke that Dame Cecily Saunders, who started the modern hospice movement, was trained as a nurse, a social worker, and a physician. So she could have a multidisciplinary team all by herself. So it's the basic level. If you're a single clinical officer, that may be very difficult. A single nurse-- that interdisciplinary team is really something that may be hard to come by. But having those basic skills is something that we need to teach. But as we move up into the limited or district level facilities, working on building teams together, and teams in some cultures-- and particularly with the nurse-physician relationship not being as strong as I think we see in most places in the United States, Europe, and Australia and New Zealand-- often these are real issues of hierarchy between the physicians and nurses. But we need to be ensuring that they do function as a team to maintain and provide the best level of care. So that's one of the things that we're looking at, recognizing that we are a team that does this. And that team continues to grow, particularly, we hope, with regional facilities or the enhanced level with the introduction of a counselor into that level. Again, if you look at the resource poor areas when you start talking counselors, one statistic I've heard is that there are three psychiatrists for the Horn of Africa, which is Ethiopia, Somalia, and those areas. And you think of only three. So the ability to train-- or having trained counselors around-- is something that is not common. So it's really integrating across the board, particularly as we move up to higher levels-- regional facilities and then to maximal, national cancer centers-- making sure that we have appropriately trained social workers and counselors available to join this team. So addressing all of the members of the team-- you know, the nursing roles, the spiritual care, the counseling-- and then just the recognition that in some places it may end up being the caregiver, or the physician, or whoever they are dealing with, that has to assume many of these roles, I think, is a nice recognition. Ideally, you'd love to have a large interdisciplinary team. But it's having the available resource, rather than who does it, that is important. Exactly right, and in many cases, it may actually be the nurse who is doing most of this work. And we even find that in our own situations here, it's often the nurses giving chemotherapy who may be doing a lot of the counseling with patients while they're administering the chemotherapy. I even make the comment to our own folks in in-patients, it may actually be the person who's working on housekeeping who is actually doing a lot of interaction and hearing of the needs of the patient, just because they feel comfortable talking to them, whereas they don't share that with others. So we don't exclude any member of this team across the board. That's really interesting. I don't know if you read Bloom County, the comic strip, but there is a storyline over the last couple of years of a sick child in the hospital. And it's the maintenance man who ends up providing most of the support to the child in this family and it's a really touching storyline. It reminds me of that a little bit. So I hope that's not because we weren't providing it, which is often something that can happen. But I think it reflects some of the comfort that people do have in dealing with like people. White coat syndrome, I think, applies as much to adults as it does to children. We need to look at those issues, that talking to that man-- that person in the white coat who stands at the end of the bed with 15 other people. That's not really a situation where you can share your inner thoughts and feelings. No, I think that's true. And then you touched on this a little bit earlier, but the seventh and certainly a very critical component of this, is the availability of opioids to help deal with pain. I guess it hadn't really occurred to me that this was a major problem, because drugs like morphine should be relatively inexpensive. But this is I'm guessing a major issue throughout the world. So 80% of the world's population lack access to appropriate pain control. And it's even made worse by the current dilemmas that we're facing, the unbalanced situation that we have in the United States with the current heroin and fentanyl crises. And I say that, because I think we've moved somewhat beyond most of the deaths being caused by prescription opioids. There's increasing evidence that people in the United States are getting first access through heroin and illicit fentanyl. So that these people are lacking access to the basic essential pain medicines, both postoperatively and as they deal with advanced cancer. And so we're even seeing some of that now reported in the United States, that people are actually being denied access to opioids, because of shortages in this country, as they deal with cancer. So it's a critical issue. We need to make sure these are all available. We saw even back in the 90s-- we saw some pharmaceutical companies in China saying, you guys don't need an immediate release morphine. Just use sustained release morphine. The reality is that immediate release morphine, even a morphine solution, together with injectable morphine, is something that should be available at the most basic settings for pain control of cancer patients. And then we can move up oral morphine together with sustained release, if you need to, in different forms. The costs can change. We see some countries in the world with fentanyl patches as the primary medicine used. But the cost of these is dramatically much greater than, in fact, it is for immediate release morphine. People say that levels are steadier, it's better pain control, and things with fentanyl patches, but the evidence doesn't necessarily support that overall. And so we will come back to the gold standard being very much based on oral morphine and making sure that's available in different formulations. And I will stress while this guideline was for adults, one of the advantages of a morphine solution does allow you to titrate and dilute the morphine appropriately for children across the board. You can't do that necessarily with tablets. So I think there are absolutely access to medicines-- and not just the opioids, but particularly the opioids-- is something that's being addressed with a number of levels and making sure that the current situation in the United States doesn't come back and not only rebound here for cancer patients, but really impact cancer patients around the world. Yeah, that's certainly a major topic in the United States, and I'm sure that's true elsewhere, as well. Well, so that brings me to my next question, which is-- while these recommendations make wonderful sense, and in many ways it's kind of reassuring. Because in some places when I talk about palliative care, and they say, well, you know, we don't really have access to specialist palliative care, a lot of this can be done just about anywhere as long as there are recognized the aspects of palliative medicine that are available and necessary. So what are the next steps to this? So the guideline is going to be published. How is ASCO going to work to try to make some of this more available? So I think it reflects the impact of ASCO around the world. ASCO is-- while it's the American Society of Clinical Oncology, it actually has very, very real impact. We're starting to see research take place. So the African Palliative Care Association is already beginning to use a palliative care outcomes scale, together with King's College in London to bring about this. So it's actually-- we're seeing a push. I think we're going to see some of the QOPI measures come out and be part of this international work. So for instance, as you mentioned, getting chemotherapy in the last two weeks of life is a negative QOPI indices. Getting people into hospice, we're seeing as a positive as we move forward. So I think that we're going to see this overall from ASCO coming out and saying, this is absolutely critical. ASCO is a player on the international scene. Works with a number of international organizations-- the NCI, Global Health Institute, the NCCN, and others are looking at the-- the Breast Health, Global Initiative. So this is all moving forward together with the World Health Organization, the Union for International Cancer Control, UICC. Many people are targeting this, and I think it's actually going to be the overall recognition of the importance of this. Many people have followed for years, saying we will do what ASCO does. ASCO is now saying, this is important. And I think we're going to see this change in low and middle income countries because of ASCO's leadership, and that's going to be critical. Well, I certainly hope that's the case. Because this really does sound like an incredibly important initiative. So Jim, do you have any take home points you'd like to give to our listeners as we wrap up the podcast? So take home points are to realize, within your own practice, that palliative care is important to integrate. But I think at this stage, it's an awareness of the importance of palliative care in cancer care around the world. We don't often think of that outside of our own settings. But it's absolutely important. Become involved in advocacy as you move forward. And promote this, both regionally within the United States, and for those listeners who are listening outside of the United States, work with your oncology organizations to say, what are we doing with palliative care and cancer care across the board? And I think it's those sorts of things where we're actually going to be seeing those changes as we move forward. Well, Jim, thank you so much for joining me today on this podcast. I'm sure our listeners are really going to appreciate this. Thank you very much, Nate. And I also want to thank the listeners who joined us for the podcast. The full text of the paper is available at ASCOpubs.org/journal/JOP published online in July of 2018. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.

This is episode 60. One of the awesome things about doing this podcast/program for the past sixty-weeks has been the chance to speak with and listen to a lot of wonderful people. It’s kept me present to the fact that there is a lot of goodness despite all the social and political parasites and white supremacists, here and abroad, who with their ignorant and retrograde intellect, insist on bringing us all to the precipice of death. One of those good people is Melissa Rendler-García. She has been working in advocacy and policy of public health for over 20-years at a global scale. From the heart of the Amazon to Romania to Afghanistan to Central and South America, Melissa has worked on issues from malaria to cancer. Her main service, to support government ministries and agencies like the Union for International Cancer Control in bringing global attention for funding to pandemics and preventable diseases like cervical cancer, affecting poor and developing nations. In this episode, she talks about her journey into the field. I’m super proud of her and admire her strength of character. Listen to her story, her sense of humanity might just give you a little jolt of inspiration. Healthcare is an issue close to my heart and should be for all of you. Our pre-existing condition is being born. For now, here is one of my favorite people, proud to call her a sister, an advocate of all of us and we both agree that healthcare is a human right.

Prof Aranda speaks with ecancertv at the 2016 World Cancer Congress about her hopes for the development of the UICC. She highlights global equity in cancer care and recognition of nurses as personal priorities.

Dr Stevens speaks with ecancertv at the 2016 World Cancer Congress about the launch of the ICCP, a web portal dedicated to international collaboration for cancer control plans. She is joined by Dr Brenda Kostelecky, who highlights some of the roles of partnership organisations, and discusses the successes of the partnership in central Asia.

Dr Herrera talks to ecancertv at the World Cancer Leaders Summit in Istanbul, Turkey, about his work with the Union for International Cancer Control's 'young leaders initiative'. The initiative works with young leaders to implement cancer care and collaboration, to achieve international cancer control.

Prof Kutluk (President-elect, Union for International Cancer Control) talks to ecancertv at the UICC World Cancer Congress 2014 about the importance of getting cancer on the global agenda with as much input and collaboration among member governments as possible.

Cary Adams (CEO, Union for International Cancer Control) talks to ecancertv at the UICC World Cancer Congress 2014 about the importance of considering the economics of cancer care.

President Hugo Chavez of Venezuela thinks the US may have developed a secret technology to give him and other Latin American leaders cancer. He said the fact that several presidents have had cancer is "difficult to explain using the law of probabilities". Is he right? Tim Harford speaks to Dr Eduardo Cazap, president of the Union of International Cancer Control. Plus, it is often said that there are more Malawian doctors in the British city of Manchester than there are in Malawi. Can this be true? And if professionals emigrate is it always bad news for the country they leave? The programme hears from John Lwanda, a Malawian doctor based in the UK; and Robert Guest, author of "Borderless Economics". This programme was originally broadcast on the BBC World Service.