There won’t be nearly enough oncologists for most of the world’s underserved cancer patients for decades to come, so if we plan to treat these people, we’ll need innovative models of care.
—Lawrence N. Shulman, MD
While disparities in cancer care remain problematic in wealthy industrial nations like the United States, the challenges faced in poorer regions of the world are, by comparison, inestimable. Nationally regarded health-care expert Lawrence N. Shulman, MD, of Dana-Farber Cancer Institute, is part of an ongoing initiative to bring oncology services to Rwanda, the most densely populated country in sub-Saharan Africa. At this year’s ASCO Annual Meeting, Dr. Shulman used his recent experience in Rwanda to illustrate the possibilities of creating a cancer care infrastructure in a low-income country.
“While it’s critical to work at the policy level, it’s equally important to demonstrate that we can build on-the-ground cancer care systems in resource-poor regions. However, many leaders in global health view this as a misguided mission, contending that we should focus our limited resources on prevention, not treating patients with cancer. I’d like to counteract that viewpoint with this presentation,” said Dr. Shulman.
Partnerships and Principles
Dr. Shulman stressed that developing strategic partnerships is key to building a cancer care infrastructure in resource-challenged countries like Rwanda (see sidebar). “We have a team from the Harvard hospitals in Boston that has worked with Partners in Health, alongside the Rwandan Ministry of Health, all of which have been bolstered by the generosity of private foundations and the pharmaceutical industry. Each entity provides a vital role in bringing a continuum of cancer care and services to the country,” Dr. Shulman said.
To focus their initiative, the team developed a set of principles of cancer care for several resource-challenged countries (Rwanda, Malawi, Haiti), which rest on what Dr. Shulman calls the diagonal approach. “Setting up an isolated cancer program won’t work, so we try to integrate a cancer care program within the country’s existing health-care infrastructure, using a diagonal instead of vertical approach, which will increase chances of success,” Dr. Shulman explained.
The worldwide work in HIV/AIDS prevention and treatment has been a successful model, but Dr. Shulman noted that cancer offers different challenges. “We need to biopsy cancer patients and process the tissue in a pathology lab before we can deliver surgery and chemotherapy. Currently, there’s no reliable, timely, or affordable pathology lab in Rwanda, so we ship all the specimens back to our lab in Boston; we’ll soon have a pathology lab in Rwanda. Naturally, in order to treat our patients, we need a supply chain to provide affordable therapies, which is also part of the ongoing process,” Dr. Shulman said.
New Models Needed
Dr. Shulman, who also serves as senior oncology advisor for Partners in Health, an organization that concentrates its cancer care efforts in Rwanda, Malawi, and Haiti, illustrated the scope of the challenge with a daunting statistic: Of the three countries, only Malawi has an oncologist, one to be exact. “The fact is, there won’t be nearly enough oncologists for most of the world’s underserved cancer patients for decades to come, so if we plan to treat these people, we’ll need innovative models of care,” Dr. Shulman said. He added that delivering cancer care relies on basic community supportive services. “It’s not possible to administer treatment in the absence of social support, clean water, and adequate nutrition, so we incorporate a holistic approach into the model.”
Another important principle in low-income countries is making the best use of limited resources. To that end, the team developed a Prioritization Document. “We have to decide which patients we treat and what treatments we use. These are very difficult clinical decisions, which we don’t need to make in the United States. In countries like Rwanda, value takes on a more intense meaning,” Dr. Shulman said.
In prioritizing cancers to treat on a “value = benefit/cost” scale, Dr. Shulman used the example of a 4-year-old girl with Burkitt’s lymphoma, which has a high rate of cure, requires low-cost drugs and no surgery (other than biopsy) or radiation, and is associated with a very long life expectancy with minimal side effects. “This would be an example of a high-value patient. If we look at a 23-year-old man with chronic myeloid leukemia, treated with a high-cost drug, imatinib (Gleevec), and no chance of cure but potential long-term survival, this we classify as a moderately high-value patient,” Dr. Shulman explained.
Although no tumor registries exist in Rwanda, Dr. Shulman commented that gastric cancer appears to be the most common malignancy in the country. He used a 60-year-old man with advanced gastric cancer and liver and lung metastases as an example of a low-value patient. “This man has no chance of long-term survival, with weeks to live, and some would argue that he should be palliated and not receive any expensive antineoplastic agents,” Dr. Shulman said.
Making an Impact
The team divided diseases up into four major categories: (1) diseases amenable to risk reduction, (2) diseases curable with early detection and treatment, including surgery, (3) diseases curable with affordable chemotherapy, and (4) diseases palliated with systemic treatment.
Fortunately, prevention efforts in Rwanda do not have to focus much attention on tobacco or alcohol control because they are simply not major issues. Cervical cancer is, however, a widespread and preventable disease. In an interview with The ASCO Post, Dr. Shulman noted that Merck had donated over 2 million doses of HPV vaccine (Gardasil) to the Rwandan effort. “But we don’t feel that prevention is a priority over treatment, as children with cancer wouldn’t be affected by a prevention strategy—they need active therapy. It should not be ‘either/or,’ but rather, treatment strengthens efforts at prevention, as has been demonstrated with HIV.”
Since many adult patients in Rwanda present with advanced disease, palliating symptoms is a major part of the prioritization strategy. During the interview, Dr. Shulman stressed, “An important component of the palliation effort will be ongoing medical education, since palliative medicine is not something that is practiced by all Rwandan doctors.”
Dr. Shulman commented that part of the long-term strategy is to develop a research agenda and infrastructure specifically designed to address questions applicable to cancer care in challenged areas like Rwanda. “One problem is that in countries like Rwanda, we actually know very little about the incidence and specifics of cancer. That’s why we need to develop good cancer registries. Also, to have a solid grasp of the effectiveness of our interventions, we need to conduct prospective studies and continually analyze data so as to lead iterative improvements in patient outcomes,” Dr. Shulman said.
“Needless to say,” Dr. Shulman continued, “Our most valuable resource is ‘human capital,’ and in regions where there is a complete dearth of oncologists, we need to train people to care for cancer patients. It must be an ongoing project, and the level of training needs to be consistent with the context of the cancer care setting.”
Success Is Incremental
At the ASCO meeting, Dr. Shulman presented a slide showing the banner hanging on the wall of his team’s training program: 1st National Baseline Cancer Training. At the bottom of the banner, the partners that made the mission possible are listed: The Ministry of Health; Dana-Farber Cancer Institute; GlaxoSmithKline; Brigham and Women’s Hospital; and Partners in Health.
“It was a very successful program. We had live didactic lectures and practical sessions, such as a breast-imaging workshop in which the doctors were taught ultrasound core breast biopsy, using chicken breasts with pimento-stuffed olives representing the lesion. The pimento allowed the students to determine that the biopsy needle reached the middle of the olive,” Dr. Shulman explained.
The takeaway message from Dr. Shulman’s compelling presentation was that despite the many challenges, successful cancer care programs can be developed in the poorest of nations. “We need to demonstrate what works and what doesn’t as we integrate screening and treatment into places like Rwanda. Moreover, the efforts need to be done in parallel with the important international policy work that is currently moving the field forward,” Dr. Shulman concluded. ■
Disclosure: Dr. Shulman reported no potential conflicts of interest.