The enthusiasm behind the open access initiative sprang from the need for scientific research that is accessible to everyone worldwide. Open knowledge based on open access also aimed to increase good research practices such as reproducibility and transparency.1 This movement was launched by developed countries to limit the barriers to available literature in subscription-based journals, which subjects university libraries to high costs, unlike open access literature. This trend was particularly noticed in settings with limited resources.
However, although open access literature may be free to the reader, the cost of publishing must still be borne by someone. Given the lack of funding opportunities and the limited budget allocated to health-care research in low- and middle-income countries (LMICs), article-processing charges in these countries are assumed by the authors. Despite available waivers for some LMICs for free open access publishing (based on the World Bank country classification), the categorization of countries to benefit from this financial support is not a truthful selection criterion.
For example, the open access BioMed Central journal BMC Cancer offers a 50% article-processing discount (~1,100 Euros, or ~$1,244 U.S. dollars)2 for Moroccan researchers, which is not affordable for authors based in LMICs and does not reflect real-world funding in similar African countries. Therefore, the financial toxicity of open access is an urgent issue that must be addressed by increasing awareness about the danger of this movement, which still does not take into consideration the lack of funding of researchers in underresourced settings.
Cancer researchers working in [low- and middle-income countries] are always frustrated by the high publishing fees associated with open access journals.— Khalid El Bairi, MD
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Cancer researchers working in these settings are always frustrated by the high publishing fees associated with open access journals. This publishing model is expanding worldwide as a response to the open science movement, and more hybrid oncology journals are transforming their publishing strategies into full open access. Therefore, the number of free journals available to oncologists in LMICs to publish their findings has been impacted considerably. In some high-income countries, article-processing charges are covered by funding agreements and arrangements that meet Plan S requirements (see sidebar on page 97) and other initiatives that support the open access movement, but others such as LMICs have yet to achieve this outcome.
Morocco’s Cancer Research Institute
Promisingly, initiatives based on alliances and partnerships between nongovernmental organizations and public institutions in LMICs have shown the determination to improve patient outcomes in these settings through the funding of cancer research publications according to international standards and guidelines. One such example is the Institut de Recherche sur le Cancer (Cancer Research Institute, or CRI) in Morocco, founded by the Lalla Salma Foundation in 2013. The CRI is a Moroccan public research center with a financial and scientific autonomy; it aims to improve cancer research based on various programs that combine national health research priorities, particularly the National Cancer Prevention and Control Plan.
This center has also embarked on other projects such as funding open access publications in oncology.3 The objectives of this program encompass the financial support of accepted papers in the field of cancer research, the dissemination of cancer research outputs to respond to the open science movement, and the contribution in enhancing the classification of the Moroccan bibliometric indicators. To be eligible, cancer investigators need to apply for free membership to become associates of the center network and benefit from funding of article-processing charges.
Moreover, the CRI has played a notable role in training cancer researchers and sustaining the organization of scientific events by successfully bringing together governmental and health systems in Morocco with academia, industry, and nongovernmental organizations such as scientific societies and patient advocacy associations. This unique feature has created a valuable environment for effective cancer-control strategies in Morocco. The CRI is a good example of the determination of African LMICs to implement the best available care and cancer research to achieve the goals of global oncology principles.
Solutions to African Disadvantages
In countries with a high income, research in oncology is sponsored by funding agencies and industry, which has meaningfully improved survival outcomes of patients with cancer. In contrast, the African continent is disadvantaged in all aspects of human development, particularly in the fields of innovation and research. Notably, oncology and cancer research are largely forgotten.4,5 There are huge deficits, as demonstrated by the marked increase of cancer burden in this area of the globe.6
Local cancer researchers have the best understanding of their local problems and challenges…. Thus, their involvement in resolving this crisis [in funding and training] is required.— Khalid El Bairi, MD
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For example, gynecologic cancers such as cervical cancer have equal or higher incidence rates in LMICs as compared with developed countries.7 However, current oncology practice guidelines do not take into account the significant resource variations between these settings. In addition, the oncology workforce in LMICs lacks research skills, suffers from poor mentorship, and has inadequate training in conducting cancer research in the real world.8,9
Building research centers and facilities that coordinate clinical and translational research between hospitals and academic institutions such as the CRI in Morocco can be part of the solution to these problems. It is expected that such regional cancer centers will deliver funding support, training the next generation of oncologists to address major global health issues, and optimal coordination of research teams with the financial support and guidance of international agencies and organizations such as the World Health Organization and the International Agency for Research on Cancer.
Studying cancer in LMICs provides unlimited opportunities to improve cancer control by addressing population-specific issues.6 Establishing this research capacity will certainly respond to the goals of global oncology and, therefore, limit the exacerbating disparities between high-income countries and LMICs. This is urgently needed to be addressed globally because of the chronic nature and costs associated with the long-term care of cancer.
The experience of the Fogarty International Center of the U.S. National Institutes of Health is an example of a successful program to train and financially support foreign researchers working in the developing world.10 The Fogarty program addressed critical global health research problems particularly by reducing the burden of noncommunicable diseases through a strengthening of research capacities in Africa (see https://www.fic.nih.gov/Programs/Pages/default.aspx). This collaborative model can be applied by similar institutes to limit the funding and training gaps in LMICs.
Moreover, local cancer researchers have the best understanding of their local problems and challenges in the context of the political, cultural, economic, and social features of their community. Thus, their involvement in resolving this crisis is required.
Studying cancer in [low- and middle-income countries] provides unlimited opportunities to improve cancer control by addressing population-specific issues.— Khalid El Bairi, MD
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The recently launched Harnessing Data Science for Health Discovery and Innovation in Africa program11 of the U.S. National Institutes of Health, which is expected to invest about $74.5 million, is another promising example of partnerships that may enable the creation of initiatives such as those of the CRI in Morocco. These initiatives can provide funding to empower research teams to focus on specific health research problems and allow local researchers to contribute to improvements in their home countries. They will catalyze research and training activities in these LMIC-based settings.
Other International Collaborations
In a recent paper in The Lancet Oncology, Ranganathan and colleagues published the findings of the International Collaboration for Research Methods Development in Oncology workshop in India, which was developed to enhance the capacity of oncologists to conduct outstanding research by training them to develop clinical research methods and protocols.12 A goal of the workshop was to cover the needs of LMICs in terms of study protocols for real-world cancer research. At follow-up, most of the participants had made remarkable progress, which supports the critical necessity of implementing similar training in other LMICs to conduct context-specific research.
Establishing clinical and translational cancer research coalitions between LMICs and high-income countries has also created a unique opportunity for this purpose. The Memorial Sloan Kettering Cancer Center–Nigerian collaboration13 and consortiums such as the African Research Group for Oncology14 and the African Organization for Research and Training in Cancer network15-18 are other successful programs that have created a sustainable potential for building research infrastructures in LMICs sharing similar research challenges. This has shown how multipartner collaborations can improve cancer research in these settings and has also created a favorable experience to be shared among LMICs.
Marked progress has has been made during the past decade to improve cancer research in LMICs, but it is not yet sufficient for ending cancer inequities between these settings and countries with high incomes. If LMICs develop initiatives similar to those of the CRI in Morocco, an improvement in existing research capabilities will undoubtedly help establish a roadmap for local evidence-based guidelines to better control the cancer burden.
Dr. El Bairi is a medical trainee at the Faculty of Medicine and Pharmacy at Mohammed First University, Oujda, Morocco.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Dr. El Bairi receives funding from the Cancer Research Institute (Institut de Recherche sur le Cancer) in Morocco.
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