In this installment of the occasional department on Global Health-Care Equity, Guest Editor, Chandrakanth Are, MBBS, MBA, FRCS, FACS, spoke with Augusto Leon, MD, a surgical oncologist and Head of the Program of Cancer at Pontifical University of Chile, Santiago. Dr. Are is JL & CJ Varner Professor of Surgical Oncology & Global Health at the University of Nebraska Medical Center, Omaha.
“We can effect positive change on a population level, it just takes cooperation between the public and private health-care sectors.”— Augusto Leon, MD
Tweet this quote
Dr. Leon, who turned 75 on the day of this interview with The ASCO Post, is from a family whose heritage stretches back 5 centuries in Chilean history. After attaining his medical degree from the University of Chile, Dr. Leon did his surgical training at the Pontifical University of Chile.
“I was in my fourth year of medical school when I discovered a lump in my neck, which I believed was lymphoma. This was in the 1960s, and the treatment options at that time were dismal, but the lump eventually resolved without treatment. That experience, plus the fact that surgical oncology was not a recognized specialty at the time, intrigued me, so I decided to go for it,” shared Dr. Leon.
Dr. Leon continued: “Despite my rebellious streak, after my surgical oncology training at Pontifical University, they hired me. One of the things I have not lost during all these many years is intense curiosity, which I try to infuse in my students. I think it’s a dangerous thing, in a good way. I doubted everything that was said to me, and most of my teachers thought I did not want to learn because I kept questioning whether something is logical or true. I tried to comply with the rules and regulations of the hospital, but I had some ideas that were not exactly in line with the common sort of dogma at that time.”
An Era Before Mammography
Dr. Leon began his career in surgical oncology in the hospital’s breast cancer service. “This was an era when breast cancer was diagnosed by palpation, the method that also determined whether the patient was a candidate for surgery. If not, she was referred for hormonal therapy. Chemotherapy had not yet entered the standard of care in breast cancer. Naturally, this was way before the advent of breast-conserving surgery, so our mainstay procedure was the Halsted radical mastectomy.”
“Soon after I began performing radical mastectomies, I began arguing with a surgeon friend of mine about the procedure, which I thought was excessive and inadequate in its outcomes. After a while, we began using as many techniques as possible to preserve muscle and tissue,” said Dr. Leon.
Early Adopter of Breast Conservation
Over the breadth of his career at the Pontifical Catholic University of Chile, which is regarded by many as one of the best universities in South America, Dr. Leon was part of a revolution in the surgical treatment of breast cancer. “When the radical mastectomy was still a fixture in breast cancer, I suggested we conduct a small clinical trial in breast-conserving surgery. We produced a trial series of about 70 patients with T1 and T2 tumors and treated them with our minimal surgical approach. It was randomized; in fact, the whole design and execution were heretical to the orthodoxy. But we went ahead and published the promising results in a number of high-value international oncology journals. Our paper was noted as being one of the first clinical trials showing that breast-conserving therapy was at least not inferior to mastectomy, which was pretty daring at the time,” revealed Dr. Leon. “From there, my career in surgical oncology accelerated, and it has been extremely rewarding to be part of a field that has made tremendous strides in bettering the survival and quality of life for women with breast cancer.”
Chile’s Cancer Care System: Current Challenges
Asked for an overview of the challenges faced by Chile’s cancer care system, Dr. Leon responded: “Compared to most of Latin America, Chile has a very high standard of living. To our credit, we have greatly reduced the level of poverty. The health-care system in Chile is a cross of government public coverage and mixed insurance-based health plans.”
“We need to do everything we can to encourage bright young medical students to enter the challenging field of oncology.”— Augusto Leon, MD
Tweet this quote
Although Dr. Leon said this system has its good points, “there are gaps in care and equity, which is something we are working on. The government has established a National Cancer Plan, which is currently being implemented in a stepwise fashion. Although we’ve seen a meaningful reduction in cancer mortality over the past decades, it is the second leading cause of death in Chile. Cancers of the prostate, colon, breast, stomach, and lung are the most frequently diagnosed malignancies,” continued Dr. Leon.
Dr. Leon noted that the scarcity of high-value cancer registries makes it difficult to design research studies to help shape public health policy. “Moreover, our prevention system needs to be made much more effective,” he stated. “For instance, even though there is no co-payment associated with screening, our breast screening with mammography rate is only about 40%, which is an issue that needs to be addressed. We’ve seen an emergence in colorectal cancer, which indicates we need to pay attention to primary care intervention and colorectal screening. That said, many of these concerns are part of the agenda in the National Cancer Plan.”
Targeting Anomalies in Cancer Epidemiology
Dr. Are noted certain anomalies in Chile’s cancer epidemiology, such as a significantly greater prevalence of gastric and gallbladder cancers than seen in other high-income countries. Dr. Leon explained: “The higher rate of gastric cancers is connected with the prevalence of Helicobacter pylori infection in our population, predominantly in urban areas with a lower socioeconomic status. The salt-rich diet has also been linked to the gastric cancer burden. Epstein-Barr virus and genetic predisposition among certain portions of the population are also contributing factors.”
Dr. Leon commented on the abnormally high incidence in and mortality from gallbladder cancer in Chile. “Our research shows that the frequency of gallbladder cancer in Chile is connected with cholelithiasis, chronic infection with Salmonella typhi, and obesity. These issues, especially obesity, need to be addressed on the public health level. Due to the increased rate of mortality associated with gallbladder cancer, we’ve seen a rise in the use of prophylactic cholecystectomy, which has been included in the national health universal access program.”
Chandrakanth Are, MBBS, MBA, FRCS, FACS
Dr. Are is the Jerald L. & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Associate Dean for Graduate Medical Education; and Vice Chair of Education Department of Surgery, University of Nebraska Medical Center, Omaha.
Due largely to the effectiveness of Chile’s National Cancer Plan, there has been progress in lung cancer prevention. “We have a very vigorous antismoking agenda, which strictly forbids smoking in public places. Moreover, the antitobacco campaign has been effective in changing the public’s perception of smoking, so that’s a good thing. We have also seen a striking reduction in cervical cancer mortality due to the dedicated effort to encourage women to have Pap smears and get vaccinated for HPV [human papillomavirus infection]. The takeaway lesson is that we can effect positive change on a population level, it just takes cooperation between the public and private health-care sectors.”
A Melting Pot
According to Dr. Leon, even though Chile is a high-income country, there are considerable health-care disparities, especially among the multiplicity of indigenous peoples and new immigrant populations. “In the past couple of decades, we have had immigration from neighboring countries, such as Venezuela, Colombia, and Bolivia, by the thousands. So, I think about 5% to 10% of our current population are immigrants, which is not a strange thing for the United States, but it is quite unusual for a country that was traditionally homogeneous. It puts the health system into some degree of stress, because once these people immigrate, they have rights by law to full access to our health-care system. It has created challenges that will need to be addressed in the future,” said Dr. Leon.
Universal Cancer Care
As a leader at his institution, Dr. Leon has been at the forefront of several oncologic initiatives on both national and international levels. “If I were to boil all of the initiatives into one, it would be our struggle to achieve universal cancer care across Chile. There is currently an initiative called the Implementation of Universal Access with Explicit Guarantees (AUGE) reform, which prioritizes and guarantees a number of issues or health conditions that are considered essential, such as cancer. The target group of each issue has the right of access, with a defined maximum time for the delivery of the service; the right to financial protection, which regulates co-payments according to the type of health insurance the beneficiary may have; and the right to quality, which means receiving health care that is guaranteed by the registered provider who is accredited according to the law,” he explained.
Dr. Leon continued: “There’s another movement called Chile Without Cancer, which offers several wide-ranging strategies to improve cancer outcomes for all Chileans, no matter where they live or their socioeconomic status. In short, we should have universal coverage of all diseases, if possible, but, of course, the distance between the good intention and reality is the amount of money. And sometimes, the conflicts of interest that are in between play a part, because one has to adjust to a new reality, with perhaps fewer patients with private insurance. We’ll have a more managed way of taking care of a patient, but it’s good for patients. So, in the end, I wholeheartedly approve and support universal coverage.”
Naturally, the COVID-19 pandemic came up during the conversation. “So, COVID has made it more difficult for patients to access timely cancer treatment, particularly surgical treatment,” commented Dr. Leon. “We have had fairly stringent regulations that prevent us from operating on our usual schedule. We can operate only for cancers that have been demonstrated as an urgent need under the hospital’s COVID-based criteria, so it’s been difficult. For me, as a cancer surgeon, it hurts to see patients having to delay their treatment, knowing how stressful it is for them. And, of course, our underserved populations have suffered more than all others about this. However, I do see improvement, and there is a light, finally, at the end of this dark tunnel.”
For all of the advances seen during his venerable career in the oncology community, Dr. Leon proffered a note of caution. “Honestly, oncology leaders in Latin American have done a poor job of developing cooperative research groups, which is the bedrock of new drug development. We should model our networks on NSABP [National Surgical Adjuvant Breast and Bowel Project] or ECOG [Eastern Cooperative Oncology Group], which have combined groups of bright and dedicated investigators to look beyond their individual ambitions and work for the common good of the oncology community and patients with cancer. To that end, we must learn to use industry as a partner in drug development, but not let them create a conflict between their needs and ours. We must always remember that we are in this field to treat patients with cancer; their needs come first.”
“I am 75 years old, but there is still plenty of gas in my tank,” shared Dr. Leon. “I wake up every day eager to work in this great profession. We need to do everything we can to encourage bright young medical students to enter the challenging field of oncology. We desperately need them to continue the progress we’re making.”
When asked about role models and mentors, Dr. Leon commented: “I’ve been fortunate to have been the beneficiary of great colleagues and physicians who have inspired me through their contributions. I’d begin with you, Chandra, for all the things you do for the community. And then the late Dr. Donald Morton, whose thoughts and ideas also inspired me. I’d also like to mention Dr. Monica Morrow, whose work in surgical oncology has shifted our approach. Furthermore, Drs. Charles Balch, Mitchell Posner, and V. Suzanne Klingberg, and others, have played important roles in my career. And I’d like to thank them for that.
DISCLOSURE: Dr. Are is a board member with Global Laparoscopy Solutions; has received research funding from Pfizer; and has a patent with the University of Nebraska Medical Center for a laparoscopy instrument. Dr. Leon reported no conflicts of interest.