https://orcid.org/0000-0001-8661-473X
In this issue of the Journal, Parascandola et al. (1) present a historical perspective on global funding from the US National Cancer Institute (NCI). The story is fascinating in so many ways, reflecting both the evolution of cancer research and the relationships, in this regard, between the United States and other countries. We are grateful for the NCI’s engagement at the global level and their desire to use their influence and funding to drive cancer research from a broad perspective.
It is important to note that these efforts have taken many forms over the years with different goals, reflecting the evolution of cancer care and basic research during this period. For one, substantial differences exist between collaborative funding with high-income countries and low- or middle-income countries (LMICs). The goals of the funding are likely to be different, and the relative roles of investigators from the United States and the partner country likewise will vary. In addition, the subject matter of the research has varied greatly from collaborative basic science research, to epidemiology, to clinical investigation, and finally to implementation science. In each of these cases, one should ask: What is the goal of the global collaboration?
In the case of basic science, it might be the opportunity to collaborate with a great scientist from another country who has developed unique methods and/or technologies, where working together could provide mutual benefit. It might be the chance to access tumor tissue from patient cohorts from other settings that might expand our understanding of the molecular heterogeneity of cancers in different ethnic groups. A study of the epidemiology of cancers across varied environmental or life-style context, differences in germline genetics, and other factors can contribute greatly to a broader understanding of cancer. Performing clinical research globally can facilitate more rapid accrual and completion of trials as well as help us understand how interventions work across different racial and ethnic groups. Differences in germline polymorphisms between ethnic groups can supply critical information in regard to drug efficacy and toxicities. Elucidating the differences in tumor somatic mutations across ethnic groups will be critical to assess therapeutic efficacy of anticancer agents for these populations of patients. In each of these cases, the approach should be to address the current greatest needs. These have evolved substantially over the decades. Our understanding of the basic biology of cancer has rapidly grown, together with an appreciation of the variability of molecular aspects of cancer across ethnic groups. These advances have led to dramatic therapeutic innovations resulting in improved survival for many cancers.
Where are we in 2022, and where should the NCI funding efforts be focused going forward? As the authors state, cancer incidence is declining in many high-income countries, including the United States, but it is rapidly rising in much of the world, particularly in LMICs. In high-income countries, reduction in smoking and better control of other causes of cancer are having a major effect. In LMICs, improved control of infectious disease (HIV, malaria, tuberculosis) has led to increases in life expectancy, which together with changing lifestyles, has resulted in increasing cancer rates. Much of the world, though, is largely ill-equipped to diagnose and treat these patients. For many patients living in LMICs, lack of access to the tremendous advances that have been made in diagnostics and therapeutics continue to result in huge disparities in cancer care and outcomes across the globe (2). Thus, the burden of cancer mortality is increasingly in LMICs. The vision for NCI has always been to reduce the burden of cancer through research and related efforts. We could have a great impact on global cancer mortality by developing paradigms that bring high-quality, well-resourced cancer care to all.
Parascandola et al. (1) describe efforts to build and support cancer research programs in Ghana and Uganda and delineate the challenges that are realities in settings such as these. But what are currently the biggest challenges in cancer in LMICs? One might argue that they are providing high-quality screening, diagnostics, and cancer treatment in the context of severely constrained resources. Human capacity, supply chain challenges, food and water insecurity, individual poverty, and national resource limitations are frequent barriers to quality cancer care. Innovative approaches to overcome all of these issues, which could create care paradigms that differ substantially for how care is delivered in high-income countries, are being developed, often through partnerships between cancer programs in high-income countries, including the United States, and partners in LMICs. Advances that are made in these pilot projects could be road maps for others and therefore have broad benefit across resource-constrained settings. But these experiments must be conducted methodically and with scientific rigor. Detailed strategies, mechanisms for data collection, and assurance of safe and effective care delivery are all critical to potential success. Implementation science approaches to these efforts will be key if they are to result in care that is high quality and sustainable (3). Increasingly, the NCI has supported implementation science research in the United States and should consider increased funding opportunities for global programs.
Regardless of the type of research, efforts must be truly collaborative and, most important, must benefit the people of the country we are working with. A colleague at the Butaro Cancer Center of Excellence in Rwanda said that the only measure of success from our collaboration is improved patient survival. In no circumstances must the focus of collaborations be solely to benefit the research, publications, and grants of the US-based investigators. Too often this has been the case. Although some of this research has led to better understanding of cancer in these countries, so-called medical tourism must not occur. Efforts should be built on a foundation of strengthening health-care infrastructure and education leading to increased in-country human capacity. Only then should research be layered on top of these foundations, as shown in Figure 1. Models of this approach have demonstrated success and sustainability (4).
Priorities and timeline for approach to in-country engagement.
The principles and practices of the late Dr Paul Farmer can be a road map for us to follow. His vision and, more so, his actions are examples of what can be accomplished in the most resource-constrained settings, with so many examples of resultant benefits reaped by those to whose care you have contributed (5). In his book To Repair the World he states, “With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership” (6).
Disparities of access to high-quality cancer care and outcomes exist across the United States as well. Increasingly, it has been mandated by the NCI that the US cancer centers they support address these disparities in their own catchment areas, as has been emphasized in the renewal process for the Cancer Center Support Grants. Innovations tested and confirmed to reduce disparities of cancer care in global sites have sometimes been adopted by US cancer programs to the benefit of their patients. Our world is ever more global, and clearly this is part of the NCI vision, accelerated by then Director Harold Varmus when he formed their Center for Global Health. A growing number of US cancer centers have programs in global cancer medicine, as described in this article. But programs are nascent and largely underfunded. The NCI could accelerate these efforts by encouraging NCI-supported cancer centers to develop and grow their global programs in an effort to reduce disparities of cancer outcomes worldwide and to report on their accomplishments as part of the Cancer Center Support Grants evaluation criteria.
Funding
No funding was used for the writing of this editorial.
Notes
Role of the funder: Not applicable.
Disclosures: LNS acknowledges research grant funding from Breast Cancer Research Foundation but this was not used for the writing of this editorial.
Author contributions: LNS: writing-original draft, writing-review & editing.
Data Availability
There were no data analyzed or generated as part of this editorial.
