Dr. Eduardo Paulino from Rio de Janeiro, Brazil, served as a 2016 GCI Global Fellow from June to December. Throughout his Fellowship, Eduardo participated in all of the projects we do here at GCI, from leading research publications on cancer control in Brazil to helping design projects that will help patients in his home country and beyond. Eduardo has been a fantastic and energetic addition to our GCI team, and in the last few days of his Fellowship, I was able to speak with him about the projects he has been working on with GCI, his time in Boston, and his goals upon returning to Brazil.
1. Could you tell us a little bit about your background, your work as an oncologist, and what you do in Rio?
I’m a medical oncologist, dedicated specifically to treating gynecologic tumors. I work in the department of Gynecology Oncology at the National Cancer Institute (Hospital do Cancer II) in Rio de Janeiro, Brazil, which is a public cancer institute. Most of my patients are under-resourced and have some serious obstacles when they try to access high-quality cancer care. In my hospital, we are able to provide public care for all women with the best evidence-based practices, which is a very rewarding environment to work in.
2. Do you like Boston? How has your experience been in our city?
Boston is an amazing city, and it has been a great host. I have had no problems at all (if you don’t count apartment hunting…) Wherever you are, you always have access to markets, drugstores, gyms, grocery stores, etc. The city is also very welcoming to foreign students and tourists, with so many schools, hospitals, and things to do. All of the Bostonians that I have met are very friendly and helpful.
3. What has been your favorite experience in your fellowship so far?
My favorite experience in my fellowship has been the opportunity to share my ideas and have them taken into account. The interaction with my mentors was very fruitful, and I believe that both sides benefited from collaborating together. It is great to work with so many different people and to meaningful contribute to projects that will change the landscape of cancer care for patients in my country.
4. What kinds of projects are you working on here with Dr. Goss and GCI? What projects or ideas are you most excited about sharing with your colleagues and starting at your hospital when you get back to Rio de Janeiro?
My projects with Dr. Goss and GCI are based on the barriers that patients in low- and middle-income countries (LMICs) face when trying to access quality cancer care. We believe that the first step is to find these obstacles and create plans to overcome them, in order to better serve cancer patients in under-resourced countries. GCI’s patient navigation programs and prospective databases are the most exciting projects that I would like to implement in my hospital. GCI already has a global database for young women with breast cancer, but since I specialize in gynecologic oncology, I helped to design a cervical cancer database, so we can begin to learn more about the treatment choices and outcomes for women in Brazil and elsewhere who are suffering from this disease. It will be very exciting to implement this database with my own patients and contribute to a global body of data that will help us help women around the world.
5. What do you think will be your biggest take-away or lesson-learned from your time here at GCI?
Multidisciplinary work! Here, I really got to experience how important it is to engage in multidisciplinary teamwork–taking into account everyone’s opinions, respecting everyone’s experience, and maximizing our impact with the best approach. This pattern of working with multidisciplinary teams is one of GCI’s key goals, and it is used in patient care, as well as any kind of research project the group performs. By engaging the right people and various experts in the field, we are able to make the best decisions possible for our patients.
6. What advice would you give to young oncologists, doctors, or students who are thinking about getting into public health or cancer research?
That is possible to make a difference! Public health, especially in LMICs, is challenging. When you hit your first obstacle, don’t give up because there will be many more ahead. With continuous effort, you do have the ability and power to change patient care (whether that is by treating individual patients, improving screening practices, connecting a patient to other services, providing palliative care, or even finding a cure). Believe in yourself!
On June 5, 2016, Dr. Goss gave a plenary lecture at the ASCO Annual Meeting on a groundbreaking clinical trial he has been leading for some time. The trial found that extending the use of aromatase inhibitors for breast cancer therapy can reduce the risk of breast cancer recurrence and decrease the chance of a new cancer forming in the other, healthy breast.
The ASCO selection committee chooses its plenary lectures based on their direct clinical application. From a review of 5,400 abstracts they select four most likely to change clinical practice. The trial under Dr. Goss’ leadership, called MA.17R, was selected as the number one trial for presentation at the world meeting, and the results were published in the prestigious New England Journal of Medicine.
In recent years, Dr. Goss has shifted his research priorities from discovering new breast cancer clinical therapies in the developed world to helping underserved patients in low- and middle-income countries (LMICs) across the globe.
Dr. Goss emphasizes that, unlike many cancer therapies, aromatase inhibitors are widely accessible – most are off-patent and, therefore, relatively inexpensive. “New targeted therapies, immunotherapies, and advanced genetic testing are scientifically exciting, but prohibitively expensive for most of the world’s population. Most money for cancer control is spent in high-income countries. Since 86% of funds spent on cancer control globally are spent on only 6% of the world’s population, people in LMICs do not benefit from these scientific advances. Patients from these populations would benefit more from enhanced access to simple, ‘bread-and-butter’ medicine,” Dr. Goss says.
Several years ago, after the global success of his original MA.17 trial, Dr. Goss traveled extensively around the world presenting results from the trial. Somewhat to his surprise, young doctors in LMICs approached him by the dozen asking to train with him, publish with him, and learn from him. They wanted to improve the state of clinical care and research in their countries, but they were always met with resistance by shortage of funds or lack of opportunity.
Dr. Goss realized that the true solution to global cancer control is not necessarily to cure cancer – which is undoubtedly important – but to help patients from underserved populations to access resources that have existed for many decades in the developed world. His chief mission is to improve the survival and quality of life of underserved cancer patients worldwide and thus he has founded the Global Cancer Institute.
So although the presentation of the MA.17R trial was a departure from his current daily focus, Dr. Goss recognizes that all patients with breast cancer – regardless of socioeconomic background – stand a chance to benefit from the results of his latest scientific research.
Our Patient Navigation Program in Mexico was only launched a few months ago, but we are already seeing what an amazing service it provides for so many patients. Here, Dr. Enrique Soto tells the story of Juana in Mexico City. With the help of patient navigation, Juana has successfully navigated Mexico City’s health system and is now excited about the prospect of helping other patients like her complete chemotherapy!
“Juana is one of the many success stories of our Patient Navigation Program,” says Dr. Enrique Soto, co-investigator for the Patient Navigation Program in Mexico City. “Juana is a delightful 77-year-old woman who lives in a village in the borough of Xochimilco, in the southern part of Mexico City. She was diagnosed with breast cancer in her community and sent to Ajusco Medio General Hospital. After Juana arrived to Ajusco Medio, she underwent a mastectomy with axillary lymph node dissection.”
Ajusco Medio is the community hospital where Wendy, Mexico’s first navigator, works to navigate cancer patients to the proper cancer centers throughout the city for follow-up treatment and care. She not only helps schedule follow-up appointments and provides information on health insurance, but she also offers support and friendly face for patients who are trying to receive care within a complex and confusing health system.
“In one of her follow-up visits, Juana was approached by Wendy, our patient navigator, who offered to help her receive adjuvant treatment with chemotherapy and radiotherapy. Juana started patient navigation and was navigated to the National Institute of Medical Science and Nutrition. There, she was seen by an oncologist within the first two weeks and enrolled in the Seguro Popular public health insurance system,” Dr. Soto explains.
To be seen by an oncologist at a tertiary cancer center within two weeks of referral is an impressive feat in Mexico City, where the median time to arrive to a tertiary care center after being referred is two full months. With Wendy’s help, Juana was able to make this journey in a fraction of the time.
“Her biopsies were reviewed and after a complete evaluation by oncologists, surgeons, radiation oncologists, and geriatricians, she was deemed fit for treatment. So far, Juana has had three chemotherapy sessions without any complications, and is getting ready for her radiotherapy,” Dr. Soto says. “She has even participated in another one of our trials exploring the use of smartphones for the follow-up of older adults undergoing chemotherapy, and she enjoys the prospect of helping other patients through her participation in research.”
Dr. Soto explains that Juana is a wonderful and energetic patient who is the perfect example of how navigation can help cancer patients move through a complex system to receive timely cancer care – with amazing results! Not only has Juana successfully started her cancer treatment, but she is now enrolled in public health insurance and is an active participant in other studies that aim to help patients just like her complete chemotherapy.
“Juana is very grateful for the help Wendy gave her and is happy with the whole navigation team,” says Dr. Soto. “But we are even more grateful for her amazing participation!”
When most people think of health in low- and middle-income countries (LMICs), they think of infectious disease. Infectious disease has, after all, been the most pressing health concern for the less developed regions of the world, and it oftentimes commands the attention of both media and global health philanthropy worldwide. However, what most people don’t realize is that non-communicable diseases, such as cancer, are overtaking infectious disease as the leading healthcare threat in these LMICs. And when the health system needs to divide its attention between what we are now calling the “double burden” of communicable and non-communicable diseases, it can get overwhelmed.
It is easy for public health officials to wave off the more gradual growth of non-communicable diseases in these countries, especially when patients are suffering from acute infectious illnesses that seem to demand more immediate attention. But as cancer incidence in LMICs rises due, among other factors, to aging, Western lifestyles, cancer-causing infections, and carcinogenic environmental factors, governments and health ministries cannot stand idly by. The burden of cancer in LMICs is now greater than that in more developed countries, as more and more patients are dying of advanced stage disease.
It is time to take action in LMICs to prevent, detect, and treat cancer as early and effectively as possible, and this is accomplished through national cancer control plans (NCCPs).
According to the World Health Organization, an NCCP is defined as “a public health program designed to reduce cancer incidence and mortality and to improve the quality of life of cancer patients, through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment and palliation, making the best use of available resources.” That’s a hefty definition, but essentially NCCPs lower the number of new cancer cases a country sees each year and improve the quality of care cancer patients receive by following a comprehensive national plan.
National cancer control plans are so important for countries that need to address the growing global cancer burden. Establishing an effective NCCP integrates existing health systems in a country and coordinates efforts to address the complexities of cancer care and treatment. However, many LMICs do not have one of these plans and are even struggling to adopt one in the face of competing health priorities, inadequate resources, and lack of expertise.
Latin America is one example of a region that exhibits a great need for national cancer control plans, but countries throughout the region are struggling to design and implement them. One big hurdle they face? Lack of adequate cancer registries.
Cancer registries are a fundamental requirement for the successful implementation of NCCPs. Why? Because you need to know the problem before you can implement a plan to fix that problem. Cancer registries collect highly valuable epidemiologic data on the state of cancer in a country – which cancers are most common, which areas have the highest cancer burden, who is most affected by cancer, etc. The data collected in cancer registries is essential for health officials to know the who, what, when, where, and why of their national cancer control plans. Armed with the knowledge of the local needs and current deficiencies in cancer care, a country can develop an evidence-based and forward-looking NCCP.
Fortunately, the percentage of Latin American and Caribbean countries that reported having a population-based cancer registry increased from 21% to 67% between 2011 and 2014. However, there is still a long way to go, as the proportion of the population that is actually covered by these registries is still quite low compared to developed countries. As the quality and quantity of data collected in Latin America grows, health authorities can begin to establish specific public health strategies to address the growing burden of cancer throughout the region.
Peru is a great example of a country in Latin America that has created, adopted, and implemented a national cancer control plan, which they have named “Plan Esperanza.” Plan Esperanza was created by a multidisciplinary team, including policy makers, that brought together different constituents to put forth comprehensive cancer control policies. The plan now impressively includes ten neoplastic diseases. Since the adoption of their NCCP, the following amazing things have happened in Peru:
- The proportion of patients included in the universal healthcare system increased from 17% to 64%
- The proportion of patients who paid out-of-pocket expenses for cancer treatment decreased from 59% to 7%
- 16 million people have received preventive interventions, such as educational sessions and counselling
- 2.5 million people have been screened for cervical, breast, gastric, colon, or prostate cancer – or a combination of these diseases
National cancer control plans like Peru’s are so important that coordinated international efforts – spearheaded by big organizations like the WHO – have been cropping up over the past few years. For example, the WHO endorsed the Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020, which aims to achieve a 25% reduction in premature mortality from NCDs by 2025. WHO and PAHO (the Pan American Health Organization) launched the Women’s Cancer Initiative to bring together partners to set up action plans for the prevention and control of cervical and breast cancer in Latin America. Finally, the International Cancer Control Planning Partnership (ICCPP) was launched due to the combined forces of the Center for Global Health and the National Institutes of Health in the United States, the Latin America and Caribbean Society of Medical Oncology, PAHO, and the Union for International Cancer Control. The goal of the ICCPP is to implement and assess national cancer control plans with a worldwide framework and international support.
Undoubtedly, there is an urgent need to plan, develop, and better implement national cancer strategies, as low- and middle-income countries continue to bear more and more of the global cancer burden. What other countries or international organizations have been particularly successful at designing and implementing NCCPs? What more is needed from the international community to make these important goals a reality? Join the conversation and comment below!
Information in this post is summarized from our Lancet Oncology Commissions on Planning Cancer Control in Latin America and the Caribbean and Progress and remaining challenges for cancer control in Latin America and the Caribbean.
The Global Cancer Institute (GCI), a 501(c)(3) public charity, has a mission to improve the survival and quality of life of underserved cancer patients worldwide. It’s an ambitious goal, but GCI is accomplishing this by connecting a network of global oncologists through an integrated and easily accessible technology platform: Google.
GCI unifies its global projects on the Google platform, utilizing the resources offered by Google for Non-Profits. Google allows GCI to connect substituents via Google Apps. Google Apps is HIPAA-compliant, which is an important capability since GCI works with health data and adheres strictly to HIPAA standards. Google’s HIPAA compliance ensures that GCI’s data remains protected, even within this cloud-based technology platform.
Some of the key Google Apps products that assist GCI in meeting its goals are as follows:
Google Drive allows GCI to give access to shared documents to their global network of doctors through a single platform, which is particularly important considering GCI’s network of over 350 doctors in more than 20 countries around the world. Google Drive allows GCI to control multiple folders and documents and thereby effectively manage and control all of its global projects with many constituents.
Google Hangouts is a videoconferencing tool that allows GCI to connect an unlimited number of viewers to participate in our Global Tumor Boards – live, doctor-to-doctor meetings that allow discussion and collaboration on complex patient scenarios from around the world. It is an extremely valuable educational tool and offers the opportunity for doctors to collaborate and learn from each other – even from different continents.
Google Forms provides a simple way to create patient questionnaires, activity tracking logs, and clinical surveys, which help collect important data for many of GCI’s projects.
Google Sheets acts as a back-end for the data collection that happens through Forms, functioning as an easily shareable spreadsheet that updates in real-time as data is gathered from around the world.
Google Extensions, like AppSheet, expand the capabilities of the Google Apps. AppSheet is a tool that converts the Forms that GCI creates into applications for an iPhone or tablet. This allows patient questionnaires and activity tracking logs to be housed on a tablet’s home screen, easily accessible and user-friendly for both patients and health workers. It also allows use in areas that do not have wi-fi, an important capability in low resource areas. The data is then uploaded to Sheets when a wi-fi connection is established.
Google Analytics allows GCI to track activity on their website in order to gauge their audiences, expand their reach, and engage with followers and potential donors.