Making a Difference: Strategies for Success

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Making a Difference Strategies for Success

• Aiming for effective cancer control in countries
  with limited resources a collaborative venture

Annual meeting 2005, Chennai, India
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Why Cancer?

• In 2002, more than half of the 11 million
  estimated patients with cancer were in developing
  countries which have perhaps 5 of global
  resources
• Developing countries still have a lower incidence
  of cancer than affluent nations, but will account
  for an ever increasing fraction of the global
  cancer burden NOW IS THE TIME FOR ACTION
• The WHA has approved a resolution (May 2005)
  recommending that countries develop and implement
  cancer control plans

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Crude Incidence Cases
Per 100,000 per annum
Thousands per annum
2002
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Estimates of All Cancer Cases, Males and Females,
Trends Included
Thousands per Annum
Influence of aging and increases in population
size
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The Problem a Vicious Cycle
Many Patients With Advanced Disease and Many
Potential Patients
High Mortality Rate
Limited Resources
POOR ACCESS
Unmet need for terminal care
LOW CAPACITY
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The Solution Build Capacity
Education Screening
Prevention
Lower Mortality Rate
Fewer Patients with More Limited Disease and
Fewer Potential Patients
Less Limited Resources
Less need and greater capacity for terminal care
GREATER CAPACITY
IMPROVED ACCESS
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Mission Statement
INCTR is dedicated to helping build capacity for
cancer treatment and research in countries in
which such capacity is presently limited and to
increase the quantity and quality of cancer
research throughout the world.
Catalysis Concerted Effort Communication
Sustainability
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The Goals

• To prevent as many preventable cancers as
  possible
• To cure as many curable cancers as possible
• To improve the quality of life of patients with
  cancer at all stages of their disease

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The Mechanism

• Establishment of long term collaborative
  projects which will have an immediate impact on
  prevention or treatment
• Associate such projects with education and
  training
• Use information collected in the course of such
  projects as a foundation on which to build future
  endeavors

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The Tool Collaboration
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INCTRs Network
Offices and Branches
Collaborating Units
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Advisory Board

• Special Panel of cancer experts from countries
  with limited resources
• Provides advice on INCTR activities
• Selects of INCTR Awardees
• Determines venues of Annual Meetings
• Disease-specific experts
• Scientific review of projects and participation
  in strategy group meetings

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Offices and Branches

• USA, UK, France, Brazil, Egypt, Tanzania, Saudi
  Arabia, India, Nepal
• Regional/national coordination of INCTR programs
  and projects
• Access to regional/national resources
• Expansion of local capacity
• Guiding principles INCTR Charter

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Associate Membership

• Corporate Membership (3)
• Partnerships with the corporate world
• Institutional/Organizational Membership (109)
• Provides access to a broad range of expertise
• Participation in INCTR activities
• Individual Associate Membership (75)
• Contributions, financially or in kind
• More important role in the future

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Partnership with NCI

• OIA has sponsored many of INCTRs educational
  meetings, courses or specific training programs
  in INCTR-recognized training centers
• Recently a collaboration has been developed with
  MECC joint meeting in Cyprus

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Corporate Partnerships

• Eli Lilly
• INCTR has provided off-site data management for a
  randomized trial sponsored by Lilly in locally
  advanced Cx cancer in 10 developing countries
• Support of Clinical Trials Workshops
• CTIS
• Provided INCTR with a powerful web Portal
• Is helping INCTR to develop clinical data bases
  and to IT-based training tools

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Collaboration with Other Organizations

• ACS Partnership Palliative care, ACSU
• UICC Steering Committee for MyChildMatters
  (Sanofi-Aventis)
• WHO Technical Committee for Global Cancer
  Control
• Institute of Medicine Report on Cancer Control
• IAEA Collaboration in breast cancer and
  potentially, expanded cancer programs
• ESO Plan to hold joint meetings
• Global Alliance for the Cure of Children with
  Cancer Organizations/institutions for pediatric
  cancer
• AORTIC Discussion phase

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Strategy Groups
International groups identify and implement
disease specific activities in prevention,
treatment, education
Cx Cancer, August 2004
Implementation Meeting, African BL, Tanzania,
August 2004
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Active Projects (8)

• Reasons for late presentation of retinoblastoma
  15 centers in 11 countries
• Survey of breast cancer management - 4 countries
• Cx Cancer screening (with IARC) 2 countries, 4
  sites
• Treatment of advanced cervical cancer (with Eli
  Lilly) 10 centers in 10 countries
• Treatment of metastatic osteosarcoma - 6
  countries
• Treatment and study of ALL in India - 4 centers
• Treatment and study of Burkitts Lymphoma in
  Africa - 4 centers in 3 countries
• Provision of palliative care Nepal (3 centers)

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Projects in Planning Phase (6)

• Treatment of locally advanced retinoblastoma
• Treatment of locally advanced breast cancer
• Treatment of locally advanced Cx cancer
• Extending cervical cancer screening into the
  health care structure India
• Expansion of palliative care program to Tanzania
  and India
• Cancer control in Cameroon

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Relevant Meetings and Expert Visits in Last Year
Workshops 10
Strategy Groups 5
Committees Meetings 4
Individual training/fellowships 16
Training Courses 3
Monitoring Visits 2
Expert Visits/Presentations 38
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New Funded Projects

• INCTR collaborating centers and branches have
  successfully competed in the UICC MychildMatters
  program funded by Sanofi-Adventis and NCI being
  awarded 4 of the 14 projects (Egypt 2, Tanzania,
  1, Philippines, 1)
• INCTR designated by Steering Committee to assist
  these projects

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New Funded Projects

• INCTR and the American Cancer Society will work
  together in promoting palliative care in India

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INCTR Strategies

• Conduct demonstration projects in specific areas
  of cancer control (cancers in women and children
  highest priority)
• Use centers involved as training sites to improve
  regional and national coverage
• Use clinical trials as a complete approach to
  training, education, research and patient care
• Maximize use of IT in training, education,
  monitoring and measuring outcomes

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Non-Governmental Organization
Visiting Experts
External Training
FUNDING
E-learning?
Government or Local NGO
Locally Run Demonstration Project
Education of other primary health care workers
or trainees
Dissemination to other centers
Dissemination to Health Care System
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Population Coverage Example (Wide Application)

• 700 cases of BL in Tanzania
• Identify centers capable of care
• Develop improved diagnostic and referral systems
• Provide training where necessary
• Develop targets for extending care to 80-90 of
  cases

Year 1 Year 2 Year 3
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Value of Clinical Trials

• Improved access of patients and professionals to
  the limited number of experts
• Carefully designed treatment approach
• Diagnosis and staging must be standardized
• Supportive care must be addressed
• Loss to follow up must be reduced
• May include non-therapeutic components
  (epidemiology, molecular characterization)
• Data must be accurately collected (surveillance)
• Increased communication and hence learning among
  all participants
• Instills good habits of clinical care, and a
  research perspective in junior staff wide
  impact
• Provides a local data base that can be built upon

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Comparison of Treatment Guidelines and Clinical
Trials
Research
Guidelines

• Designed for a specific population in the context
  of available resources
• Usually entails collaboration and mutual learning
• Associated with quality assurance and ethical
  review
• Identifies deficiencies
• Associated with outcome measures
• Generates new information

• Based on available evidence may be from a
  different population and with different resources
  
• Rarely entails collaboration or learning
• No quality control or ethical review
• No identification of deficiencies
• No outcome measures
• No new information

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Obstacles to Conducting Clinical Trials in LR
Settings

• Lack of academic mindset health care is
  increasingly seen as a business or service by
  practitioners and outcome is ignored
• Lack of financial or professional rewards
• Lack of required infrastructure and funds
• Lack of institutional will to collaborate
• Lack of incentive to perform trials (except
  financial inducement by Pharma)
• Inability to ensure good follow-up

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Disadvantages of Joining Existing Cooperative
Groups

• Can join existing groups based in affluent
  countries, or Pharma trials but
• Many, perhaps most, such trials will not address
  locally important problems
• Patients may not be comparable to those entered
  in affluent countries
• Limited opportunities to play a role in
  identifying or designing studies
• May be limited availability of resources (unless
  Pharma sponsored, when sustainability an issue)
• Regulatory differences can inhibit collaboration

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Maximizing IT - 2006

• Use telesynergy or internet based lectures and
  discussions
• Provide presentations, documents and training
  modules on portal
• Identify sources of funding (Fund Raising
  Committee) consistent with the new IT era

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IT the Nervous System of the Global Community

• New major projects underway that require
  collaboration and standardization
• Cancer Control Planet (NCI)
• caBIG (NCI project to develop a universally
  valuable and collaborative bioinformatics grid)
• Requires standards for communication syntax,
  vocabulary, semantics, messaging etc.
• Various systems exist and are being harmonized,
  particularly in USA CDISC, HL7, BRIDG
• Global Community of Practice WHO, UICC, BCC
• INCTR will work with partners, especially CTIS,
  to try to ensure that developing countries are
  involved from the beginning

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Annual Meeting 2005

• Award lectures (Dennis Wright, Suresh Advani)
• Individual presentations (posters, oral)
• Reports on ongoing activities
• Keynote lectures
• Educational sessions and workshops on regionally
  important cancers
• Consensus panels hereditary breast cancer
• Multidisciplinary conference DLBCL
• Meet the expert sessions
• Members meeting

Local Host Cancer Institute (WIA), Chennai, India
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Thanks to Sponsors

• Cancer Institute (WIA), Chennai
• Office of International Affairs, NCI
• Pasteur Institute, Brussels
• Leukemia and Lymphoma Society (workshop on ALL)
• Susan Komen Foundation (workshop on breast
  cancer)
• Jiv Daya Foundation
• Agfa, AstraZeneca, GlaxoSmithKline, MSD
• Local sponsors

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Special Thanks

• Drs Shanta, Rajkumar, Sagar, and Local Committee
• Organizing/Scientific Committee, Indian National
  Committee and INCTR India (Dr Bhargava)
• INCTR administrative staff Cedric, Elisabeth,
  Béné and Suzanne, Tom
• INCTR Program Directors Melissa Adde, Ama
  Rohatiner, Aziza Shad, Stuart Brown, Kishor
  Bhatia and Marina Gutierrez, Sabine
  Perrier-Bonnet
• All speakers and presenters
• Delegates
• All who have contributed to INCTR activities or
  collaborated in the past years

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Countries Associated with INCTR