Cancer Around the World: A Global Health Challenge

Episode Transcript
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OLIVER BOGLER (00:04):
Hello and welcome to Inside Cancer Careers, a podcast from the National
Cancer Institute where we explore all the different ways people fight cancer
and hear their stories. I'm your host, Oliver Bogler from NCI Center for Cancer Training.
Cancer is a global problem. You will find people working on cancer in every country in prevention,
treatment, and research. Today, we're going to focus on work happening here in the US

(00:27):
on this global health challenge. In a future episode, we will talk to
people working at global institutions. These are all interesting career paths.
Listen through to the end of the show to hear our guests make some interesting
recommendations and where we invite you to take your turn. And of course,
we're always glad to get your feedback on what you hear and suggestions on what
you might like us to cover. The show's email is NCIICC@nih.gov.

(00:52):
So it's a pleasure to welcome two US leaders in the global fight against cancer,
Dr. Satish Gopal, Director of the NCI Center for Global Health. Welcome.

SATISH GOPAL (01:04):
Hi Oliver.

And Dr. Peter Kingham, Surgeon at Memorial Sloan Kettering Cancer
Center and Director of the Global Cancer Disparities Initiative at MSK. Welcome.

PETER KINGHAM (01:14):
Thanks, Oliver.

So let's start with the global challenge that cancer presents.
Is cancer the same everywhere? And can we use the same approach to it? Satish?

So first, cancer is a huge global burden. I think Peter and I appreciate that quite
well. But it often is less appreciated than you might think by people who don't work on
this problem primarily. So I think that's the first point is just appreciating that there's
10 million cancer deaths per year and that these occur primarily in low and middle income

(01:47):
countries. And the burden is escalating sharply, often in countries and health systems that don't
really have a lot of capacity currently for dealing with this escalating problem.
I think one of the additional problems with cancer in a way is that it doesn't
sort of come on with the speed of an infectious pandemic. And so, you know,

(02:08):
if you look at the number of people that cancer kills per day, it's far in excess of the,
for example, the number of people that were killed by COVID globally at the peak of the pandemic. And
of course that isn't to pit one disease against each other, another, it's just to highlight that
I think we often, because it comes, tends to come on slowly and these are deaths that occur

(02:30):
over months and these are incidents trends that are occurring over years and decades. I
think it doesn't tend to attract the kind of political attention that it really requires.
So that's first point is just emphasizing how important it is globally. And then in
terms of how it differs around the world, of course, it differs quite a lot. I mean,
different cancers occur with different frequency all around the world. Populations are very

(02:54):
different around the world, both in terms of their genetic background, their environmental exposures,
their social and demographic characteristics, and health systems are very different all around the
world in terms of you know, how they are able to address a problem like cancer that often
requires fairly high intensity, multidisciplinary type approaches. That's hard to deliver often in

(03:18):
some settings, on the, know, conversely, many settings have much more sophisticated
community health delivery apparati than, you know, than we have traditionally in the US.
So in that sense, think cancer is a huge problem globally and also really
fascinating just because it's so different in so many ways all around the world.

Peter, anything to add?

Yeah, think Satish hit a lot of the main points here about how challenging
a problem this is. And I'll just echo that, we often traditionally would say in a high income
country like the US, you know, cancer works this way, X, Y, and Z. It's these genetic mutations,

(04:02):
you know, this footprint is colorectal cancer or is breast cancer. And what has
become clear is that that's just not true.And to truly understand cancer, using it as
sort of a very broad word to describe all the cancers, you obviously have to look in a lot of

(04:23):
different regions. So you don't have to look at a specific cancer in every country in the world,
but in every region in the world you do, just to even understand what causes it there, because it's
different between so many different places.And what is so hard is, there's so much money
has been invested in cancer research and there's been endless breakthroughs that
have helped save patients' lives and decrease mortality rates. Most of that has been done

(04:47):
in high-income countries. And unfortunately, we often can't extrapolate from high-income
countries to low-middle-income countries. Our group alone have disproven what is really
been proven in high-income countries. It doesn't work so well in low-middle-income countries. And
that makes it challenging but also an interesting field to be in because we really have to have

(05:12):
to challenge our beliefs of what cancer is and how to treat it and how to prevent it.

Satish, you spent some considerable time in Malawi.
For a period of time, you were the only certified medical oncologist there serving
a population of approximately 18 million. If you could describe how this experience
shaped your understanding and maybe in the context of what you both just described,
in general terms, what were the sort of specific manifestations of that in your experience there?

Yeah, Oliver, as you noted, my academic life was basically spent living and
working in Africa prior to coming to the NCI in 2020. And that was taking care of
people with cancer in the public sector, which occupied a fair amount of time. As you noted,
I was the only medical oncologist at the time in a country of 18 million people. And I led an NIH

(06:02):
NCI-supported cancer research program, which is really what funded me to be there. I saw hundreds,
thousands of patients, but generated zero clinical revenue. So a source of support
for my salary was largely derived from NIH grants.And I mean, it was just a formative experience for
me. mean, and I think it really informs everything that I do now. Paradoxically, I became interested

(06:29):
in cancer living and working in Africa. So when I finished residency, my wife and I were interested
in exploring a global health career and I lived in Tanzania for a couple of years with my wife
and then six-month-old daughter. We were sort of testing out whether or not we would enjoy,
thought we would enjoy a career in global health and I was, I thought it was going to be a global
HIV researcher and by that point, this was 2007 to 2009, HIV treatment scale-up was already happening

(06:57):
and so it was clear that the questions vary, that it worked just as well as it did in the
United States and that the questions very quickly were going to be economic and implementation and
not so biomedical, which is where my brain is primarily oriented. I sort of like the virtuous
cycle of bench to bedside translation.Conversely, there was tons of cancer,

(07:18):
which I had not fully appreciated until living in Tanzania. Nobody was thinking seriously about
it. A lot of it occurred in association with HIV. So, I always kind of joke that ironically,
wasn't when I was training at NCI designated cancer centers in the US, it was when I was
living and working in Africa that I became fascinated by, you know, how do you deal with
this complex set of diseases in the set that often require very intensive multidisciplinary care in

(07:43):
settings where a lot of that infrastructure is not available. And that's intellectual problem,
I think really piqued my curiosity and drove my, you know, subsequent training and career
path. So that's sort of how I got on the sort of trajectory that I got on, you know, in a nutshell,
happy to elaborate on that as needed, but Peter, I'm sure we'll have interesting insights as well.

Peter, you've participated in surgical missions to several African countries,
right? And I wonder if you could share some particular experiences from those and how they
relate to sort of the general global health challenges that you described a moment ago.

Yeah, I started in medical school and then residency where I pretty
much spent any time that I didn't have to be on a clinical rotation, so vacations, electives,
et cetera, outside of the U.S. And actually I had some really important experiences in
Malawi as well. I didn't live there. I was only there for maybe two months. But I was a

(08:44):
surgery resident and in the public hospital in the capital and I had been in three or four African
countries before that working with surgeons, but I was senior enough now where I had a lot more
responsibility and the mortality rate was just shocking to me because a few patients made it in,

(09:06):
a lot died on the way and if they made it to the hospital, died very quickly. Some patients
made it in the operating room, some died in the operating room and a lot of patients died after.
And I had done, I'd been in South Africa and done high volume trauma surgery. The
outcomes for that were much better. And it was because of how advanced everyone's

(09:27):
disease was. Things like colonic volvulus, Malawi's part of the volvulus belt. And...

Can you, sorry, can you elaborate on that? I'm not sure I know what it is.

Sure. Yeah, sure. So colonic volvulus is where your colon twists on the
mesentery that brings the blood supply in. And it's associated with sort of
a belt through Africa dietary related where with high fiber diet constipation,
you get these very stretched out colons and stretch out the mesentery. And if it twists,

(10:00):
it cuts off the blood supply. And that can be an emergency because your colon can die.
So it was, I mentioned that because I think I operated on 20 patients for that in two
months in Malawi and four patients in my career outside of Malawi. And it really
stood out for me personally that while I enjoyed helping the individual person,

(10:22):
I became much more interested in thinking about larger scale questions. And how do you identify
diseases earlier in lower resource settings?How do you train more people to deal with
what's common in one area but not common in another? So I took a step back and thought,
for me as an individual, I'm not as interested in doing a surgery in another country,

(10:46):
but would much rather participate in trying to answer larger scale questions and training.

Thank you. So that then led to, I guess, your work back in New York,
in MSK, right, with the Global Cancer Disparities Initiative.

Yeah, it was a bit of a circuitous route. When I was a fellow,
I started an NGO called Surgeons Overseas with another surgeon, Adam Kushner. And we were really
trying to help small West African countries build surgery residency programs because at the time,
Sierra Leone and Liberia, for example, didn't have surgery training programs. So

(11:22):
we spent a lot of time trying to do that and we failed. They have since started and maybe
what we started talking about back then contributed a little bit, but overall we
failed in what we were trying to do at the time.But it again showed me how important research
was because the one thing we did succeed in, for example, in Sierra Leone, we asked the question,

(11:43):
how common are surgical diseases in the general population at home? Because
everyone just reported what was published from the hospitals, we had done that too,
and that's really not representative. So we did a randomized cluster-based sampling
in Sierra Leone throughout the country and did verbal physical examinations and asked,

(12:04):
know, how did someone die in the last year and what was going on with them? And probably 15 to
20 % of people who had died in the past year, it's reasonable to think a surgeon would have
evaluated them. So the numbers were much higher than had previously been shown. And it showed
me how valuable with a small budget, asking this novel question really, it could be very valuable.

(12:28):
And at the time I was finishing fellowship and becoming a cancer surgeon. And I realized
while I had been doing more general surgery work, if I didn't have cancer as my focus,
it was hard to see how that fit in my career. And I was becoming a surgical oncologist. So
the timing was sort of right for me to focus on global oncology, which traditionally has not

(12:49):
had a lot of surgeons involved in it. But when you really look at for solid tumors,
where most of the treatment is coming from, even in palliative care, it's from surgeons,
especially in low middle income countries. So the timing was right for me. And I think as
global oncology sort of rose in importance, the timing was right to fit into this field.

Interesting. Satish, coming back to your current role as the leader
of the Center for Global Health at NCI, Peter was describing some works of some
non-profit he led. You're representing a very important government component
in this work. What are the strategic goals of the center and where are you leading it?

Yeah, well, thanks for that question. mean, the NCI, as you know, Oliver,
as a colleague here at the NCI, the NCI is the largest funder of cancer research
in the world. And I think that comes with it an important responsibility in relation
to cancer worldwide. And indeed, the NCI has always been engaged in global cancer research,
really, since the Institute was first founded in 1937. This really isn't something new.

(13:52):
But as you know, when Harold Varmus was the NCI director in 2011, it was felt at that time that
there was enough need and opportunity that the NCI, again, as the largest funder of
cancer research in the world, really required a much more coordinated and concentrated effort in
this area. And that's why the center was created.I must say, I think this was really important for

(14:15):
the community generally. I feel I was at a cancer center, attempting to move to Africa to establish
a career as an NIH-supported physician scientist. I think that was very much enabled by the,
my cancer center being aware that the NCI had created a dedicated center for global health.
We've seen since that time, a steady increase every year in the number of awards that are made

(14:37):
by the NCI that include international components, both numerically and as a proportion of the
overall extramural portfolio, even when it is not being directly funded from an NCI center for
global health program. So I think that signal is really important. And as you know, I mean,
that's the kind of platform and visibility that we often have at the NCI that's quite valuable.

(14:59):
I came to the center in 2020 and what I tried to do is bring this decade of taking care of
people and trying to do what we perceived as being impactful research that was addressing
kind of local needs and priorities and bring that lens to the NCI. I mean, I remember at
the time when I was kind of offered the job by Doug Lowy, who was the acting director at the

(15:21):
time. He really pitched it as an important public service opportunity and that spoke
to me. It really resonated and I thought, you know, maybe I have a set of experiences and a
background and perspective that will be valuable for the NCI in trying to achieve its mission.
We spent a lot of time, as you and others may know, developing a strategic plan at the center,

(15:41):
a five-year strategic plan that actually runs through the end of next year. And this includes
support of applied research and control agenda in LMICs specifically. This includes a big technology
development portfolio technologies that are really designed to solve critical cancer control problems
in LMICs, major investments in implementation science in recent years. We're thinking a lot

(16:05):
about trials. We're thinking a lot about how to connect domestic disparities work,
which of course is a huge portfolio at the NCI with some of the more LMIC
facing work that the NCI supports. So we have a big focus on research, obviously,
as the NCI. We support a lot of research training. Of course, we do a lot of this
in close concert with you at the Center for Cancer Training and your staff there.

(16:29):
And then we have a suite of activities that are what we call partnerships and
dissemination activities. So we try to hold scientific meetings that really feature a
lot of the excellent work that's being done by investigators in LMICs. We try to connect with
WHO and IARC and ministries of health to ensure that as NCI is supporting evidence,

(16:52):
generation that this evidence is really being brought to bear on global cancer control policies
and practice in meaningful ways. So, you know, I won't be able to talk about everything that we do,
but that's kind of our portfolio in a nutshell.We're actually really excited. We're already
planning for a center level evaluation next year to sort of assess what our progress has
been against this five-year strategic plan and then we'll use that to inform a refresh of our

(17:16):
strategic plan that we hope to launch at the beginning of 2026 without there being a cap.

Fantastic. A lot of things going on. Amazing. I want to pull on that one thing,
one comment you made about the connection between domestic health
disparities and the work that is done in LMICs. I'm curious,
can you tell us a little bit more about why there is that connection?

Yeah, so I think there's a tremendous amount of scientific and
philosophical kinship. I think some of what Peter was alluding to earlier, you the fact that we
sometimes learn when we're humble enough to study interventions or diagnostic tests in populations
that have historically often been excluded from cancer research, they don't work as well. Or

(17:59):
sometimes they work as well, sometimes they don't. And I think it's hubris to
think that we know whether it will work or not before we actually deign to study it.
That's often been an issue even for certain communities in the United States,
right? And one could argue that our inability to meaningfully reach out to all communities in
the United States really underlies a lot of the persistent and troubling cancer health inequities

(18:23):
that we observe even domestically. And that's true in LMICs as well. In addition to the fact
that we have large immigrant populations in cities like New York where Peter works
that are often very connected to their home countries in terms of cultural practices,
environmental exposures, travel back and forth.So I think for a whole variety of reasons,

(18:45):
can bring, historically, think cancer health disparities research domestically and global
oncology have been somewhat separated from each other. I don't believe they're the same thing. I
actually don't think that global oncology is just sort of a subset of cancer health
disparities research, but I think there are important areas of, again, scientific

(19:07):
and philosophical overlap that we should do a better job of kind of realizing as a community.

Interesting. Peter, Satish described how the NCI has positioned itself
in this work as a global health researcher and surgical oncologist at one of those NCI
designated cancer centers, how does that feel and what's your perspective on what Satish shared?

Yeah, actually, even me personally, the Center for Global Health was really important.
And I would say it was important for me personally before it was important institutionally. In 2010,
right before Dr. Varmus left, he met with myself and the seven graduating surgical
oncology fellows. He did this every year. We invited him for pizza. And

(19:54):
everyone got five minutes around the table to sort of tell Dr. Varmus your research.
And everyone other than me was really talking about translational basic science stuff that
they planned on doing and no offense to my colleagues, they're all fantastic, but
hard to impress a Nobel laureate basic scientist with at a fellow level your basic science ideas.

(20:15):
And I said, well, I'm just going to be honest with them, tell them what I'm really focused
on. And I started talking about global surgery that I'd done and how I plan on transitioning
more into answering cancer questions. I didn't really know of his interest at the
time. I hadn't read his book where there's a whole chapter on this. And he… my colleagues
were fantastic and they still remind me of this. They basically gave up all their time to me and

(20:39):
he and I spoke with them there for about 30 minutes and I ended up making him slides that
he was using in his talks and he invited me down when the Center for Global Health started
because there weren't many surgeons involved.And that link was so important. I was a brand
new faculty member and now I could come back to Sloan Kettering and say,
I have a place that I am a member of that I have a role in down in the NCI. And the first grant

(21:05):
we got here was a pilot grant that the Center for Global Health put out at maybe $40,000,
something like that. That really helped us start with our data collection on colorectal cancer
back in 2011-12. And that raised some eyebrows too. Wow, okay, you already have an NCI grant.
And then as the Center for Global Health, which originally was, you know, we're here as a center,

(21:29):
we're not going to fund grants that really morphed into becoming a regular center. And
that's been invaluable to then come back to our institutions as we're all trying to grow
this as a field within our cancer centers to say, there's a Center for Global Health at NCI,
there are grants, we now have R01s, UG3s, D43s, all of these grants. It's a pathway to

(21:53):
academic promotion that follows the standard pathway that our institutions all recognize.
And so that's really been vital for all of us at the cancer centers to get a footprint. And then
when it comes time for the core grant, now there's really a big role for us to highlight how invested
our institutions are in supporting this. So it's really been vital to have that NCI footprint to

(22:21):
help our field even begin and grow, I think.OLIVER BOGLER: And I should just mention for
our audience that the core grant is sort of the big NCI
grant that comes along with being a designated NCI cancer center and funds
a lot of the infrastructure at those cancer centers. We'll put a link to all the cancer
centers in the show notes. There's over 70 these days. But Peter, I want to push a little more on

(22:42):
the Global Cancer Disparities Initiative. Is that connected to this work as well?
Yes, so when I got hired, I had a mentor here at Sloan Kettering, Murray Brennan,
who had been our department chair of surgery for many years and was shifting to head the
International Center here. And he sort of took me with him to the International Center and said,

(23:02):
we're going to carve out a little piece where you and I can create this program.
And so we started the Global Disparities Initiative in 2012, really as a way to try
and cross departments and divisions at Sloan Kettering. Because originally it was myself and
Dr. Brennan sitting in a room and then slowly as I got grants and publications and I spend

(23:28):
probably as much time even now on internal PR as on external PR within the institution.
And it went from Sloan Kettering doesn't do this to this is an important focus for
our institution. And every few months, someone was knocking on my door saying,
wow, I've been collaborating as a nurse with a nursing education institute on cancer research in

(23:52):
East Africa for 15 years. I didn't know anything like this existed in Sloan-Kettering. There were
radiologists joining our faculty who had been working for 10, 15 years in sub-Saharan African
countries with collaborators there. So, over the years, this sort of grew this group where now,
rather than myself and Dr. Brennan, there's 15 to 20 very active faculty and other 20 to 30 who are

(24:13):
somewhat involved. We have people with K awards. This is the primary focus, academic focus for
people. This is important for recruits because a lot of the younger generation of whatever field of
oncology they're in have this as a focus and our program can really help them with their
professional development. So this became a way for us to create an initiative that really spans

(24:38):
the institution from… and also often groups that aren't put together. So we have nurses,
pharmacists, information technologists who all are members, very active members of the group.

Thanks for sharing that. Satish,
your own work is focused on developing innovative approaches to cancer care in
resource-limited settings. I wonder if you could tell us a little bit about that work,
maybe give us an example of a program that you've been working on and how that tackles a challenge.

So when I lived in Malawi, we oversaw a program that really sought to do
kind of applied research and control focused on the highest burden cancers in Malawi. And
this included three that were HIV associated, so cervical cancer, Kaposi sarcoma, and lymphoma, all
of which are HIV associated to varying degrees, given that HIV prevalence is quite high in Malawi.

(25:31):
And actually it's an interesting feature of successful HIV treatment, that when people with
HIV are treated successfully for their HIV, one of their leading causes of death becomes cancer.
This has happened all around the world. It's happened for many, many years in the United
States and is starting to happen in Africa as well. Actually an inability to control cancer
effectively will undermine some of the progress that has been made against HIV as a result of

(25:55):
PEPFAR and other seminal U.S. governmental investments. And then we had two cancers,
esophageal cancer and breast cancer that were high burden cancers that don't have an HIV association.
In some ways like what Peter described, supported work across those five priority cancers. My
own work is primarily focused on clinical translational studies related to lymphoid

(26:19):
malignancies in Africa. In some ways, I think this is an effort to try to complete a 60-year story
that actually began at the NCI in some ways when shortly after Burkitt lymphoma was discovered,
NCI investigators from the Pediatric Oncology Branch traveled to Uganda to learn how this

(26:42):
new cancer was being treated and brought that experience back to the NIH and treated children
here in the same way and received about the same results and published that in the New
England Journal of Medicine. We discovered EBV and new oncogenic virus. We discovered myc, a
new human oncogene. We discovered kind of modern principles of multi-agent chemotherapy.

(27:03):
It's pretty amazing what that initial fairly … you know, this was Dennis Burkett,
a surgeon living in Kampala, who just described, you know, in a way, an unusual tumor that was
presenting to him, you know, in some ways, I think in spirit, this is very similar to the
work that Peter and I have sought to do. And this initiated many, many decades of really seminal

(27:25):
discoveries in cancer biology and treatment.So, but the point I always like to make is
that a lot of the benefits of these seminal discoveries have not accrued to the very
children and communities who helped to initiate them by, you know, braving enormous obstacles
to even come to Kampala so Dennis Burkett could examine them, right? And I say this because during

(27:48):
the decade that I lived and worked in Africa, we routinely saw children who presented just
like they did for Dennis Burkett in the 1950s and 1960s were probably treated pretty similarly and
experience about approximately the same outcome.So a lot of my work is focused on trying to
improve that kind of last mile problem. Part of that is through better understanding of biology,

(28:09):
which we often don't understand as well as we might like, you know, in other populations and
settings around the world. But then, you know, trying to translate all of that into being into a
willingness to implement both kind of things that we already know worked in US settings, but haven't
necessarily tried in the same way in African settings, and also potentially new and innovative

(28:31):
treatment strategies. So that's a lot of the work that I have done and continue to do at the NCI.

Peter, Satish just sort of talked about how Burkitt's lymphoma still looks a lot
like it used to. And you've both alluded to the fact that what we learn in Western medicine and
in research that's focused very much on a small group of small population doesn't extrapolate
to every setting. I wonder in your time, of having done this global work in Africa,

(29:02):
have you seen progress? And can I entice you to make a prediction of what is ahead?

Yeah, think there's, think I'm at baseline a pragmatists that leans optimistic,
I would say. And I think that there has been a real reason for optimism. I'll give you just
some small examples. When we started collaborating with the group in Nigeria, there were some really

(29:31):
impressive junior faculty members. One of them, we helped get a master's in clinical research. He
spent some time at MSK and he saw that the most women after a mastectomy go home in two days,
three days, and they maintain their drains at home. And then they come back, you know,
10 days later, have their drains taken out. But in Nigeria, most women stayed in the hospital
for 12 or 13 days until the drains dried up. And he asked the question, well, why can't

(29:57):
they go home at day two or three like at MSK?So he went back and he developed a research
trial and did this and showed that the outcomes were the same as far as seromas, infections,
all these other things. And the quality of life was much better. Patients saved money.
They weren't paying to be in the hospital. They also loved the fact that they were recovering
at home with their loved ones as opposed to being an open unit, where often the woman

(30:21):
having a mastectomy was lying in bed next to a woman who was unfortunately on palliative care,
dying of breast cancer. Hard to recover from your operation when seeing that side of the disease.
And they got a phone call from the surgeon on day five and they all loved that the surgeon thought
enough to call them at home. So this completely changed practice and it was a small study. So it's

(30:45):
an example of how important research training is because I wouldn't ask that question in Nigeria.
That's a question that's going to be generated by people like Olalekan Olasehinde who's a fantastic
surgeon in Nigeria and has changed practice.And we've done this on large scale as well.
I mentioned that we've sort of disproven beliefs in how cancer should be diagnosed

(31:10):
in low-middle-income countries by extrapolating from countries like the US. So we did almost 3000
patient study looking at blood in the stool to identify early stage cancer patients or people
with polyps, which is considered a standard of care throughout high-income countries around the
world. And we found that there were way too many false positives and not cost-effective.

(31:32):
And there's a lot more internal hemorrhoids. And for 15 reasons, the test didn't work like
it was supposed to work in Nigeria. And that was led by Isaac Alatise, who's been my collaborator
from the beginning in this, the last 12, 13 years. And during COVID, accrued about
3,000 patients to answer this important study.So the pessimism is when you see that cancer

(31:57):
rates are rising and there are many patients in low middle income countries who still don't get
access to care that we know can help them live a lot longer if not cure them. But when you meet
people in the field who are dedicating their life to this and you see that there are more and more

(32:18):
junior faculty in sub-Saharan Africa, for example, with this as a focus. Hard not to be optimistic.

Satish, how about you, can I entice you to make a prediction
about what the next few years, five or 10 years hold?

So I tend to be optimistic. I think it's hard to be a medical oncologist
who spent most of my life living and working in Africa without having some intrinsic optimism. I
think the formula just doesn't work without that. And I would agree with Peter. mean,
I think one of the things that's really rewarding is you can see measurable progress and it often

(32:53):
doesn't take as much time or as much money as one would think. This the, this kind of truism
about human experience or perception. We tend to overestimate what we can do in a day, but
we tend to underestimate what we can do in a year, right? I mean, that's kind of the philosophy here.
I think when you're, when you mount a sustained effort around some problem,

(33:15):
that's really grounded in local experience and expertise and collaboration, I just think we
were really amazed at how much we were able to get done. And I think as Peter's alluding to,
is really this, people get it. I mean, people living in Africa or other parts of the world

(33:35):
understand that cancer is a big problem. And a lot of the smartest young people,
just like we've enjoyed in the United States for many decades, in some ways we're at the
tail end of this now, right? We're worrying in the US about how to continue recruiting
the smartest young minds to cancer research.This is not a problem, think, in LMICs. I think
people recognize how big a problem this is. They're really motivated to try to address it.

(33:57):
We had so many people as part of our program who got sponsored against tremendous odds to
go outside their country, get trained. They all wanted to come back. They all recognized
cancer was a huge problem. They all wanted to dedicate their careers to trying to address it.
So people like that need relatively little support to do a lot, right? This is a really high return

(34:21):
on investment kind of seed investment. And so I think there's an opportunity with some strategic
and catalytic support to really unlock kind of a lot of opportunity. And obviously we're thinking
a lot about how to do that at the NCI.I also think, I mean, the other thing is,
you know, as there's more of a community, I think in part, because the NCI has shown a willingness

(34:44):
to support these kinds of programs since at least 2011. People have the sense that they're making
some progress in their own local environment, but also that there's parallel progress occurring in
other places. And we're starting to do a better job of connecting those experiences in a way that
creates more of a community and shared learning and understanding across the entire network.

(35:06):
And that's when I think you start to generate enough momentum that you get to a tipping point
where, you know, often it feels to many of us like we talk about the same problem over and
over and over again and nothing really happens. And then, but then all of a sudden, you know,
there's this tipping point where there's enough attention, you know, and a momentum that all of

(35:27):
a sudden you can catalyze a lot of effort in a relatively short period of time.
And I think that's going to happen. It seems inevitable to me that that will happen. That's
sort of what we saw for HIV, right? I mean, in the early 2000s, there was legitimate academic
discourse about whether Africans were smart enough to take HIV medicines because they didn't know
what time it was and they wouldn't be able to take multiple pills multiple times a day. And

(35:49):
I think that's where the scientific community can be very, very valuable because we'll just test it,
can this work or not? And when it does work, then you get the advocacy community and the development
funders, they respond to evidence that speaks to them. I think some of the challenges we've
often generated evidence that doesn't really speak to the end users. And I think we can

(36:11):
do a better job of that.PETER KINGHAM: You know,
one of the buzzwords is personalized cancer care. And I'm sitting in clinic today,
patients come in and they want and expect that the care will be individualized to them. Now,
what that actually means is probably very different than
what most patients know. Patients often think, I want my tumor in a petri dish and you tell me

(36:32):
exactly which chemo works, et cetera, et cetera.But when you think about doing, getting regional
data, that often uncovers differences that we didn't understand and using regional data
to develop early diagnosis, cancer prevention, cancer treatment, even palliation strategies that

(36:53):
can personalize care, using personalization sort of in a regional way. And I do think that that's
another thing to be optimistic about. I've watched in Nigeria as now Isaac, my colleague, present to
the Ministry of Health only Nigerian data about some of the cancers that we study. There's no
modeling from a cancer registry six countries away. This is Nigerian data prospectively

(37:16):
collected. And now there's therapeutic trials that are about to start based off of the
Nigerian data. So that's pretty personalized. So I think that's another reason to be optimistic.
Yeah, I just want to add one comment to that, Peter, because we've had exactly the same
experience in Malawi where mean cancer treatment always seems expensive to Ministries of Health
relative to HPV vaccination or water. They have to take their health budget and apply it to all

(37:40):
health needs. But when you apply relatively time limited treatments to young, healthy patients
without a low without many comorbidities who then might have decades of event-free survival.
When you actually model this out from a health system perspective over a lifetime horizon,
the cost effectiveness of a lot of these interventions is actually quite favorable

(38:03):
compared relative to HIV treatment, for example, where you have to take a pill every day for the
rest of your life currently. And we've, again, generated data within Malawi, shown that to the
ministry of a trial of a targeted cancer treatment done in Malawi with embedded cost-effectiveness
analyses that really spoke to them. And they say, yeah, this makes sense. This seems expensive to

(38:24):
us relative to other things that we're used to doing, but we understand now that this is
a really good investment and we're going to prioritize greater public sector availability
of this medicine that was previously thought to be completely unaffordable for our system.

Sounds like it's an incredibly exciting time to be in
global cancer health. So thank you for sharing your insights on that.

Well, it's another frontier, right? I mean, if you think about it,
we're all about frontiers in cancer research, right? And one frontier is going deeper within
the cell. Another frontier is to go as wide as possible across the world, right? So it's all
about frontiers. I mean, in my view, given how historically underrepresented LMICs have been
in cancer research, there's just in reams and reams and reams of information to be gathered

(39:11):
in those settings that are theoretically going to enrich our understanding of cancer overall, right?
I mean the more knowledge we have about cancer in its various forms, the better and that often
involves going deeper in the cell, but it can also involve applying standard methods and
approaches to populations in settings that have never participated in cancer research before.

It becomes really interesting when you think of AI, because there's a big
push in AI in medicine and AI in every aspect of life. And when you look at the algorithms
that most AI is generated from, they often don't include patients from LMIC. I mean,
AI makes a lot of sense to help with pathology and radiology, where it's pattern recognition

(39:57):
and machine learning can help with that but without inclusion in the algorithms,
that is not, similarly like, know, we don't understand cancer by studying it in New York,
we understand cancer in New York, that's it, not the rest of the world. AI, I think, also
becomes an interesting avenue where disparities can really be highlighted and hopefully overcome.

So lots of career options and we're
gonna take a quick break now and when we come back, we're gonna talk to our
guests about what got them interested in science and medicine and global health.
[music]
Calling all senior oncologists committed to community oncology and reducing health
disparities! Are you passionate about shaping the next generation of researchers?

(40:45):
Apply to The Worta McCaskill-Stevens Career Development Award for Community Oncology and
Prevention Research (K12) program and mentor promising clinical scientists.
This unique NCI program supports the training of clinical scientists
in community cancer prevention, screening, intervention, control,
and treatment research. The program welcomes proposals for innovative research and career

(41:09):
development programs with an equity lens and a focus on increasing diversity in clinical trials.
As a program leader, you would guide clinical scientists from
various oncology specialties as they conduct research, potentially even leading their own
independent clinical trials. This is a chance to leverage your expertise and
make a lasting impact on cancer research and care in underserved communities.

(41:33):
For more information about the McCaskill-Stevens K12, including
how to apply and our staff contact details, visit our webpage – link is in the shownotes.
[music ends]
Okay, we're back. Peter, let's start with you. What was the moment

(41:53):
when you first thought you'd like to have a career in science and medicine?

We found my autobiography from first grade and on the page titled,
What I Will Be When I'm Older, I wrote, I will be a surgeon whose patients really like him.

Okay, how's it going?

So, well, I'm a surgeon. can't vouch for the patients part of it, but I'm a
surgeon. get a couple of cards at Christmas, so I guess they like me. My grandfather was an OB-GYN
who also was an Army surgeon, drafted and sent to the Pacific in World War II as a military surgeon

(42:30):
and was told, you know, don't tell the guys that you're actually an obstetrician. You know how to
use a knife and you're now a trauma surgeon. And I was extremely close to him. And basically, since I
was born, I knew that I was going to be a doctor.And I also knew that I was going to have some
connection to Africa with that career. I'm dating myself now, but I spent a lot of time buried in

(42:56):
Encyclopedia Britannica when I was young. And I would read through all of the African countries.
And no one in my in my family we know for at least two generations has ever stepped foot on
the continent of Africa. So it's an interesting connection. When I ask Isaac in Nigeria,
when I tell him this, he just sort of laughs. You know, of course it's obvious because in

(43:16):
Yoruba culture, the birth of all life, the seed of life is in Ile Ife, which is
actually the city that Isaac's based out of. So for him, I am the son who has come home,
which is my Yoruba name. That's actually what it means. So for him it's quite obvious,
but for most of the others it's hard to know this connection, but it was extremely young for me.

That's fascinating. Satish, how about you?

I also was interested in science and medicine, I think, from an early age. I actually
don't know why. We don't have really doctors in my immediate family. I mean, obviously medicine
and science are strongly encouraged classically in Indian or Indian-American sort of societies and
cultures. So I never encountered major opposition to pursuing a career in medicine. But yeah,

(44:05):
I'm not actually sure where it came from.I think I actually what I liked about it was
the way it brings science and the humanities together. I I liked literature quite a lot. I
read a lot when I was younger. Medicine seemed like this discipline that kind
of inhabited elements of both science and the humanities in a way that really appealed to me.

(44:27):
And then in terms of global health, think a lot of that came from growing up as a
first-generation Indian immigrant in the United States. I traveled back to India to
visit family frequently with my parents every couple of years. And I just remember having
this imprinted on my brain at a very early age, would, as you know, in Indian cities,
kind of more well-to-do middle-class neighborhoods where my family mostly lived are often immediately

(44:51):
adjacent to kind of lower income or more shanty town-like parts of the city. So,
you know, if you're walking around an Indian city on a trip home, I remember just encountering kids
who looked just like me but had much less opportunity available to them. I think that
experience just imprinted itself on my brain over and over again early in childhood and, you know,

(45:14):
I think made me feel committed on some level to try to address those kinds of inequities.

So with this sort of both of you having this dual motivation towards science and
medicine and towards global health, Peter, how did you practically approach that then
with your passion for Africa and for surgery? What did your path look like?

When I went to medical school, I thought I might end up in trauma surgery.
I actually worked New York City EMS, the ambulance in the Bronx for the first year
before med school and then my first year of med school I worked part time. And so I was, and I
was a volunteer firefighter growing up. So I sort of thought I was going to be a trauma surgeon. And

(45:58):
I chose general surgery in part because I thought whatever field of general surgery I ended up in,
I could have some link medically to Africa and it could be short term, long term. I felt there was a
lot of flexibility. Now obviously I was making these decisions on things I knew very little
about, but that was my gut instinct at the time.And my first experience doing any medical care in

(46:23):
Africa was in medical school where I got to live in very rural Tanzania for six weeks as part of
sort of a medicine and ethics course where they let you really do anything you created.
And I lived with a paramedic who provided medical care to the village and there was
no power and water. And I was in the middle of a cholera outbreak and got quarantined in. And

(46:47):
he really had nothing other than a stethoscope.And I just learned what was basic life and health
care like in a really rural village. As opposed to turning me off because it was not that, you know,
it wasn't an easy place to live. It just opened the floodgates for me. I knew that this would be
part of my career and used every opportunity in residency to really network and get opportunities

(47:13):
to go to South America and Africa and then started this NGO. And that sort of set me on the way
for research. And then the path through Sloan Kettering is where everything was solidified.

Satish, for you, fast forward,
you just and you shared with us that you lived in Malawi for over a decade, is that right?

It was like a decade total in Africa basically. Most of that was in Malawi.

Ah, understood. So that sounds like
a huge leap. Tell us about what informed that decision.

So when I finished my residency, I think in some ways, like Peter described, when I
was in medical school and residency, I looked for opportunities to go abroad for elective rotations,
but these were generally fairly limited in time. And I think I appreciated that when you go for
two or four weeks or even a couple of months at that career stage, you're taking a lot from the

(48:10):
environment and contributing very little. mean, those experiences can still be quite important,
but that is what occurs, right, during those.And so I wanted to get trained. And so when I
finished my med peds residency, I could work as an internist, I could work as a pediatrician. And I
wanted to go and try to have a more sustained and immersive experience in an LMI … global

(48:31):
health setting to see if that was something that I liked. And my wife had an interest in
the same. We were married, we had a six-month-old daughter. She had spent some time in the Peace
Corps and been in many years ago. And so we found an opportunity that allowed us to live in Tanzania
for two years with our six-month-old daughter at the time who's actually applying to college this
now currently, which is kind of wild to believe.So we moved to Tanzania for two years and that

(48:56):
was really just a generating preliminary life data about whether or not that was an
environment that we both liked well enough to live there and to pursue careers as a family,
right? Because it's different when you're doing it on your own versus in a family. It really
has to work for everyone or it doesn't work at all. And so I think that two years was really

(49:17):
confirmatory that this was a trajectory that we both really enjoyed, that we could see living
abroad together. And then, as I mentioned earlier, living in Tanzania is actually ironically when
I became interested in cancer, which I had not been terrifically interested in during residency.
And so then I pitched this idea to a number of cancer centers in the US about, I'd like to come

(49:38):
back and train in medical oncology and infectious disease and then try to initiate a career doing
cancer research, you know, with NIH support living abroad. And there was no real role model for that
at the time. It was completely made up. So most places just kind of dismissed it out of hand. But
UNC was interested. They had a fairly mature clinical research program in Malawi. So I kind

(50:03):
of came back to do this combined fellowship at UNC with the understanding that as I finished,
I would join the faculty and move to Malawi and try to leverage some of their existing HIV
clinical research infrastructure to initiate an NIH-funded cancer research program. And of course,
at UNC, I met Ned Sharpless and Kim Rathmell, and so there were some ancillary benefits as well.

So in closing, I wonder what advice you might have for listeners. You both
mentored numerous early career US and African cancer investigators. If someone's listening
and thinking, wow, this sounds really interesting, what would your advice be?

Peter, you wanna go first?

Sure, think that it came up a little bit earlier about how there's such
massive opportunity here. I don't look at the lack of data as a barrier to progress. I think
it's a call for more people to be involved. And so I think it's a fantastic time to be trained in

(51:02):
whatever facet fits into global oncology. It can be, as I said before, nursing, pharmacy,
physician, it doesn't matter. And you often, don't need to recreate the wheel. You don't
need to do what Satish did when he started. You don't need to do what I did when I started. There
are a lot of places that have really healthy collaborations that you can join in and add a
new column to the database and add a new focus of research and take advantage of the infrastructure

(51:27):
that's there and spend your time answering really important questions with a good collaboration.

Yeah, I'll echo what Peter said. I I think this is an incredibly exciting time.
There's so a lot of energy, a lot of momentum, a real community out there that's really focused on
addressing these questions quite seriously. And I think, again, with escalating burden,
think cancer, it's a big enough problem that it's going to get dealt with. Right.

(51:56):
we can't just sit and watch this forever. I think that's beneath humanity in some
respects. So I think this, you can sort of feel that momentum starting to generate it.
In terms of more specific advice that I usually offer to people at earlier stages of career,
I do think it's important to seek out a really immersive experience. I think that

(52:18):
historically global health has often been a hobby rather than a discipline. And I think
one of the things I respect about someone like Peter, and I tried to do this myself,
is really approach it like a discipline, right? This is a thing I'm gonna do with my career. And
I need to develop real expertise and rigor in how I approach this so I can make a real contribution.
So I try to encourage young people to try to have immersive experiences with adequate mentorship so

(52:42):
they can really establish that kind of trajectory. Because I think we probably don't need an infinite
amount more of dilettantism sort of dropping into 10 different places to sort of put them on your
CV. And I don't think that's what the younger generation is really interested in anymore.
I think immersion, I the time I spent in Africa, I learned so much. I had such better ideas at the

(53:06):
end of it than I did at the beginning. I mean, I just, it's like anything, right? You wouldn't
expect to drop into a genomics lab for a couple of weeks and expect to be a genomics researcher. So I
don't understand why people think that's somehow possible in global health. It really isn't.

Thank you. That’s fantastic advice. People should take that to heart.
[music]OLIVER BOGLER:
Now it's time for a segment we call your turn because it's a chance for
our listeners to send in a recommendation that they would like to share. If you're listening,
then you're invited to take your turn. Record a voice memo, send us a tip for a book,

(53:45):
a video, a podcast, or a talk that you found inspirational or interesting or
amusing. Send them to us at NCIICC@nih.gov and we'll play it on an upcoming episode.
But now I'd like to invite our guests to take their turns. Let's start with you, Peter.

I'm gonna actually recommend the opposite of everything you just mentioned which
is do three days with zero phone or computer. And true cognitive rest. No reading a book.
I recently did this and it was probably some of the best three days of my life.

(54:27):
Really with time to sit and daydream and watch the world go by. So my recommendation
is don't listen to a podcast or read a book or use a computer or anything
with screens and religiously do it for a couple of days and you'll be ecstatic.

Sounds fascinating. How did you achieve that?

I literally had my schedule, this was away from work and I literally had
my schedule written on the back of a used envelope. So I didn't have to look at my
phone. I did have to order one Uber. So I used my phone for 30 seconds. Otherwise it was,
impressive. It wasn't that hard. And the more I got into it, it was like a drug.

(55:07):
You just wanted more. It was the best three days. So highly recommended. Yep.

Digital detox, sounds really healthy. Satish?

Well, just to follow up from Peter, I my wife has done a silent meditation retreat and
I've never been brave enough to attempt something like that, but maybe I'll be inspired by Peter.
I'm going to recommend something a little bit more conventional, which is a book,
and it's a book I've been thinking about a little bit because it kind of motivated me to enter
medicine when I was sort finishing undergrad and applying to medical school, which is My
Own Country by Abraham Verghese. And some of you will know that he actually gave the plenary talk,

(55:40):
I think, at Lynn Schuchter's invitation at this last year's ASCO. Abraham Verghese is an internist
and a novelist based in California, Stanford, maybe. But My Own Country was the first book
that he wrote that really brought him to, I think, national and international attention. And it was
about the experience of being an Indian immigrant doctor in the rural US treating the patients

(56:04):
infected with HIV at a time where there was tremendous amounts of stigma, especially in rural
communities about that illness in particular.And there's just so many, I think a lot of the
health inequity themes that emerge out of the book are highly relevant today. A lot
of the ways in which immigrants contribute to the United States. That theme is very relevant

(56:27):
today. So it's just a really inspiring book, I think, particularly for young people who may be
thinking about a career in medicine or global health or public health. And I think a lot of
the thematic content feels as relevant today as it did 20 years ago or whenever it was written.

I think I'm going to pick up a copy and read it right after I've
done the three day no-digital that Peter recommended. Thank you both.

It actually would be a great reemergence from silence.

Yeah.

There you go. Perfect. Well,
thank you for those recommendations and thank you both also for the time you spent with us
and your work and the expertise you shared and the advice you gave. Thank you so much.

Thanks, great to be with you Satish. Thanks for the invite Oliver.

Yeah, same. This was really fun. Thanks for inviting me.
[music]OLIVER BOGLER: That’s all we
have time for on today’s episode of Inside Cancer Careers! Thank you for
joining us and thank you to our guests.We want to hear from you – your stories,
your ideas and your feedback are welcome. And you are invited to take your turn
and make a recommendation to share with our listeners. You can reach us at NCIICC@nih.gov.

(57:34):
Inside Cancer Careers is a collaboration between NCI’s Office of Communications and Public Liaison
and the Center for Cancer Training. It is produced by Angela Jones and Astrid Masfar.
Join us every first and third Thursday of the month wherever you listen – subscribe
so you won’t miss an episode.If you have questions about

(57:55):
cancer or comments about this podcast, you can email us at NCIinfo@nih.gov or
call us at 800-422-6237. And please be sure to mention Inside Cancer Careers in your query.
We are a production of the U.S. Department of Health and Human Services,

(58:15):
National Institutes of Health, National Cancer Institute. Thanks for listening.

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