Peter, you’ve convened this meeting, you’re hosting it, you’re chairing it. It’s the National Cancer Institute Directors’ meeting, tell me, what is the importance of this meeting?

Well you’ve got to look at the history. We started off with the first meeting of this in 2002 in Milan when we had five cancer directors who came for a symposium. And it’s something that grew and grew and grew. We’re now in the eighth meeting, we missed it for a couple of years but now there’s about ninety people from forty countries here. Some of them are directors of cancer institutes, some of them are heads of oncology groups, but the end of the story is it’s a tremendous opportunity to put people together, to put people in contact and collaborations grow out of it. We pay particular attention to bringing in people from low and lower middle income countries and they benefit from it enormously in terms of future collaboration, funding, opportunities, training, so it’s a meeting.

Yes, there have been some marvellous contributions here, I’ve noticed, from Africa, from Pakistan and a number of countries, certainly not the West alone.

It’s not the West alone, it’s not intended to be that. There’s a fabulous phrase by Antoine de Saint-Exupéry who was born in Lyon; he wrote The Little Prince among other things. He was the pioneer of Aéropostale, air mail, and he wrote in one of his books, “La grandeur d'un metier, c’est d'unir les hommes” – the strength of any profession is to bring people together. And that’s exactly what we’re trying to do.

And you’ve been doing this for a few years now. What concrete things do you feel that this organisation, this meeting, has achieved so far?

We’ve increased the awareness of the disparities which exist. We’ve looked for solutions in the disparities in diagnosis and treatment around the world and there’s various collaborations which have already built up. People in particular from low and lower middle income countries have benefitted enormously from ideas they’ve seen here and taken them back and implemented it. So we’re not solving the cancer problem, we’re not solving the cancer disparity problem but we’re making a contribution to making people know about it and some little steps have been taken to try and resolve it.

So you have got a big emphasis on low and middle income countries, what’s the motivation for everybody, though, to be part of that effort?

The motivation, to my mind, is quite simple because I believe very much in global public health. Health is not just the absence of sickness, health is much, much more than that. So around the world we’ve got Departments of Health spending all their money on sickness and now we’ve got to try and change their mind and show that preventive strategies like vaccinating girls against HPV can make a huge impact in Africa where cervix cancer is one of the top three cancers there. We’ve got to look, for example, at the whole issue with AIDS, HIV/AIDS, because in Africa the commonest cancer in Africa is Karposi’s sarcoma which is directly linked to HIV/AIDS. So we’ve got to bring up that awareness and start to look for not only ways of earlier diagnosis, potential prevention, let’s look at it and let’s not wait until you’ve got people coming along with Karposi’s sarcoma that covers half their legs and their whole body and is totally untreatable.

You’ve also been involved in the World Breast Cancer Report, tell me about the importance of that and what have you done so far?

The World Breast Cancer Report was a report where we… there are so many reports out there which just say, ‘Oh, this is nice and this is good and this is bad and we need to do more research.’ You know, it’s time to put that beyond us, we’ve finished, we’ve gone past that. I think we’ve got to concentrate on moving away from anodyne type reports into something which is really looking for situations where you can intervene and do some things much better. So, for instance, you take breast cancer – there’s 1.65 million new cases of breast cancer this year. The incidence of breast cancer in the last thirty years has been increasing at 3.1% per annum around the world. Now, that’s better than you’ll get in any bank on your money, so it’s a huge increase. Thirty years ago there were 600,000 new cases of breast cancer each year, today there’s 1.6 million, there’s a million more this year. Breast cancer is more common in the high resource, the developed, countries but the mortality, number of deaths, is equal in the developed as in the developing countries. When you look at that a little bit further, if we look at deaths in women below the age of 50 three-quarters of deaths from breast cancer below the age of 50 are occurring in the developing countries.

Now these are alarming statistics but what is your take on what needs to be done about them?

The problem, we did a survey we sent round to a number of institutes all over the world at different resource settings, and this is in the report, that we asked them to look at consecutive series of cases of breast cancer and just record what treatments they had for them, what stage they were diagnosed at. If we take for example Kenya, every breast cancer diagnosed in Kenya, in the series of a hundred consecutive breast cancers, they were all T3 and T4. In Uganda 54% of cancers when the breast cancers presented were T4 which is advanced metastatic breast cancer which is totally incurable. Now there’s nothing at all to cure them, a lot of these women are going to develop severe pain and in thirty countries of Africa there’s neither a radiotherapy machine nor any opioid medication to control the pain. So it’s a terrible situation.

So you could make a big difference by early intervention in those cases?

I think what we’ve got to do is we’ve got to remember that we’ve been doing screening studies, particularly with breast self-examination etc., in these countries and different countries of the world not at the highest resource levels. We’ve been looking to detect early cancers. We’ve got to change our mind because if you take a stage 2 breast cancer and turn it into stage 1 the difference in survival is 13 percentage points. If you take a stage 4 breast cancer and diagnose it as a stage 3 then the difference in survival is over 30 percentage points. So with half the cancers in the low resource countries presenting at stage 4, the quickest way that we can reduce the disparity gap, we can increase survival, reduce mortality, is by turning the stage 4s into stage 3s.

So even a modest improvement in detecting the disease at that stage will have a big pay-off, not necessarily going for mammography for everybody?

We can’t have mammography in Africa, there’s no electricity, there’s no technicians to read it, we don’t have the resources to do it.  We’ve found in this report that the difference between what’s available to treat women in high resource countries and in low resource countries is remarkably different. What we do know, and this is the exasperating thing, it’s not a research issue. If all women, all over the world had the same access to the same level and quality of treatment as women have in the Istituto Europeo di Oncologia in Milan then we would have a huge reduction in the death rate from breast cancer around the world. It’s achievable, it’s a matter of investment, it’s a matter of education. It’s not a question of research, it’s achievable, it’s just a matter of appropriate and sustainable investment from the high resource countries.

So what other highlights would you pull out of this meeting here in Lyon?

Highlights, this is an unusual meeting, it’s not like ASCO where everyone’s running around trying to find… you can’t meet anyone. It’s not like ESMO where it’s a huge meeting in a confined space. This is a meeting where there’s maybe a hundred people at the meeting from different backgrounds and they can’t go away, they’ve got to talk to each other. The programme isn’t three days about breast cancer, it’s not three days about colon cancer, it’s about all sorts of ideas. That’s the strength of this meeting. We had a presentation this morning, a very technical presentation, about markers and their role in targeted therapy and how to look for them. And this afternoon we’ll have a presentation that’s labelled Red Diesel from Geoffrey Hamilton-Fairley and myself. Simple idea – one of the big problems is that we send drugs cheaply to low resource countries and three days later they end up in middle income countries on the black market so how can we do something about that? Very simple – you look at the situation in the United Kingdom where in the cost of diesel fuel, if you’ve got a diesel car, it’s much greater than it is if you’re an agricultural person getting diesel fuel for your tractor. For your tractor you’ve got a red dye put into it and if you’ve got one of these gas-guzzling diesels in the middle of London, for example, diesel cars, and the police have got the opportunity to look into it and if they see the red dye, which rests there for two years, they can confiscate the car and fine you £5,000.

So there are simple interventions that can improve things?

Every drug going to low resource countries, every vaccine, we make it red.

Make it traceable?

Make it red. Just make it red, just put in a dye or something that won’t interfere. Make it red so that if you’re walking around Brazil or Indonesia or China, anywhere, and you see any pill which is red or any vaccine which is red or any medication which is red you know that that has been taken away as a parallel import from a low resource country.

Now where would you put the resources of these national cancer institute directors? Where would you counsel them to guide their efforts? Because there’s also prevention we haven’t talked about, there are other forms of screening, not just breast cancer. So how do you decide, if you’re a national cancer institute director in perhaps a low resourced country, where to put your money?

That’s a good question, it depends on local circumstances. In Africa there’s about a third of all the cancers in Africa theoretically preventable by vaccination. Whether we find a vaccine for AIDS, that would be great, human papilloma virus, hepatitis B, we might find a vaccine for C, EBV, there’s all sorts of things we can do. The theory is quite good but we’re not achieving it. It depends on where you are; if you’re in a low resource country in south-west China your problem is nasopharyngeal cancer and what you want to do there is have a vaccination programme against EBV because it’s all EBV related. So what you want to do in terms of prevention is dictated by your local circumstances.

So what is your unifying call for action, then, coming out of this international meeting being held right here in Lyon?

In specific terms for the breast cancer, from the Breast Cancer Report it’s to launch a concerted and sustainable action to eliminate stage 4 breast cancers at presentation. A lot of that work is going to involve elimination of stigma, particularly in the low resource countries. That’s something that should have a profound effect on increasing the life and the quality of life of many women. If, and only if, we’ve got adequate therapy in place to treat the women who are then diagnosed at stage 3 or stage 2. We’ve got to make… it’s a continuum. It’s like screening, you screen a woman, you say, ‘Great, on you go, you’ve been screened.’ If they’ve got a suspicious mammogram then they need to have it examined, they need to have it treated and if you don’t do that all the screening in the world counts for nothing.

And in other cancers?

What would you screen for in other cancers? 

And the priorities in other cancers for action?

There’s some fantastic work on very simple, cheap, effective screening for cervix cancer with acetic acid and Lugol’s iodine in the low resource countries. It works, it really works - 50% reduction in the incidence, bigger reduction in mortality for breast cancer. So you put what you can do, what you can prevent, you adapt that to the circumstances of the local situation. But what is really happening in Africa brilliantly is now there’s this pink ribbon red ribbon campaign which is started off by Susan G. Komen, the Komen Global Alliance, where they’ve now got a mandate to work on cervix cancer outside the United States and they’ve set up this programme with the George Bush Foundation to go to Africa and reduce the incidence of cervix cancer by 25% and to start to take strides to reduce the mortality from breast cancer.

So I think I’m getting from this that you are fundamentally optimistic but what would you advise people to remember about the important messages coming out of this meeting now?

The important message is absolutely that there’s two things. One, there’s hope, things can get better. If we could get every woman with the same access to care and diagnosis and lifestyle as they had in Milan I think we could get rid of at least half of breast cancer deaths, a quarter of all breast cancer, I think it would be. These are just estimates off the top of my head but they’re a remarkably high number we could do. There’s hope and I think the disappointment is that in 2012 we’re faced with enormous disparities. There are disparities in treatment facilities, availability, knowledge, ability, access to care between north and south, between East Europe and West Europe and even within the inner cities of Europe, between the blacks and whites in the United States, there are big disparities which exist. These disparities, to solve the disparity problem it’s not a question of research, we know how to do it, it’s just a matter of a significant investment, a sustainable investment and the will of governments and individuals in society to do it.