Prof Ahmed Elzawawy on global cancer control

Dr Eduardo Cazap – Editor in Chief, ecancer
Prof Ahmed Elzawawy – Suez Canal University, Ismailia, Egypt

Good morning, I am Eduardo Cazap, Editor in Chief of ecancer. We are producing now a new series of interviews to global cancer leaders in order to know his or her vision about the future, the current situation about cancer control worldwide and see how this very selected group of people understands and thinks about the current situation of global cancer control. In this opportunity I have at my side Professor Ahmed Elzawawy from Egypt and he’s one of the visionary leaders that is really extremely active in several parts of the world, not only in his country or his region, he’s very active at the European Society of Medical Oncology, at ASCO and training different groups. He was past President of the African Organisation for Research and Training In Cancer, AORTIC, and he has many, many other positions. But today that we are now in Boston he’s one of the leaders of the Win-Win initiative that is one of the strong partners of this new, well, not so new, five years by now, Global Harvard initiative for really gathering people and organisations from different parts of the world in order to improve access to better cancer care. But I would prefer to have directly the words and the really profound knowledge about our world today and our challenges and concerns directly from Professor Elzawawy. Please share with us, with the audience of ecancer, your main ideas and thoughts about the current situation.

Thank you very much, Eduardo, for giving me this opportunity. What I would like to say is not really just my personal view, this is our view. It has become now clear to all that we are facing a problem of lack of affordability of better value cancer treatment. According to many publications the gap is widening between what is required and what is available. The problem touches the rich and the poor and with different variabilities, yes, and different backgrounds and different depths of the problem. But it was surprising and painful at the same time to read that ASCO survey this year that 40% of American cancer patients in the United States abandon us as oncologists, abandon oncology. Why? The cause was mentioned by ASCO in this ASCO survey, ASCO study, published that the main cause was the cost of treatment. This cost comes surprisingly before fear of death, before fear of pain. This is in the United States, imagine what is going on in developing countries.

Exactly but the general idea when you are really at the meetings and the cancer meetings and the scientific societies, the idea is that this is a problem that is restricted to low and middle income countries.

No, no. The problem, if we would like to find a global solution so we should search for a solution for all the world. Why? I’ll give you an example, I published before something about shortage of cancer drugs and generics in the United States. What is the second phrase after? Brainstorming directions for the world. If you would like to solve the problem in generics in the United States we should think about the world in general. If you would like to find a scientific solution then it would be and it should be cooperation between institutes in Harvard, here where we are now, in Oxford, in Heidelberg, in Argentina and developing countries. This will be for the benefit of all.

With a skyrocketing rise in cancer drugs then the problem is an alarm to the economy, the health economy. We can’t go forward like this with this skyrocketing and it becomes impossible to treat patients in some areas in the world now.

Okay, so this issue is closely related with healthcare systems?

Yes.

Do you think that there are countries in the world with healthcare systems that are minimising this problem or do you think that this problem of the cost of drugs affects all systems in the world?

The cost of drugs is only part of the problem because it’s a total cost of treatment. I’ll give you an example, and we have to search about innovative things. In one of the Scandinavian countries they give fees for the surgeon who admits patients for mastectomy for one day, no nights, no night stay in the hospital. Is the fee exactly like the patients twice, fees twice. If the patients stay five days or something after the operation then you give his usual fees. This is thinking about the reality, about human incentives. This is not only the health system, this is about thinking about an incentive for all. What is the gain? The gain is that you save the total cost of surgery provided that there would not be a complication. If the surgeon thinks that the patients should stay ten days for medical reasons then okay, no problem. But they encourage them to… This is something like we should think about innovative things. In radiotherapy, for example, there are many studies on how to minimise the total cost of treatment. As you saw yesterday, some developments in scientific solutions that could lower enormously the cost of treatment while not compromising the outcome and not compromising the scientific approach. It is by the use of science, the use of innovative things in medical oncology, in cancer drugs. There are many approaches already published but we should give them more space to spread for publications about how to lower the total cost of treatment. It’s not the cost of drugs, per se, sometimes the drug represents a small fraction of the whole treatment. But when speaking about the total cost of treatment without compromising the outcome and even you can have better outcomes and better quality of life and this increase of value of treatment.

So you included in this explanation several points because one is that the cost of the drugs is only one part of the total cost of the cancer treatment. But you added also some other things like value and like keeping for the people, for the patients, a good level of quality of the treatment. So could you expand a little bit more about how it is possible to maintain a balance between the cost of the new technologies and how to control the cost of the total cost of treatment with innovative approaches.

This is really our role now, all of us. This is what I am speaking about. ASCO has a big role in this, ASCO, ESTRO, all scientists, because this is really very interesting work but also it gives us solutions, scientific solutions. I’ll give you an example. If a drug you select another way for administration and you use these pharmacokinetic studies and you can reduce the dose to be 20% without compromising the result – prolonged infusion and lower dose of this drug, for example. I don’t speak about companies or drugs but this is all published. Then you can give the same dose for four or five patients and without compromising the outcome and without even asking to lower the price of drugs. So it’s not the price of drugs per se.

I know but when you see, in general in the scientific meetings, in the large presentations, you see more and more high cost drugs, more and more new technologies, more and more new interventions that are really very sophisticated. How do you think that it would be possible to try to really share with our colleagues and institutions to be more cost effective in the treatment of cancer?

I see this is a role as we are for this interview. For ASCO, this is a big role for ASCO to have devoted a part of its activity for this direction. It is very scientific, it is not romanticising, it is very scientific and it contains many scientific approaches. Unlimited fields of research. There are many published examples. I published already many examples, I didn’t invent anything, there are many things to apply. But I don’t know why we go beside it.

Ahmed, I agree with ASCO, with ESMO, with our local societies and regional societies in different parts of the world. But ASCO or ourselves, we do not decide about the regulations, about the treatments. There is a role for governments, there is a role for civil society in this complex problem.

Exactly. Why I say ASCO because it is not exclusively ASCO but because we are speaking about ASCO now, but this is a role of all. But this is an important element to show that it is scientific, if you apply this you are not away from science, you are applying the science but surely you have no authority to tell people to apply it. Also there are incentives, there are other aspects because sometimes incentives, to be frank, go against science frankly. So there is another message that this is not only ASCO this is all of us, this is what we are doing in the Harvard Global Catalyst Win-Win initiative. We raise the flag that this way could save the world from risk of collapse. If we continue like this all will lose, we can’t continue like this for the rich and for the poor. This is an alarm to change the direction, to save countries, particularly the poorest countries where already most of the patients have no access to better value treatment or any treatment sometimes, and at the same time how to show it in smart scientific ways that all would win. Pharmaceutical companies would win, medical devices would win. As you see today and yesterday we have representatives, high representatives, even CEOs of some companies, leading companies, because what we are saying to them is that you will flourish your marketing, we are not against the gain. And for governments it should be the message that this could lessen much the burden on you, we will solve your problems. And for doctors we have to find a way that you don’t lose, frankly, the interest, particularly for lower income countries. We know that there are many incentives with some of them are not illegal, yes, it is true, this is a fact in life, but how to organise things and to show these things that all would win. This is possible.

That is exactly the point that I would like to share with the audience because usually we disseminate the latest things about molecular possibilities, about genetic things and very sophisticated approaches. But in this very meeting here in Harvard at the Global Initiative, for example, yesterday the presentation of the cancer situation in Kosovo, a country that was destroyed by the war, or the people that are attending from Moldovia or from other countries, many African countries, really their comments are completely different. This is another world in which pathology is difficult to have access and where the machines are one or two radiotherapy units for 100 million people. So how we may really make more equal this world in order that cancer patients could have a better access for good and proper cancer care.

Yes, that’s what we are doing together, by the way, in the Harvard Global Health Catalyst Win-Win initiative.

So please explain, explain the core concept.

We have, as we saw yesterday, a showcase, showcases, and today in the dinner [?] you have showcases also from Georgia. The first mission I went to Georgia it was an ICEDOC mission as the President also of ICEDOC, the International Campaign for Establishment and Development of Oncology Centers, it’s based in Texas. We went on a mission in the year 2000 and I have the report about it, we have the report with colleagues from the United States, from Poland, from Germany. Compare with what we will hear today that Christina Keele [?], Professor Christina Keele from Chicago, went to Kutaisi, this is the second city in Georgia. There is nothing, only one oncologist and one resident. And they have now a department, modern technology and every day from her home or office Professor Christina Keele in Chicago revises a plan of treatment of patients and she goes sometimes along the year and that is why she is not present today with us because she is in Georgia. But her video was presented today – high technology.

And there are promising examples – Rwanda came from below zero. I don’t say zero, it was below zero, and in 2017 it was asked starting of some equipment but no department. November 2018 there was soft running of this department with clinical oncology and with clinical pharmacy and it will be attached to a unit of research and what is the plan? We are, with the Minister of Health, Dr Diane Gashumba, and it’s now adopted by… Fortunately we can speak as we wish but it is adopted by President Paul Kagame and become national and Dr Diane Gashumba now is an honorary ambassador of our Win-Win together. Why? Because we asked her, before telling her that you are a Win-Win ambassador, you confirm the plan that President, His Excellency the Honourable Paul Kagame, is confirming that Rwanda will be covered, all the patients in the next three or four years, and after seven years will receive patients from outside, even from Europe.

But I think that this example is accepting the philosophy of the group. So to move from documents and declarations and plans to real and concrete actions in the daily world, is this the core idea of the group?

Yes, exactly. And to give different models. There is no one single model that can treat everything. Today in the morning I have a discussion with some responsible in some companies. We discussed, frankly I have no conflict of interest with any company. Like you, our main interest is to see millions of cancer patients who will get the treatment with dignity, better value treatment in their countries. This is a noble cause but no one can do it alone, we need all to be in this objective, the rich and the poor, the highly developed institute and the small community health service in developing countries, we can work together and we can connect together. There is no excuse now because with the third revolution in health and now the fourth revolution in health communication is okay. We are launching yesterday, as you see, the Global Oncology University. It is online with some training, on-site training, and it is not to compete, not to challenge, but accept all. As you see the stuff, and you are a director in this Global University, accepting all contributions from any organisation of society. We are not competing, this is not a time for competing and for challenging and raising some, have some glory, whilst the conditions are very gloomy. No, we can change this if we are together with respecting the entirety and independence of any organisation or society. There is a lot to do.

There is some side value. You know that oncologists now retire early in the United States and even some can sometimes say, ‘Okay, this is a very pessimistic speciality. Why don’t you specialise in anything, even not medicine?’ And if you connect these community doctors in the United States, the community oncologists or professors or something in the United States, in Oxford, in Argentina, with doctors in developing countries in something searching for help to scientific approaches to increase affordability. Believe me, positive thinking, positive action, positive work, having hope that you will do with this experiment or this trial or this research, you will modify something, not just publications but publications that will serve hundreds or thousands of people. This, believe me, will change the mood - the positive ideas always and positive contribution. We need contributions for all. Who will work in a small office, it could be already beneficial, who will work in a high institute, who will work in the small countries, connect all. This is we have no excuse now easily. We gave a lecture in last year’s courses, a complete lecture in chemical research, in radiation oncology, in physics and surgery and we are starting surgical oncology. You can deliver the lecture for everyone in the world and the students are listening and discussing with you from everywhere, from different countries. You are discussing, you have exposure and after you have something like on-site training for after.

And in research we can do the same. We discussed this morning the quality of research coming from developing countries. We can improve a lot, connect all this together so you will not be worried about the quality of research, the quality of data and the quality of statistics. Share with them, use new researcher investigators – Professors from the United States, Oxford, Heidelberg, everywhere in Sweden, use these young investigators as your co-workers while they are working at home. This is a source of extra funds, it is a source of also giving them a part of international community and you will assure the work coming, the quality of the work. You advise the statistics, advise the data and everything and combine work. We can do a lot.

Yes. I think that your explanation about really the core ideas behind all this movement are very clear. A final point that I think is very important and this is about dissemination of this knowledge that is not the usual knowledge available in the publications. I believe that this is a central, really, component to which ecancer can contribute for the dissemination of all this information internationally. How do you envision, how do you think, that the publications may contribute in a way that they will include not only the top science, that they will include the needs and really the real life of patients and doctors in many parts of the world that usually they do not have access to this type of dissemination?

First of all, my dear friend Eduardo, I have reservations with the term top science. Science, if you find a solution for a small problem of something and modify things, that is science. But if you have something very complicated but not used it’s not science. Science is always we come back to what is the definition? What does science mean for us? When we invented an aeroplane for something this was a need to travel. Then it is top science. When we discover something, an antibiotic or something, to discover an antibiotic it was top science because it solved a problem. If you discovered an antibiotic which was not relevant for any pathogen then it is not science, this science is theoretical. So top science solves our problems. The value of the fourth revolution of health and the third revolution, third and fourth, the third is patient-centred, if we say our own patients are not going with the need so you are not going with the third revolution of health, the third revolution aside. About the fourth revolution, now there are many things. We are now scaring about artificial intelligence and big data and the development of computers. No, it will help us, it will solve all this. And, by the way, you say we start with something very simple for developing countries. No, the fourth revolution in health, the third revolution in science and health, rich countries and underdeveloped countries and developing countries face it together alike. So it is a chance to make a jump and to be real with a society of globalisation. The good side of globalisation, forget about some reserve of many, but take the good science, the good side of globalisation that is convergence around and focus around common benefits. The benefits may be different and maybe for different issues but the common interests and common incentives.

So science is to solve our problems, not to use it as part of the problem. Because sometimes it is something that we can’t afford, it creates a problem. Okay, this is not the role of the inventor but there is another step or how to adapt this, how to find solutions and how to apply it and how to use it for more people. This is not against invention, something very difficult, no, but there is a second step to complete these scientific actions but with other scientists, other doctors, other physicists, other chemists, all science including, by the way, business models, business sciences, economic sciences. All these together to find a solution to be more affordable and more beneficial to human beings. Otherwise it will not be scientific because this is one element of the third revolution and now the fourth revolution is to be patient-centred. For industry it is customer service, for us as doctors the customers are our patients, are us because nobody is immune.

As you know, here we have a very good example of people that are thinking, not only following the classic paradigm of doctors and patients. We are talking here about access, we are talking here about dignity, we are talking here about the actions that are around the patient, not around the system or around the economy or around the politics. So really one of the main things that a group of leaders, I believe, can contribute to the knowledge and to the worldwide actions to improve cancer control, to diminish cancer incidence and to improve curability is with commitment, with innovation and also with…

Partnership.

With partnerships, thank you, and also with a contribution of the platforms like ecancer and other publications really to disseminate these ideas outside the classical picture of doctors and academic discussions. This is not only about academic discussions, this is about connecting better ways of care with countries that need improvement, that need help but also that need champions at the country level to really implement the things in the countries. Because cancer is a global problem but the solutions must be local.

So Professor Elzawawy, my dearest friend Ahmed, thank you very much for your experience and for your collaborations and for pushing everybody of us to make things better. Thank you very much.

Thank you very much.