Panel Discussion:  Towards A Global Cancer control Program

Introduction

Efforts to enhance cancer control in resource-constrained/challenged countries are currently conducted through a number of organizations at government, inter-governmental, non-government, academic, medical, industry, patient and civil society levels. Given that all such organizations and personnel share a common understanding of the need to enhance capacity building and knowledge transfer to improve population-based cancer control, the question of the value and possible structure of an "overarching" collaboration among these organizations to enhance achievement of common goals was discussed by invited panel members and delegates at the 10th Anniversary Meeting of INCTR in Brussels, March 2010.

Discussion

A number of "rate limiting" challenges constrain initiatives to enhance cancer control. Among these, the most important are the funding required to implement programs and the challenges of recruitment and retention of committed personnel with appropriate skills in low and middle-income countries, given the abundant opportunities (and temptations) for trained personnel to emigrate and the lack of incentives to remain in their country of origin. Additional challenges include the lack of awareness of the need for population health approaches to cancer control, the mal-distribution of resources for the treatment of advanced disease, which are most often available in urban but not in rural settings, the failure to appreciate the cultural and contextual conditions needed to align attitudes and approaches to interventions that can genuinely yield improvements in cancer control, and the frequent lack of resolve and political will to effect change. These challenges are often compounded by the absence of a patient/public voice and the failure to engage civil society in promoting, through advocacy or direct participation, the improvement of health systems. The lack of coordination and coherence of various stakeholders groups, not to mention the humanitarian efforts of individuals, internal and external to the country being assisted, is also seen both as an impediment to progress, and as a source of potential confusion and duplication of effort that could be readily mitigated through increased collaboration.

Indeed, increased collaboration is a means whereby a number of constraints that presently hinder optimal actions could be addressed – by ensuring focused, complementary goals across cancer organizations (and even other organizations, particularly those dealing with other non-communicable diseases), by taking advantage of synergies, such as addressing exposure to shared risk factors or the need for palliative care, and maximizing complementarities through shared planning, maximizing and optimizing strengths in various necessary elements of cancer control planning, implementation and evaluation, and leveraging resolve and political will through concerted engagement with policy makers. To date, at least some cancer organizations have established a good precedent for collaboration through agreement with respect to the needs in various resource settings and through "partnered" relationships in education, programmatic and service delivery in these same settings. There are, however, unrealized opportunities for further collaboration to overcome constraints through the creation of additional partnerships, e.g., with organizations concerned with HIV/AIDS, maternal and reproductive health, child health/infant mortality etc, and in recognizing the commonalities between the social determinants of health and environmental risk factors underlying both communicable diseases and chronic diseases. In addition, the promotion of linkages across governments, funding organizations and foundations, e.g., the Global Alliance for Vaccines and Immunization (GAVI) and the Global Access to Pain Relief Initiative (GAPRI), to simultaneously address health challenges related to infections, chronic diseases and cancer could present new opportunities for economy and synergy.

Collaboration is seen as a means to build and reinforce awareness of the need for cancer control at a population level with the simultaneous opportunity of influencing many widely accepted texts and bodies that, in turn, influence the actions of governments and major foundations alike, including the Millennium Development Goals, the World Cancer Declaration, and global political bodies such as G8/G20. It should create a coherent approach to resource acquisition and utilization; broader access to networks of people, knowledge and resources; shared information re: ideas, directions and priorities; complementary approaches to assist and support developing country agendas; and establishing common strategies to promote capacity building in cancer control.

When considering how collaboration could be enhanced, the priority must be given to what needs to be done, i.e., a functional rather than a structural (organizational) collaboration. The endeavor requires definition and alignment of strategic priorities and coherent approaches to implementation to ensure capacity to support key cancer control elements such as registries and capacity-building. The impact of interventions must be evaluated in order to ensure that the goal of incremental self-sufficiency and maintenance of a scientific, evidence-informed approach to population-based cancer control is being achieved.

Recommendations for action and direction in the context of global collaboration included:

• The need to ensure that all stake-holders recognize the importance of cancer/NCDs from medical, societal and economic perspectives on communities and countries. This has implications for the collection of accurate incidence, mortality and survival data, and educational campaigns directed towards policy makers and the public.
• One message, one voice – the need for a combined approach to promulgate priorities and actions to enhance cancer control. Notwithstanding differing organizational governance, solutions for the global community require common, overlapping and reinforcing messages to influence political, medical and public resolve.
• The overwhelming importance of prevention, when possible, in the control of cancer and NCDs: tobacco use may be the single most important risk factor for NCDs, closely followed by diet and a sedentary lifestyle.
• The engagement of new domains and forums, e.g., NCDNet, the World Economic Forum, World Bank, etc.  This will focus attention on the overall global health agenda, incorporating, but not focusing exclusively on cancer control, and is in line with the importance of NCDs as a major and growing global health problem, even in the low-income countries.
• Finding synergies for action within existing resource settings and ongoing programs and seeking support for new funding through combined, collaborative strategies both within and across cancer and NCDs.
• A coalescence of focus on influencing global policy through incorporating cancer and NCDs into the wording of the MDGs, recognizing that this will require a parallel process of demonstrating that cancer is preventable, treatable and sometimes curable, and the identification of channels to present the case for population-based cancer control at regional, national and global levels.
• Learning lessons from effective strategies for other conditions/diseases with substantial medical, social and economic consequences, e.g., HIV/AIDS. Particularly relevant are the comprehensive public health approach aligned with a medical intervention program, and the role of concerted civil engagement and societal resolve to address disease control.

Conclusion

Collaborative action between cancer control organizations presents an opportunity to define strategy, priorities, clarity of purpose, coherent and concerted influence at political, medical and public level, an optimized approach to human resource development and deployment, and rational use of assets and resources across the spectrum of cancer control. Avoidance of duplication of roles and activities would result in greater effectiveness with reduced confusion of purpose. Such collaboration among a broad range of organizations with very different motivations and areas of focus – governmental, intergovernmental, non-governmental, academic, philanthropic and private (including commercial) - could be achieved through focus on strategy and function without compromise of role or governance. However, appropriate forums for discussion and an inclusive approach on the part of lead organizations are essential if duplication, failure to grasp opportunities for complementation, failure to agree on priorities and opportunities to economize through joint action are to be avoided.

Simon Sutcliffe
INCTR Canada
Vancouver, Canada