Highlights of the Annual Meeting

The second Annual Meeting of the International Network for Cancer Treatment and Research, Improving Cancer Care in Developing Countries, took place in Brussels in mid-April. The Annual Meeting has several objectives, but it is primarily an occasion for cancer-related health professionals from all over the world to come together to discuss progress made in ongoing INCTR programs and projects, to identify important areas for new endeavors, and to discuss existing models that might be emulated. The 2001 meeting included educational sessions focused on clinical trials management and issues pertaining to accurate diagnosis—a sine qua non of effective cancer treatment, as well as two major themes—cancer in Africa and uterine cervical cancer. After welcoming remarks by Mr Mettens, the Chef du Cabinet of the Belgian Ministry of Science and Economics, and the INCTR President's report, Karol Sikora, former head of the World Health Organization Cancer Unit, gave the Keynote Address.

Figure 1

He quoted data from the International Agency for Research on Cancer, indicating that the global cancer burden could well double in the next two decades, reaching 20 million by 2020. By then, 75% of cancer deaths will be in developing countries. He also pointed out the enormous discrepancies between sales of anti-cancer drugs and the distribution of cancer throughout the world (Figure 1), and provided a lively picture of the contrasting motives of different stakeholders in cancer care. Dr Sikora suggested that the future of cancer control would be shaped by the rapid progress being made in the areas of biotechnology and information technology.

Educational Session
Jorge Ortero of Eli Lilly introduced the educational session on clinical trials by emphasizing the importance of conducting clinical trials in developing countries. He commented not only on the high fraction of patients with cancer who live in resource-poor countries, but also the differences in cancer patterns in different world regions. He stated that clinical research benefits go beyond the study question, and include improvements in patient care, exposure of local physicians to the ethical principles of research, training and education of staff, investigation of locally important problems, motivation of doctors to remain in their own countries, and opportunities to participate in international studies. The INCTR, through its Clinical Trials Office headed by Melissa Adde, will promote the conduct of high quality clinical trials, and plans to develop educational and training programs for all personnel associated with their conduct. It will also promote good clinical practice through local Ethical Review Committees (ERCs), its own ERC having been recently established.

Participants at the INCTR Annual Meeting included (from left): David Ebirere (Nigerian Embassy, Brussels), Mr. and Mrs. Chris Williams (Canada), Yetunde Akenova (Nigeria), and Jaiyeola Thomas (Nigeria).

Cancer Education Programs
Elmer Huerta, a member of Board of Directors of the INCTR's US Branch, opened this session with an entertaining presentation on public education in the context of cancer prevention and early detection. He described his concept of a "Preven-tarium," i.e., a hospital unit dedicated to prevention and early detection through education and screening, and discussed his experience with such a unit at the Washington Hospital Center. He stressed the importance of the repeated delivery of health education messages from trusted professionals delivered via accepted public channels. Physicians remain, at least in the context of health, the most trusted professionals among Hispanic people, whilst radio, particularly in illiterate populations, remains a particularly effective communications tool. Public education and strategies to ensure early detection must be a high priority for the INCTR, because of the large fraction of patients in developing countries who present with advanced disease. If early detection could be improved, cancer care would be less complicated, less expensive, less toxic, and more effective, while existing resources would be better able to cope with the cancer burden.

Cervical Cancer
Harald zur Hausen, Chairman of the Cancer Research Center in Heidelberg, Germany, who first discovered the link between Human Papilloma Virus (HPV) and cancer of the uterine cervix, gave the keynote lecture in the session on cervical cancer. He provided an elegant overview of the role of the virus (which infects 50% of women) in this and a number of other human cancers. He went on to describe recent, very promising efforts to develop preventive and therapeutic HPV vaccines, and the importance of simple routes of delivery in developing countries. His own research group has developed a vaccine in which HPV DNA is delivered by adeno-associated virus (AAV), which naturally infects the human body via the nasal mucosa. Prof zur Hausen stated that 600 women die of cervical cancer every day, and quoted estimates that efficient Hepatitis B and HPV vaccines have the potential to prevent 15% of cancers in women and 10% in men throughout the world. Cervical cancer, which will become an important area of endeavor for the INCTR, remains a particular problem in Latin America, Asia and sub-Saharan Africa. Phil Schein, President of INCTR's US Branch, who reported on the Branch's recent meeting on cervical cancer in Florida, is exploring the possibility of developing programs focused on cervical cancer in Latin America. The INCTR is also working with members of the International Agency for Research in Cancer (IARC) in developing a collaborative program for cervical cancer screening in selected centers.

Sub-Saharan Africa
Because many of the poorest countries in the world are in sub-Saharan Africa, this region was the focus of an entire session. Dr Freddy Sitas, an epidemiologist working with the South African Institute for Cancer Research, highlighted the dramatic differences in the incidence of various cancers in different parts of Africa, which provides a plethora of scientific opportunities, particularly with respect to epidemiology. Unfortunately, the low socioeconomic status of most sub-Saharan African countries means that all aspects of cancer control are sadly neglected, and life expectancy is actually dropping. Kaposi's sarcoma varies in incidence from one country to another, but is as common as carcinoma of the colon, and has become a particular problem because of the AIDS epidemic. Inam Chitsike from the University of Zimbabwe pointed out that KS is now the commonest cancer in her country. Interestingly, the prevalence of the causally associated virus, Human Herpes Virus 8 (HHV8), as measured by serum antibodies, is similar across the continent and has not changed with time, clearly indicating the important role of HIV infection as a cofactor in the genesis of a virus-associated cancer. HIV acts as a cofactor in a number of lymphoid neoplasms associated with Epstein-Barr virus, and also, although less clearly documented, of HPV-related cancer of the uterine cervix. The INCTR plans to initiate programs in sub-Saharan Africa, focusing on problems such as inadequate numbers of trained personnel, cervical cancer, Burkitt's lymphoma, and perhaps AIDS-associated cancers. Needs in sub-Saharan Africa are particularly great, but this means that, given a minimum of added resources, initial progress could prove quite rapid.

(From left): Angelo Rosolen (Italy), Sidnei Epelman (Brazil), and El-Nassir Lalani (UK) converse at the Annual Meeting dinner.

Histopathology
Bharat Nathwani gave a pragmatic yet energetic account of the problems faced by the pathologist, and emphasized the importance of close collaboration between the clinician and pathologist. He stated that histopathology, increasingly supplemented by immunohistochemical and molecular techniques, remains the cornerstone of diagnosis, and there is no substitute for properly prepared tissue from an adequate biopsy interpreted by an experienced pathologist. Because of its fundamental role in cancer diagnosis, education for pathologists and pathology technicians will be included in the INCTR's education program.

Reports on INCTR Programs
In the penultimate session, reports were given on programs being conducted with the support of the INCTR, including the Retinoblastoma and Osteosarcoma Strategy groups, the Middle Eastern Children's Cancer Association, the Indian Group for the Study of Leukemia, as well as the molecular profiling of leukemias being conducted at the Research Center of the King Faisal Specialist Hospital in Riyadh. Joe Harford, an Associate Director of the National Cancer Institute (NCI) in Bethesda, which presently provides the bulk of INCTR's financial support, provided information on NCI's international programs and reminded the audience of the central role of anti-tobacco programs in any cancer control program. While the INCTR does not intend to overlook this important area, it will approach tobacco control more from the perspective of health education than from policy issues—more the domain of organizations such as the World Health Organization, IARC, and International Union Against Cancer. Michael Saba, now working with the INCTR, gave a brief overview of funding strategies and was much in demand for advice on this topic.

Summary
In the concluding session, Anslim Narinesingh, Executive Director of the INCTR, pointed out that the end of INCTR's first year of operations signaled the beginning of a period of controlled expansion into new areas.

Throughout the meeting, participants expressed a sense of encouragement instilled by talking to other dedicated oncologists and health professionals working in similarly difficult circumstances, and by the existence of an international organization focused exclusively on cancer in countries with limited resources. They valued the opportunity to learn from each other and to take part in international projects that would benefit their own patients as well as the wider global community. They recognized that by working together, resources are likely to be much better utilized, and that although there is a great deal to be gained by collaborating with affluent countries, scientific advances need to be adapted to the needs of their own countries—and to be made there. Cancers there tend to be much more advanced, and seemingly identical cancers differ biologically in different world regions. Given the increasing share of the global cancer burden borne by the developing countries, participants recognized the increasingly important role that they must play in cancer research of all kinds in the future. Scarce resources can often lead to novel solutions, and developing countries do not lack for opportunities in a broad range of clinical and scientific research which are often relatively unique. In this respect, the developing countries are resource-rich! Thus, the potential contribution of such countries to cancer research should not be underestimated. Strategies for prevention—even preemptive prevention of cancers still low in incidence, but rising because of epidemiological transitions—and early detection might appropriately be emphasized. These aspects of cancer control, which are dependent upon a sound knowledge of causal factors as well as human psychology and sociology, may require some adjustments to the training provided to health care personnel in general, to careful estimates of both existing human resources for public health and additional resources required, as well as to the form and means of transmission of information to the public. In all, improving cancer in developing countries presents a huge challenge, but also poses many opportunities that we cannot afford to overlook.