INCTR Awards

Dr John L. Ziegler (right) of the National Cancer Institute, received the first Paul P. Carbone Award. He and Ian Magrath worked together in Uganda, and subsequently at the NCI.

This year, INCTR introduced two awards that will be presented annually to individuals who have made outstanding contributions to cancer treatment or research in one or more developing countries. The purpose of these awards is not simply to recognize and honor the recipients, although this is certainly an important element, but also to show, by their example, that much can be accomplished even when resources are limited. It is hoped that their work and philosophy, brought, through the Award Lectures at INCTR’s Annual Meeting, to a broad audience, will also provide inspiration to cancer specialists in developing countries who often work under conditions of great hardship due to the limitations of available resources.

Each of the awards is named after a distinguished oncologist. They began their careers when there was so little knowledge about the causes of cancer, that people could only live in fear that they would one day be a victim, while the diagnosis was usually hidden from those unfortunate enough to develop cancer because so little could be done for them. It is thanks to the resolution and fortitude of Dr Nazli Gad-el-Mawla, Dr Paul P. Carbone, and others like them, who worked through a time when cancer specialists were often accused of prolonging the misery of cancer victims through their efforts at treatment rather than helping them, that today, at least in the wealthier nations, more than half of those who develop cancer can be cured. Both Dr Nazli and Dr Carbone were responsible for training numerous young people, and so leave us a precious legacy through which their work will be continued.

The Nazli Gad-el-Mawla Award is given for outstanding contributions to cancer control by an individual from a country with limited resources. Nazli Gad-el-Mawla was an pioneer Egyptian oncologist, who, as a member of a small group of oncologists working at the National Cancer Institute in Cairo in the 1960s and ‘70s, helped to build the institute into one of the premier cancer centers in the Middle East. She founded the Department of Medical Oncology in 1970 and, as part of it, developed a strong pediatric oncology program. She is known particularly for her work in the chemotherapy of cancer of the bilharzial bladder, which accounts for some 25% of all cancer in Egypt, and in hematological malignancies. She was highly respected both by her colleagues in Egypt and also by the international community of oncologists in which she became increasingly active throughout her career.

The 2002 Award is made to Dr V. Shanta, who has devoted more than 50 years of her life to the care of patients with cancer in India. She was instrumental, with Dr. Krishnamurthi, in developing the first Cancer Institute in India, for the establishment of the first Cancer Control Program in India (at Kanchipuram), for the creation of the first separate medical oncology program in India, and for the recognition and practice of Medical Oncology as a specialty in India. She has held many important national and international positions. She is, for example, a member of the WHO Advisory Committee on Cancer and Convener of the State Advisory Board on Cancer. She has been Chairman of the INDO-US Collaborative Group on Lymphoid Neoplasias (Indian Chapter), member of many Committees of the Indian Council for Medical Research (ICMR), member of the ICMR Task Force on Registries and member of the Syndicate of the Anna University. She was President of the Indian Society of Oncology (88-90), President of the Asian & Pacific Federation of Organisations for Cancer Control (97-99) and President of the 15th Asian & Pacific Cancer Conference (1999). She has participated in a number of Scientific International Collaborative Programs. She has won 26 awards for her contributions to advances in the management and control of cancer, and was the recipient of the Indian national award, Padma Shri, in 1986 and an honorary doctoral degree in 1997 by the Shri Venkateswara University, Tirupati, Andhra Pradesh. By her example and work, she has played a critical leadership role in the evolution of the practice of oncology in India, and through this, and the training of many young oncologists, has helped to ensure that the future of oncology in India is bright.

Dr Advani, Chief of the Medical Oncology Department at the Tata Memorial Hospital, Mumbai, India, speaks with Dr Magrath.

The Paul P. Carbone Award in International Oncology is given for outstanding contributions to oncology or cancer research in a developing country by an individual from a resource-rich country. Paul P. Carbone was a pioneer American oncologist, who, as the Associate Director for the Clinical Oncology Program at the National Cancer Institute, Bethesda, played a critical role in the development of cancer chemotherapy. Subsequently, he continued his work as the Director of the Cancer Center at the University of Madison, Wisconsin. From the beginning, he recognized not only the needs of patients in developing countries, but also the contribution that scientific research conducted in such countries could and should make to the global efforts against cancer. Dr Carbone’s family have established the Paul P. Carbone MD Foundation for “the support of scientific, educational, and charitable endeavors that reflect Dr. Carbone’s practice of the art and science of oncology and his lifelong dedication to teaching and mentoring.”

The 2002 award is made to Dr John L. Ziegler, who joined the National Cancer Institute, Bethesda, in the mid 1960s. Shortly after, with the help of Dr. Carbone, he founded the Uganda Cancer Institute at Makerere University in Kampala, which brought much needed emphasis to cancer treatment in East Africa. Dr Ziegler’s work on the chemotherapy of African Burkitt’s lymphoma resulted in significant improvements in survival rates, and led the way to the cure of this disease in the USA and Europe. Indeed, Dr Ziegler was also a pioneer of the treatment of this disease outside Africa, becoming Chief of the newly established Pediatric Oncology Branch at the National Cancer Institute in 1972 and publishing several important papers on the chemotherapy of Burkitt’s lymphoma in the United States. He subsequently became Associate Director for Clinical Oncology and Editor of the Journal of the National Cancer Institute. In 1981 Dr Ziegler joined the University of California, where he took up research on HIV and malignancy, and made several important observations, amongst them the demonstration of the predisposition to lymphoma by HIV. Subsequently, he conducted studies on Kaposi’s sarcoma, again in Uganda. Most recently, Dr Ziegler has directed the Cancer Risk Program (genetic counseling and testing) at the UCSF Cancer Center. Dr Ziegler is a recipient of the prestigious Lasker Award. His important work in Africa led not only to the cure of many African children with this disease, but also demonstrated that research in developing countries may have far reaching implications.

Dr. V. Shanta

My encounter is a narration of the origin of the Cancer Institute (WIA), Chennai, founded in 1954 by a non-governmental voluntary social organization, the Women’s Indian Association Cancer Relief Fund in an environment of total official apathy and public ignorance about cancer. It highlights the evolution of cancer care at the Institute through 1954-2002, the growth of a cottage hospital, located in small huts, to a Comprehensive Cancer Centre with a hospital of 427 beds, a research centre, a College of Oncologic Sciences and a Center of Preventive Oncology. It also deals with aspirations for the future of the Institute.

The major problem faced in 1955 was the desperately advanced loco-regional cancers, the common cancers being oral cavity, cervix and breast. The observation of the “centripetal contraction of the malignant zone” after radio therapy led to the introduction of the concept of a multimodal approach in cancer management. Pre-operative radiotherapy followed by surgery could reduce the size of over 50% of locally advanced oral and breast cancers such that they became surgically operable, resulting in an enhanced 5 yr. disease-free survival. In view, however, of the limited applicability, a series of controlled clinical trials was begun in 1960, to study the possibility of chemo-sensitization of radiation response. These trials did document benefits but seemed, in practice, to touch only the fringe of the problem.

The crux of the problem was early detection. The first Cancer Survey in India, in Chingleput underscored the urgent need for cervical cancer screening. As a non-governmental organisation, the Institute had to go through considerable toil and labour to establish the first WHO Cancer Control project, funded by NORAD, in Kanchipuram in 1969.

The rapid progress the world over from the mid-60s, including the introduction by DeVita of multi-drug chemotherapy in Hodgkins Disease in 1969, also saw the introduction of the first medical oncology unit in India, at the Institute, in 1971. The Indo US Collaboration began in 1976 after a chance meeting with Dr Ian Magrath, when I visited NCI to discuss the contrasting results in pediatric acute lymphoblastic leukemia (ALL) in the Caucasean and Asian children. It started with the introduction of a protocol for pediatric ALL (MCP 841) at the Institute and later extended to other centers in India. The collaboration has shown significant enhancement in survival in pediatric ALL and also highlighted the differential patterns of leukemia sub-types.

Medical oncology ushered in a new era in cancer care. Adjuvant and neo-adjuvant chemotherapy led to a significant enhancement in survival in breast cancer, in all pediatric malignancies, in testicular tumors, and made limb conservation possible in Osteosarcoma. Every one of these state-of-the-art therapies is provided irrespective of socio-economic class.

The concept of a multi-modal approach to cancer care, and the increasing role of medical oncology in enhancing survival stressed the need for specialized oncology personnel. It took us over 10 years to get the concept of oncology accepted by the Medical Council of India and the first super speciality training in medical and surgical oncology was introduced at the Institute in 1984.

It is hard to convince the bureaucrats that a hospital and laboratory are indivisible parts of a whole. Organizing an oncologic research laboratory in a developing environment was a hard task. Despite these obstacles, the Institute has built a modest research centre. We look forward to contributing to a better understanding of cancer in our collaboration with INCTR and the developed world. It has been a long and arduous journey but we see no end to it because there is so much to be done.

Looking back 48 years ago, the story of cancer was a dismal one, a diagnosis of cancer was a virtual sentence to death. A desperate patient was treated by an equally pessimistic physician. The horizon has certainly changed. The Institute has provided state-of-the-art diagnosis and therapeutic facilities to the poorest of the poor in the country.

I wish to record my deep appreciation and gratitude to Dr Ian Magrath for all that he has done for the Institute and for inviting me to deliver the first Nazli Gad-el-Mawla Memorial oration. It is an honor conferred on the Institute.

John L. Ziegler

It is a great honor to be the first recipient of the Paul P. Carbone Award in International Oncology. Paul was my mentor, professional collaborator, and good friend for over 35 years. His untimely death in February this year was a tremendous loss for oncology, for his family and for his many admirers worldwide. Paul epitomized the complete physician-scientist. He was first a visionary, anticipating important advances and stimulating colleagues to explore new areas. He was an exemplary doctor, compassionate, involved, and dedicated to his patient’s wellbeing. Paul was a committed teacher, writing papers, guiding students, and lecturing internationally. Finally, Paul was a leader, inspiring the formation of new institutions, cooperative groups and oncology programs. Although he received many awards and honors, Paul was known for modesty and understatement. In my talk today, Paul’s influence figures prominently, as his special passion was in encouraging clinical research in developing countries. I shall try to place his many contributions in the proper perspective.

I also wish to pay special tribute to my colleague and long-time friend, Dr. Nazli Gad-el-Mawla, whose memory is also being honored today in the form of a memorial Award. Nazli’s loss was a great blow to oncology in the Middle East. She was a pioneer of cancer chemotherapy in Egypt, and a strong advocate of cooperative clinical research in developing countries. With characteristic humility, she set about to advance our knowledge of the chemotherapy of bladder cancer and lymphoma in Egypt. Despite limited resources, her contributions to the field were impressive. Nazli’s premature passing has left a void; fortunately, her many students will follow the path she has opened.

My own introduction to cancer in developing countries began in 1964 as a house officer at Memorial Hospital in New York City, where I cared for a young girl with Burkitt’s lymphoma (BL). Although she had a dramatic remission following cyclophosphamide, she died. My teachers, Dr. Joe Burchenal and David Karnofsky were astonished by the extraordinary tumor responses and believed that careful study of BL would be instructive for other malignancies. At the National Cancer Institute (NCI), Dr. Gordon Zubrod and Paul Carbone were similarly impressed, and in 1967 I was given the opportunity, by NCI, to set up an investigative unit in Kampala, Uganda, to study BL in an endemic setting.

The creation of the Uganda Cancer Institute with our counterparts at Makerere University in Kampala, Prof. Sebastian Kyalwazi, Prof. Ian McAdam, and many others, started my lifelong career in oncology. The lessons we learned from the study of BL were many, including the strategy of tumour debulking, treatment of meningeal disease, the use of drug combinations, the recognition of tumour lysis syndrome, and the importance of patient follow up. We also learned much about multifactorial aetiology (roles for EB virus and malaria) and tumor immunology. Many of these research ideas came directly from Paul Carbone. Most importantly, we learned the value of partnerships with scholars from the host country. Through educational exchanges, Ugandans came to Sweden, UK and the USA for further training in oncology, and Makerere University hosted many medical and graduate students from abroad. The Institute staff taught in the Medical School and participated in local, regional and national conferences.

Our bilateral exchanges paid rich dividends, as the Uganda Cancer Institute survives today, having weathered 15 years of civil unrest during the 1970s and 80s. Today, the Institute is fully staffed and funded by the Government of Uganda. It is the only dedicated oncology unit in sub-Saharan Africa, and it has been internationally recognized in its contributions to cancer and AIDS research. If Paul Carbone were here today, he would be immensely proud of the accomplishments and legacy that began with his vision and inspiration.