Special Issue: Global Collaboration
The Cancer Expert Corps: An Idea for Building Human Capital
A recent editorial in the New England Journal of Medicine highlighted a little-publicized fact about global health: if current trends in cancer incidence continue, by 2020 a majority of cancer cases will occur in the developing world.
The projection threatens to outpace and overwhelm the medical infrastructure in developing countries, where physicians often do not have access to even the most basic chemotherapy drugs or radiation therapy equipment. In addition, developing countries often suffer “brain drain,” whereby physicians and researchers leave their home countries in search of facilities and funding for their work abroad. “I think human capital can often be the more challenging thing to get and maintain,” said Dr. Norman Coleman, associate director of the Radiation Research Program (RRP) in NCI’s Division of Cancer Treatment and Diagnosis.
Since 2000, Dr. Coleman and Dr. Bhadrasain Vikram, chief of the Clinical Radiation Oncology Branch in RRP, have been working on the idea of a Cancer Expert Corps (CEC)—a cadre of tenure-track health care professionals dedicated to committing a percentage of their time to mentoring cancer care providers and cancer researchers in the developing world and to helping clinicians and researchers who want to return home in hopes of establishing world-class programs.
Committed to the Future
The idea of a dedicated, long-term commitment sets the CEC apart from other mentoring efforts, explained Dr. Vikram. “A lot of times people go and give a lecture or two and maybe spend a few days somewhere. But to really make a difference, to maintain progress, you have to stay engaged in a sustained manner, for a period of years,” he said. “What is needed is a means of sustainability by which the time commitment for mentoring is a bona fide part of one’s career,” Dr. Coleman emphasized. “In-kind donations and volunteerism are welcome, but long-term commitment is crucial.”
The two radiation oncologists envision funding for the CEC mentors coming from peer-reviewed grants that individuals and institutions would compete for through mechanisms similar to standard research grants. The funding allocated for one regular full-time equivalent clinician or researcher through a typical NIH grant could fund about 20 percent of the professional time of five CEC mentors and provide financial and institutional support for their mentoring activities.
“That would make mentoring a legitimate professional track, something that’s valued by a mentor’s institution, a ‘Peace Corps for Cancer’—people wouldn’t just have to do it on their nights and weekends,” said Dr. Coleman. “That’s what happens now—people use up their vacations, their weekends; they put all their free time into these projects and eventually they burn out,” he continued.
Modern telemedicine technology, like that adopted in 2004 with NCI support at King Hussein Cancer Center in Amman, Jordan, would allow mentors to coordinate activities such as chart rounds and quality control without extensive travel time, explained Dr. Coleman. Investment in infrastructural technology would also allow its use by physicians working in other areas of medicine, such as diabetes and cardiovascular disease, perhaps someday allowing the expansion of the concept to a broader Medical Expert Corps, he continued. A similar concept of academic service has been proposed by other research groups.
Institutions interested in acquiring mentors would need to provide local investment, such as facilities and personnel. International partners, including the International Network for Cancer Treatment and Research, NIH’s Fogarty International Center, and cancer centers in Singapore, Ireland, Canada, Switzerland, and Israel, have expressed interest in participating in the CEC, but for now the project remains in the planning phase.
A Twin Solution
As a proof-of-concept endeavor, the RRP has begun an informal “twinning project,” attempting to connect international mentor–mentee pairs with appropriate funding opportunities. These research pairs were identified through a call for interested participants distributed by the American Society of Clinical Oncology, the International Union Against Cancer, and other professional groups. Out of about 50 interested teams, six pairs are now working with Dr. Vikram and Dr. Maithili Daphtary, a contractor with the RRP and coordinator for the CEC, to identify grants for which they can apply.
One pair of researchers working together through the twinning project is Dr. Lorenzo Leoncini, from the University of Siena in Italy, and Dr. Joshua Nyagol, from the University of Nairobi in Kenya. The two first met in Kenya during a visit by Dr. Leoncini to the Nairobi Hospital. Dr. Nyagol later received his Ph.D. in quantitative and molecular diagnostic pathology under the supervision of Dr. Leoncini at the University of Siena.
The two researchers remained in touch and are planning a collaborative project investigating the direct role of viruses such as HIV, Epstein-Barr virus, and human herpesvirus 8 in the pathogenesis of aggressive B-cell lymphomas, which are prevalent in Africa. Their research will examine the expression of biomarkers associated with the viruses, including microRNA expression profiles, and examine whether the viruses play an indirect oncogenic role by disrupting the immune system. “The results from our proposed study may allow the identification of new targets for treatment,” said Dr. Leoncini.
The researchers have already collected biospecimens from several Kenyan lymphoma patients, but since “people have observed heterogeneity in disease presentation and disease patterns among different regions, in the future we hope to target the whole of East Africa to recruit study subjects,” commented Dr. Nyagol.
Another pair of researchers working with the twinning project is Dr. Yoichi Watanabe from the University of Minnesota and Dr. Shanmugam Senthilkumar from the Government Rajaji Hospital and Madurai Medical College in Madurai, India. Dr. Watanabe sponsored Dr. Senthilkumar for an international cancer fellowship through the Union for International Cancer Control in 2008, while Dr. Senthilkumar was working on his doctoral thesis in medical physics.
“One of the realities of Dr. Senthilkumar’s hospital in Madurai was that the institution had only one piece of rather outdated radiation therapy equipment but treated more patients than most radiation oncology clinics in the U.S.,” said Dr. Watanabe. The two began working together on ideas to inexpensively improve radiation therapy in Dr. Senthilkumar’s home state of Tamil Nadu.
They chose the combination of new motion-sensing technology developed by Dr. Senthilkumar with three-dimensional (3-D) arc therapy using a radioactive source (Cobalt-60) that is affordable and widely used in India. With 3-D arc therapy, “even a small movement from the patient during treatment significantly affects the accuracy of radiation delivery. The device developed by Dr. Senthilkumar is able to sense patient motion during treatment and automatically pause treatment delivery, to allow for the necessary readjustments,” explained Dr. Watanabe. “This system should be able to deliver highly focused radiation to a tumor as precisely as more advanced technologies used in the United States.”
The two researchers hope to obtain funding to build and test a pilot system at the Government Rajaji Hospital to determine if it works the way that they expect it to and whether it could be used in other community hospitals in the region.
These two international projects provide examples of how an effective mentor–mentee relationship could influence cancer research not just in a single institution, but in an entire country and beyond. “A program like the CEC could make a newly established center into a training and research hub for a whole region,” said Dr. Coleman. “So a physician would be returning home not just to run a center, but to create a whole enterprise and become part of a major solution to the recalcitrant problem of sustainable care to the underserved,” he explained.