Episode 32: In the Clinic - Discussing Global Oncology with Dr Susannah Stanway

This week the Simply Oncology podcast goes global!

Over 80 % of the world population is living in low or middle income countries.

In this podcast, we're hopefully going to try and cover what is global oncology, what some of the challenges that low middle income countries are facing in terms of delivering cancer care.
We also touch on how clinicians in the UK might be able to cooperate and contribute to improving Cancer care globally, and to do this, we are delighted to welcome Dr Susie Stanway to the podcast. 

The scale if the issues is HUGE and Susie talks us through some thoughts on what may help and how we can get involved.

A truly humbling episode

John & Mike

Transcript

Simply Oncology Global Cancer podcast recording-20241218_163917-Meeting Recording

 Hello. I'm doctor John McGrane and I'm doctor Michael Rowe. And in today's episode we are going to be talking about global Oncology, which is a huge topic that we're going to try and get through in a short podcast. In this podcast, we're hopefully going to try and cover what is global oncology, what some of the challenges that low middle income countries are facing in terms of delivering cancer care and also touch on how clinicians in the UK might be able to cooperate and contribute to improving Cancer care globally, and to do this, we are delighted to welcome Dr Susie Stanway to the podcast. 

Susie, could you introduce yourself?

 Susie Stanway   
 Yeah. Hi. Thank you both so much. So, my name is Susie Stanway. I am a medical oncologist. I'm working in the UK, and I have for some time had an interest in the intersection of global health and cancer care.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Susie, thank you so much for joining us and this is a fascinating topic.
 But not a standard route that most oncologists would have taken. Could you just tell us how you became interested and what was your journey into developing this interest in global oncology? And then as a follow on what you would define global oncology is.
Susie Stanway   
 Sure. So I'm I guess my grandfather fled from Eastern Europe to the UK during World War 2.
 I went to a very International School and I grew up having a mother who was an advocate for breastfeeding, and so did a lot of advocacy work both in the UK and around the world, and writing books and things like that. So that sort of primed me for an interest in the world around me. I then studied medicine, which I really enjoyed, and I really liked that intersection between science and art, which I suppose is what draws many of us into finding medicine fascinating.
 Entered oncology off the back of volunteering in a Hospice as a teenager so that that world of oncology was opened up to me and I found that really interesting.
 And then it was really when I was undergoing my oncology training, I was fortunate enough to meet a young girl who had been brought to the UK from a sub-saharan African country and that really got me interested in what cancer care was like in her country and why she had ended up in the UK. And so my interest really spawned from that and.
 I just it's sort of it got me thinking around inequalities really and I think we all realised probably from quite a young age that the world is an unfair place.
 I think you know when you've got 76% of the world's wealth in the hands of 10% of the world's population. That's unfair. As we all know, inequality is detrimental for society, except detrimental for health, for social cohesion, for democracy, for social justice, human rights, economic sustainability, so environmental and economic sustainability, and you know, etcetera. So, I think although we appreciate, there's always going to be inequalities, I think that many of us want to play our small part in.
 Increasing equity and particularly around healthcare as a doctor.
 

 ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 That is, that's a really great like setting the scene. And what about global oncology? What, what? Whenever you think global oncology or if you're giving a talk on it, what is your kind of summary sentence that would say I think global oncology is?
Susie Stanway   
 Sure. So, I lectured a couple of universities and how I sort of open up as it's the endeavour that's going to provide evidence based accessible quality care of value across the continuum for all irrespective of geography or income level. So, it's a bit of a mouthful, but for me that sort of gets across what we're all trying to achieve here.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 And that is a mouthful, because it is a huge a huge task to do. And so that's a really complex narrative that hopefully try and break down in this episode. Now the next question for you, Susie is.
 Global Health is a very complicated thing. Health systems are very complicated in developed countries in lower middle developing countries as well.
 In lower middle-income countries.
 Typically, there have been other priorities in the past, haven't there? In terms of, you know, access to, you know, sanitation, clean water.
 Can I interrupt Mike? Of course I do like to interrupt, Mike, I think at this point, for me anyway, I hear a lot about low and middle income countries and I always wonder like, well, what does that mean like so I moved from Northern Ireland to England and everyone talk about the north-south divide and then somebody says it's at the Watford gap wherever that is, but.
 Where is Suzie? Can you just open us up a wee bit? What is a low- and middle-income country?
 It is their definitions? Or is it by geography?
Susie Stanway   
 OK.
 Sure. So, these are World Bank defined and they change over time. So high income countries of those countries that have GDP per capita of over 14, roughly over 14,000 U.S. dollars per year.
 Middle is divided up into high and low, with high being around 4 1/2 thousand to 14,000 and low being around 1000 to four and a half thousand and then low income countries are those where the GDP per capita is around less than.
 1100 U.S. dollars per year.
 So there are, you know, relatively few low income countries, the vast majority of the world fits into the middle income setting.
 And yes, and then again a few you know, less high income countries, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Thank you. Thank you for that. I'll let Mike have his question. Yes, thanks, John. So, we're talking about the scale of global health and the complexity of global health. And traditionally in low middle income countries where previously there were other priorities in terms of sanitation, water, infectious diseases, cardiovascular health. Where does cancer sit now?
 Amidst all of those competing priorities and what is the scale of the problem of cancer care in these countries?
Susie Stanway   
 Yes. So, the scale is huge and becoming bigger. So, if we look at the broader picture of non-communicable diseases, so that is diseases that aren't caused by infection basically that's the cause of death of 41 million a year. So that's 70% of the deaths worldwide and that's diabetes, stroke, cardiovascular disease, cancer etcetera. And these have cross cutting.
 Risk factors and shared health system solutions. So, to some extent we all need to work together.
 So globally, cardiovascular disease is the number one cause of death and cancer #2. And if and if you look at cancer, that causes one in six deaths globally. So 17,000,000 cases per year 9.6.
 Deaths per year and as countries transition non communicable diseases become more prevalent.
 So in sub-Saharan Africa, for example, cancer is this or was a couple of years ago the 7th leading cause of death.
 With malaria.
 Our illnesses, HIV still above it, but this is changing as company as countries transition.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 So you're saying that as countries get more welfare, improved GDP, that cancer actually becomes more of a relative mortality issue?
Susie Stanway   
 That's correct.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 And I'll just touch on that as well. I suppose that's it is more complicated as well in terms of the sort of the viral vectors of cancer as well.
 Being contributing to that and thinking specifically viral hepatitis for HCC, HPV for cervical cancer in these countries alongside Co infections with things like HIV.
Susie Stanway   
 Absolutely. So, there are countries that are transitioning and then you have you have infection coexisting with cancer. So, for example, South Africa, where you've still got a high prevalence of HIV people present with cancer. And then there's that to deal with as well. Yeah. And then you've got the broader sort of geopolitical security landscape. So, I think you know we're at.
 A pivotal point, a sort of Inflexion point. As a species, I suppose, where there are multiple other crises going on which interact with non-communicable diseases, cancer. The broader healthcare picture.
 And you know this sort of panopoly, of existential threats, many of which are manmade such as conflict, you know, 2 billion people in the world, living countries in conflict, such as problems with earth systems, governance, climate change, for example, which not only, you know, you think about things like pollution, cause cancer, but also are systems that that manage cancer cause pollution.
 And then you've got other issues such as pandemics. And we've seen the effects that.
 COVID-19 pandemic has had you know it's been well published in this country. You know the detrimental effect on people presenting with cancer, getting diagnosed and treated. And then you've got other issues such as artificial intelligence and how that hopefully will be a cause, you know, a source of good for healthcare but also does have other nefarious implications such as malinformation, disinformation, misinformation.
 As an article in The Economist today about Agentic AI, you know how AI is shifting from chatting to actually doing.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Mm hmm.
Susie Stanway 
 Oh, that, that, that this is going to play and the need for governance. So, I think that it's on this backdrop of these sort of post Bretton Woods institutions which were not established to function in the world in which we currently live. And so, despite sort of valiant attempts to reform there are you know the rules based international order is being tested like never before. And I think now more than ever we need to have strong sensible.
 Smart leadership, you know, perhaps with disruptive thinking, courage, inclusivity, flexibility, versatility and new paradigm new paradigms that are fit for the 21st century.
 And this this is where all of this sits. You know, we sit in the backdrop of this. And so, I think that that, you know, the desire for good health and a system that encourages it and supports it and will weather these wider security challenges is not unique to any country or jurisdiction or to any person, rich or poor. And we're all in this together. And we must work collaboratively with, you know, measured, creative, sensible leaders.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 That first point that you mentioned about conflict, I don't want to focus on it, but we have our own issues here in the UK, which would come out as a high income country and we've got our own inequalities with healthcare and how we deliver it and in oncology. But I can only, I can't even imagine how you would consider delivering cancer care in the middle of a conflict.
 And I'm absolutely staggered by that comment. 2 billion people in the world.
 Are living in some form of conflict.
Susie Stanway   
 And I think there's more armed conflict now at any point in time since World War Two. And these situations are all very different. So, if you look at what's happening in in Palestine and how cancer cares being delivered there, for example, that's different to what's happening in Sudan, to what's happening in Ukraine.
 You know these settings? Yes, there are learnings, but they're very different. Your ability to get drugs in and out is, is different, provide radiotherapy facilities is different.
 Manpower issues are different, so it's complicated.

 ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Absolutely. Take your point that it is complicated and it's really difficult to try and talk about these things without sort of focusing on in on specific countries. But you touched already on certain challenges that lower middle-income countries have in delivering healthcare, for example, stable democracy, lack of conflict. Can you give us other sort of broader sort of challenges?
 That the that that people in these countries are currently facing.
Susie Stanway   
 Yeah. So, I think I think when it comes to looking at the challenges in providing healthcare, it's quite maybe helpful to think about what is necessary to provide good cancer care. So, I think probably at the top of my list or the top of any list, I suppose I would put political will because you need political will to be able to do that. And with that is the associated funding.
 And I think that we all need to get better at working with economists, at working with finance ministers.
 You know, selling the point that actually it's an investment, not a cost. And you hear this said again and again, but not investing in cancer care will ultimately cost you as a society. So that's one thing and it doesn't need to be huge amounts of money and actually there you know beyond a certain amount, there isn't necessarily a correlation between cancer mortality and the amount that you put in.
 
 It's more complex than that, so I I'd also say that you need to have that you need to have cancer preparedness. And by that I mean you need to have a well-funded National Cancer control plan that's been committed to by the government.
 And you know, there were organisations like the International Cancer Control Partnership that work with UN agencies that work with governments that work with NGOs to help coordinate all of that, and you also need to have cancer intelligence systems because you need to have data on what the scale of the problem is in your setting. So political will cancer preparedness, you need to think about the whole continuum. This isn't just about treatment.
 This is about prevention. This is about diagnostic.
 It's survivorship. It's about the whole continuum.
 And I think really there needs to be a focus on prevention because no country is going to be able to afford to treat its way out of cancer.
 So there are cancers that are almost, well, entirely preventable, like cervical cancer that you alluded to earlier on. But there's other cancers like lung cancer, which is the number one cause of cancer death. If you take both sexes together in the world. And yet 80% of the world's smokers live in lower middle income countries where they're often not protected by mechanisms that we are in higher income countries.
 I think that there needs to there needs to be a focus on early detection and on timely diagnosis.
 And by early detection, I don't necessarily mean screening because you need to have a healthcare system that's developed to a certain degree before you start screening programmes. Otherwise, you may find yourself finding cancers and then not having a system in which to treat them in.
 And timely diagnosis as well.
 And ideally, I think that these systems need to fit within the UN Sustainable Development Goals. So, the 17 goals that were outlined for taking us from 2015 to 20, thirty, 169 associated targets.
 And, you know, met all of these are pertinent to cancer, probably most focally STG 3, which is around reducing the premature death from cancer by 1/3 by 20-30. And also, that touches upon universal health coverage.
 Because really, you've got, you know, 4.5 billion people in the world that aren't covered by essential health services. And it's very it's more challenging to deliver good quality cancer care if you haven't got universal health coverage.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   18:05
 Can I just repeat that so 4.5 billion people in the world?
 Are not covered by an essential healthcare system.
Susie Stanway   
 They're not fully covered by health services.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 OK, that is staggering, isn't it?
Susie Stanway   
 So just because you haven't got a system like the UK where we have universal health coverage, that's we at the point of delivery, you know many other countries have got different systems.
 Which work some you could argue work better, but I'm talking about the vast swathes of the world that haven't got access to that and you know, there are lots of people that are experts in this area. You know, Rob Yates spoke at several events during London Global Council week this year. He spent a large part of his career working on universal health coverage and helping governments around the world commit to UHC reforms. And you know, I'm always interested when he says that.
 You know, universal health coverage often comes out of a crisis. So if you think about our NHS that came out of World War 2.
 If you think about, say, universal health coverage in a country like Thailand that came out of the Asian financial crisis.
 So yeah, it is possible and so maybe coming back to my shopping list, we've done political, rural cancer preparedness. It needs to be across the continuum early detection time diagnosis ideally sitting within the Sdgs.
 And you need to have some degree of cancer literacy. And this isn't just within your workforce, it's also within the broader population, because if people don't conceptually understand what cancer is, then it's difficult for them to know and to present.
 You need to have an adequate workforce, you know everybody in around the world at the moment is having workforce crises, but this is about, you know, a well trained workforce. It's about building capacity. It's about avoiding the brain drain and abiding by The Who codes of ethical recruitment.
 And it's and it's about using the workforce you have in in intelligent ways and then we need to define what research priorities are, because these are different around the world and what works in our country won't might not work in a, you know, rural country and South rural area in Southeast Asia, for example. So, you know this is different and needs to be thought about.
 Cs premise and various other colleagues published a great article in Nature Medicine a couple of years ago about research priorities for cancer care and low middle income countries, which is well worth the read. And then we need to think about other sort of broad cross cutting movements such as the choosing wisely movement in the common sense and oncology movement that bishal gowali and Chris Booth in Canada are sort of leading.
 You know ways of sensibly spending money to get high quality cancer outcomes.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 It all feels so big, you know, it feels so big that it's very difficult to kind of get your head around. It's almost like when you look at a mountain and you think, well, I've got to climb that one tiny step at a time, and presumably it requires huge amounts of collaboration. Then between all sorts of international groups.
 What international and National Health bodies and groups are kind of engaging with cancer care and healthcare in these low- and middle-income countries?
Susie Stanway   
 So I suppose that that's a huge question. So obviously you've got in governments that are doing, you know, heavy lifting, then you've also got multilateral organisations that organisations like, UN agencies that are doing huge amounts of work. So you know The Who, for example, is focusing on childhood cancer, breast cancer, cervical cancer with their with, you know, various initiatives that they've got.
 Then you've got umbrella organisations such as the Union for International Cancer Control, which is the world's largest umbrella organisation for cancer charities.
 You've got International Development banks, you've got structures such as the Commonwealth, you know the Commonwealth is home to the world 2.5 billion people, 56 countries.
 Then you've also got regional groups, so organisations like aortic, the African Organisation for Research and Training and Cancer ESMO in Europe. You've got MAESTRO, you know the Middle Eastern radiotherapy organisation, you've got slackom in South America.
 And then you've also got national groups like in our country, Cancer Research UK, for example, and the royal colleges or in the US ASCO, Astro. And then you've also got private sector involvement. I've recently been in Bangladesh and was there with a colleague from the Electra Foundation and was learning about a lot of work that the Electra Foundation, for example, are doing around radiotherapy provision in Rwanda.
 So I think it needs.
 Top down approaches but also it needs bottom up approaches and there are other fantastic organisations such as City Cancer Challenge.
 Who are doing work in at city level and coordinating research information systems, leadership, government financing system, strengthening workforce, etcetera. But from the city at the city level, which is really interesting and it's fascinating to read more about and then you've got organisations that are interacting with other sort of domains such as climate change. So, ISIS in a group that's been being led by an oncologist in the US, for example, called Jane Schiller.
 And it's called oncology activists unite for climate and health, and it's specifically looking at that intersection. And then you've got other sort of international groups that have been set up, like the global coalition for radiotherapy, which again, you know, is looking at a particular part of cancer care.
 And then, yeah, many other groups doing incredible work. I mean, The Lancet oncology, for example, is doing, you know, a huge amount of work, not only publishing really high quality evidence with its really high impact factor, but also coming, you know, being a platform to present solutions for inequities and health injustice.
 And other publishing houses like E Cancer, which is much smaller. But this is a group that was set up.
 You know several years ago, and every single paper has to have an author from a learned middle-income country on it. Because if you think about the fact that the majority of the world's cancers happen in lower middle-income countries, it's only right, that's reflected in what you publish, who we hear from.
 Yeah. So, endeavour and many people around the world involved.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 And I'm going to just touch on that point about evidence because you also mentioned earlier on about making sure that the cancer care that is rolled out or delivered needs to be of high value and needs to be common sense oncology. It needs to be treatments that are going to make a difference and going to be worth the as you say and it's not cost, it's investment and I think.
 In in certainly in the UK, we really lose perspective.
 On that as to what is, what is value and obviously value is different for each individual person country health system.
 And we and it's very easy to be in our echo Chamber of the UK going. Oh, yes, I want to give pembrolizumab to this one because there's this, you know, 3% survival benefit, completely unrealistic for other countries. What? How?
 What?
 Is being done or what is available out there to? Because ultimately I think these decisions need to, as you say, come from the ground down on the country that knows their health system, knows their limitations, knows what they can and can't reasonably deliver, but where do they get the information from in terms of cost effectiveness, and how much these drugs cost or how much these machines cost or what? How do they make those decisions.
 There might be a difficult question I don't know.
Susie Stanway   
 
 We got a lot of places around the world. Look to organisations like what used to be called Nice that you know critically appraise that. But I think that this is probably a question that has to be answered by individual societies as well and individual governments and what they think is worth. You know what they want to spend their money on and obviously it's different in different health systems or where you've got countries where you've got different health systems, where you've got a public system and a private system and people.
 To pay. And then you've got sort of resource stratified guidelines which suggest different things for different financial settings.
 But yes, that group, the common sense and oncology group, and that choosing wisely movement is well worth looking into and paying attention to what they're publishing because these are exactly the kind of questions that they're asking. And I think it's important that we all engage with that. I also think it's important that we.
 Continue to do work around treatment minimisation and that it's not just adding on new expensive drugs, which inevitably is going to, you know, it's great. I think we've got to make progress here. We want to get better control of cancer and that's going to come with, with, with incremental improvements. But we've also got to be sensible and make sure that we do research looking at how we can stratify, who's going to benefit from what.
 And so I, you know, I think that trials such as, you know, the START study looking at hypofractionation for breast cancer, that was led by John Yarnold, for example or.
 You know, studies that are looking at things like lower dose immunotherapy and many of these are coming out of mid, you know, middle income countries like India. So, you know these are being led and by other places. And I think it's really important that that those kinds of studies carry on as well.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Because as you say it's it has an implication for all health systems. You know, obviously we've got a resource, limited health system hugely if we've got evidence of a cheaper treatment, give less of its equal outcomes, huge, hugely beneficial, absolutely.
Susie Stanway   
 Yeah.
 Yeah, they were all resource constrained. We all are to different degrees, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Now, what is? You've obviously got involved in this. Is there a role that you know? So, we're down in Cornwall, Mike and I, you know, how do we get involved? How is there a way for oncologists and the wider oncology community in the UK and say Europe in being involved in trying to kind of bridge the gap or improve this equity?
 In delivering value cancer care globally.
Susie Stanway   
 So I think that there's multiple ways of getting involved and I think.
 I think that there's a lovely German phrase. I forget exactly how it goes because I don't speak German, but it's sort of there's a there's a lid for every pot is what it is, what it comes to. And I think that it's just a matter of us all working out where we can play our very small part to work collaboratively with colleagues to improve this situation.
 So whether it's around advocacy, whether it's about being an ally, which I think is really, really important, because at the end of the day.
 We all have to work, you know, together and people on the ground in any situation know what's going on the best.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Mm hmm.
Susie Stanway   
 But that doesn't mean to say that somebody from elsewhere can't come along and help when invited.
 And be of use, but this has to be led by the people in, in in their settings. So, I think there's a role for advocacy. There's a role for activism. There's a role for allyship. There's a role for research. So, there's a role for teaching.
 There's and that's not only teaching, maybe helping teach in low- and middle-income countries, but also maybe teaching people in high income countries to make them aware of this.
 Issue. There's a role for convening.
 And there's a role for networking. There's a role for mentoring. There's a role for getting involved in policy. So, it just depends on what your interest is and where your where your skill set is and where you think you can. You can help, I suppose. I got into it a little bit through convening because it was when I was, it was back in 2016. I just sort of heard on the Grapevine that there were lots of people in the UK doing this kind of collaborative work.
 But there didn't seem to be a time where they all got together and spoke about what they were doing with their collaborators, and it struck me that there was perhaps some inefficiency in people working in similar countries that didn't know about it.
 So we set up a day meeting at the Royal Society of Medicine, which then, with the catalyst of somebody called Mark Lodge, became London Global Cancer Week in 2019, which was in its sixth year this year. So, it depends on what you're interested in and yeah.
 I would say that.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 This has been amazing. This has been it's do I keep using the word huge? All the numbers you've used are huge. All of the challenges are huge. I don't think I have the right to complain if I've got an overbook clinic anymore. I don't think I could complain about 30 patients in the clinic or less help because that seems like a very small issue in comparison.
 There's been brilliant, but we like to round every episode up with three take away points.
Susie Stanway   
 Yeah. OK. So, I think I would say as my first point, the majority of cancer deaths are in low- and middle-income countries. And for a panoply of reasons, these numbers are rising and there are not only inter country disparities, but there are also intra country disparities.
 So those need to be addressed. I think that would be my .1 my .2 would be that cancer is an all of sustainable development goal issue. It's an all of government issue and an all of society issue.
 It's a global challenge and requires global solutions, and I think my Third Point would be that we can all make a difference in our own way. Stay humble, keep your head down and get on with the work that needs to be done collaborating with colleagues.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   
 Can I? We are so it is coming up to Christmas.
 And I don't know if you believe in Santa Claus, but say Santa Claus is going to give you one present. You've got you’ve got a Christmas wish. What Christmas wish. Would you like to try and help tackle a large part of this kind of inequality in global cancer care?
Susie Stanway   
 I think it would have to be political will.
 Because with that many of these other.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   32:38
 Yeah.
Susie Stanway   
 Issues, you know, solutions come.
 

 ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   32:45
 Llike Domino's.
 Susie, thank you so much for your time. Despite what you've described, an almost Herculean task I have left with nothing but actual positivity about, you know, ways that this could be addressed. We've talked about nothing but problems, but I've come away feeling slightly more positive and I think that's a reflection of your, your dynamism and your knowledge on this topic. So thank you so much for joining us today.
 I'm sure our listeners will find that incredibly interesting.
 And we'll put some links on our simply oncology X page just to some of the things like the choosing wisely campaign that you mentioned based in Canada, so that that's been an absolutely amazing. Thank you so much.
Susie Stanway   
 Thank you ever so much for having me. It's been really interesting to talk to you both.