Oncology, Etc: - Cancer Care Partnership With Kenya

The availability and quality of cancer care varies in different parts of the globe. Some locations find it difficult to have proper equipment, access to medications or even trained staff on hand. In this ASCO Education podcast we look how a group of doctors are sharing their skills and experience to set up training programs to help improve outcomes for patients with cancer in Kenya. Our guests will explore the creation of a pediatric oncology fellowship program in Kenya (11:48), how a young doctor found herself interested in improving global health (14:30), and discuss lessons learned that are applicable to health care in the United States (21:07). 

Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. Terry Vik: Research Funding Takeda, Bristol Myers Squibb Foundation Dr. Jennifer Morgan: None

Resources: Podcast: Oncology, Etc. - Dr. Miriam Mutebi on Improving Cancer Care in Africa Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 1) Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan Part 2

If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org.

TRANSCRIPT

Disclosures for this podcast are listed in the podcast page.

Dave Johnson: Welcome, everyone, to a special edition of Oncology, Etc., an oncology educational podcast designed to introduce our listeners to interesting people and topics in and outside the world of Oncology. Today's guest is my co-host, Dr. Pat Loehrer, who is the Joseph and Jackie Cusick Professor of Oncology and Distinguished Professor of Medicine at Indiana University, where he serves as the Director of Global Health and Health Equity. Pat is the Director Emeritus of the Indiana University Simon Comprehensive Cancer Center. Pat has many different accomplishments, and I could spend the next hour listing all of those, but I just want to point out, as many of you know, he is the founder of what formerly was known as the Hoosier Oncology Group, one of the prototypes of community-academic partnerships which have been hugely successful over the years.

 He's also the founding director of the Academic Model for Providing Access to Healthcare Oncology Program, which has grown rather dramatically over the last 17 years. This includes the establishment of fellowship programs in GYN oncology, pediatric oncology, and medical oncology through the Moi University School of Medicine in Kenya. Through its partnership with the Moi Teaching and Referral Hospital, over 8000 cancer patients a year are seen, and over 120,000 women from western Kenya have been screened for breast and cervical cancer in the past five years. Pat is also the co-PI of the U-54 grant that focuses on longitudinal HPV screening of women in East Africa. He currently serves as a Senior Consultant of the NCI Cancer for Global Health. 

So, Pat, welcome. We have with us today two special guests as well that I will ask Pat to introduce to you.

Pat Loehrer: Dave, thanks for the very kind introduction. I'm so pleased today to have my colleagues who are working diligently with us in Kenya. The first is Terry Vik, who is Professor of Pediatrics here at Indiana University and at Riley Hospital. He's been the Director of the Fellowship Program and the Pediatric Hematology-Oncology Program and Director of the Childhood Cancer Survivor Program. He got his medical degree at Johns Hopkins and did his residency at UCLA and his fellowship at Dana-Farber. And he's been, for the last 10 to 15 years, been one of my co-partners in terms of developing our work in Kenya, focusing on the pediatric population, where he helps spearhead the first pediatric oncology fellowship in the country. 

And then joining us also is Dr. Jennifer Morgan. Jenny is a new faculty member with us at Indiana University as an Assistant Professor. She, I think, has 16 state championship medals for track and field in high school. I've never met an athlete like that in the past. She ended up going to Northwestern Medical School. She spent time in Rwanda with Partners in Health, and through that, eventually got interested in oncology, where she completed her fellowship at University of North Carolina and has spent a lot of her time in Malawi doing breast cancer research. I don't know of anyone who has spent as much time at such a young age in global oncology. 

Dave Johnson: So Pat, obviously, you and I have talked a lot over the years about your work in Kenya, but our listeners may not know about Eldoret. Maybe you can tell us a little bit about the history of the relationship between your institution and that in Kenya.

Pat Loehrer: It's really a remarkable story. About 30 some odd years ago, Joe Mamlin and Bob Einterz, and Charlie Kelly decided they wanted to do a partnership in Global Health. And they looked around the world and looked at Nepal and looked at Mexico, and they fell upon Eldoret, which was in Western Kenya. They had the birth of a brand new medical school there, and this partnership developed. In the midst of this came the HIV/AIDS pandemic. And these gentlemen worked with their colleagues in Kenya to develop one of the most impressive programs in the world focused on population health and dealing with the AIDS pandemic. They called it the Academic Model for Prevention and Treatment of HIV/AIDS or AMPATH, and their success has been modeled in many other places. They have many different institutions from North America and Europe that have gone there to serve Western Kenya, which has a catchment area of about 25 million people. 

About 15 to 20 years ago, I visited AMPATH, and what they had done with HIV/AIDS was extraordinary. But what we were seeing there in cancer was heartbreaking. It reminded us, Dave, as you remember back in the ‘60s and ‘70s with people coming in with advanced cancers of the head and neck and breast cancers that were untreated. And in addition, we saw these young kids with Burkitt's Lymphomas with huge masses out of their jaws. And seeing that and knowing what was possible, what we saw in the States and what seemed to be impossible in Kenya, spurred me on, as well as a number of other people, to get involved. And so, we have built up this program over the last 15 and 20 years, and I think it's one of the most successful models of global oncology that's in existence. 

Dave Johnson: That's awesome. Terry, tell us a little bit about your involvement with the program at Moi University. 

Terry Vik: Sure. So, I took an unusual path to get to Eldoret because I started off in work in signal transduction and protein kinases, then morphed into phase I studies of kinase inhibitors that was happening in the early 2000s. But by the end of the decade, Pat was beginning to establish oncology programs in Kenya. And because half the population is children and there were lots of childhood cancers, and many of them can be curable, he mildly twisted my arm to go with him to set up pediatric oncology in Kenya. And through his help and Matt Strother, who is a faculty member on the ground, establishing that, I first went in 2010 just to see how things were running and to see all the things that Pat had recognized as far as things that needed to be done to make Eldoret a center for cancer care.  

And so, the last 13 years now, I've been working, going anywhere from one to four times a year to Kenya, mainly helping the Kenyans to develop their medical care system. Not so much seeing patients or taking care of patients, other than talking about best practices and how we do things in the US that can be readily translated to what's going on in Kenya. And so, we've been able to establish a database, keep track of our patients in pediatric oncology, recognize that lots of kids are not coming into care, not being diagnosed. There's a huge gap between numbers who you would expect to have childhood cancer versus the numbers actually coming to the hospital. As the only pediatric treatment center for a catchment area of 25 million, half of whom are under the age of 20, we should be seeing a lot of kids with cancer, but we are probably only seeing 10% of what we would expect.

 So, myself, many of my colleagues from Indiana University, as well as colleagues from the Netherlands Princess Maxima Hospital for Pediatric Cancer, we've been partnering for these past 13 years to train Kenyans to recognize cancer, to have treatment protocols that are adapted for the capabilities in Kenya, and now finally starting to show real progress in survival for childhood cancer in Kenya, both in leukemias, lymphomas, and solid tumors, with a fair number of publications in Wilms tumor and Burkitt lymphoma and acute lymphoblastic leukemia. So, it's been really heartening, I think. 

I tell people that the reason I go to Kenya studying signal transduction and protein kinase inhibitors in pediatric cancer, I can maybe save a couple of kids over a career by that kind of work. But going to Kenya to show people how to find and treat kids with leukemia, I'm literally seeing the impact of hundreds of kids who are alive today that wouldn't be alive otherwise. So, that's really been the success of pediatric oncology there.

Dave Johnson: Is the spectrum of childhood cancer in Kenya reflective of what we see in the States, or are there some differences?

Pat Loehrer: It really is surprisingly similar. I think the only thing that– Well, two things that are more common in Kenya because of the so-called ‘malaria belt’ and the association with Burkitt Lymphoma, there's a fair number of kids with Burkitt’s Lymphoma there. Although, as mosquito control and malaria control has improved, actually, the numbers of cases of Burkitt’s have been dropping, and a lot of cancers were sort of hidden, not recognized as leukemia or not recognized as other lymphomas. Just because if Burkitt’s is endemic, then every swelling is Burkitt's. And I think that's been shown by looking at pathology retrospectively to say a lot of what they thought was Burkitt's was maybe not necessarily Burkitt's. And then nasopharyngeal carcinoma with Epstein-Barr virus prevalence also is a little bit more common than I'm used to seeing, but otherwise, the spectrum of cancers are pretty similar. So, it's heartening to know that we've been treating childhood cancers with simple medicines, generic medicines, for 50 years in the US. And so I like to tell people, I just want to get us up to the ‘90s, maybe the 2000s in Kenya, and that will really improve the survival quite a bit.

Dave Johnson: You mentioned that there were adjustments that you were making in the therapies. Could you give us some examples of what you're talking about?

Terry Vik: The biggest adjustments are that the ability to give blood product support, transfusions of platelets is somewhat limited. So, for instance, our ability to treat acute myeloid leukemia, which is heavily dependent on intensive myelosuppressive chemotherapy, we're not so good at that yet because we don't have the support for blood products. Similarly, the recognition and treatment of infections in patients is somewhat limited. Yet, just the cost of doing blood cultures, getting results, we actually have the antibiotics to treat them, but figuring out that there actually is an infection, and we're just beginning to look at resistance patterns in bacteria in Kenya because I think that's an indiscriminate use of antibiotics. In Kenya, there are a lot of resistant organisms that are being identified, and so figuring out how best to manage those are the two biggest things. But now, in Eldoret, we have two linear accelerators that can give contemporary radiation therapy to kids who need it. We have pediatric surgeons who can resect large abdominal tumors. We have orthopedic surgeons and neurosurgeons to assist. All those things are in place in the last three to five years. So, really, the ability to support patients through intensive chemotherapy is still one of the last things that we're working diligently on improving.

Dave Johnson: So one thing that I've read that you've done is you're involved heavily in the creation of a pediatric oncology fellowship program. If I read it correctly, it's a faculty of one; is that correct?

Terry Vik: Well, now that two have just graduated, it's a faculty of three, plus some guest lecturers. So I feel quite good about that. 

Dave Johnson: So tell us about that. That must have been quite the challenge. I mean, that's remarkable.

Terry Vik: That goes back to one of my longtime colleagues in Kenya, Festus Njuguna, who is Kenyan. He did his medical school training at Moi University and then did pediatric residency there. They call it a registrar program there. And then he was, since 2009, 2010, he's been the primary pediatric oncologist. Although he always felt he did not have the formal training. He'd spent time in the US and in Amsterdam to get some added training for caring for kids. But it was his vision to create this fellowship program. So Jodi Skiles, one of my colleagues who had spent some time in Kenya and myself and he worked on creating the fellowship document that needs to go through the university to get approved. That finally got approved in 2019. And so the first two fellows…I was on a Fulbright Scholar Award to start that fellowship program for a year right in the middle of the pandemic, but we were able to get it started, and I was able to continue to go back and forth to Kenya quite a bit in the last two years to get through all of the training that was laid out in our curriculum. And two fellows, Festus and another long-standing colleague of mine, Gilbert Olbara, both completed the fellowship and then sat for their final exams at the end of last year and graduated in December. So it really was heartwarming for me to see these guys want to build up the workforce capacity from within Kenya, and being able to support them to do that was a good thing.

Pat Loehrer: Parenthetically, Dave, we had the first Gynecology Oncology program in the country, too, led by Barry Rosen from Princess Margaret, and they have 14 graduates, and two of them now are department chairs in Kenya. Jenny's spearheading a medical oncology curriculum now so that we have that opened up this year for the first time.

Dave Johnson: It's uncommon to find a junior faculty as accomplished as Jenny. Jenny, tell us a little about your background and how you got interested in global health, and your previous work before moving to IU. 

Jennifer Morgan: I was an anthropology major at undergrad at Michigan, and I think I really always liked studying other cultures, understanding different points of view. And so I think part of that spirit when you study anthropology, it really sticks with you, and you become a pretty good observer of people and situations, I think, or the goal is that you become good at it. I think my interest in medicine and science, combined with that desire to learn about different cultures really fueled a lot of my interests, even from undergrad and medical school. I really felt strongly that access to health is a human right, and I wanted to work for Partners in Health when I graduated from residency. I had heard a lot about that organization and really believed in the mission around it.  

And so I went to work in Butaro in Rwanda, and I really didn't have any plans to do cancer care, but then I just kind of got thrown into cancer care, and I really loved it. It was a task-shifting model that really where you use internists to deliver oncology care under the supervision of oncologists from North America. So, most of them were from Dana-Farber or a variety of different universities. And so it made me feel like this high-resource field of Oncology was feasible, even when resources and health systems are strained. Because I think a lot of people who are interested in Oncology but also kind of this field of global health or working in underserved settings really struggle to find the way that the two fit sometimes because it can feel impossible with the hyper-expensive drugs, the small PFS benefits that drive the field sometimes. And so I think, Butaro for me, and Partners in Health, and DFCI, that whole group of people and the team there, I think, really showed me that it's feasible, it's possible, and that you can cure people of cancer even in small rural settings. And so that drove me to go to fellowship, to work with Satish Gopal and UNC. And because of COVID, my time in Malawi was a bit limited, but I still went and did mainly projects focused on breast cancer care and implementation science, and they just really have a really nice group of people. And I worked with Tamiwe Tomoka, Shakinah Elmore, Matthew Painschab, really just some great people there, and I learned a lot. 

And so, when I was looking for a job after fellowship, I really wanted to focus on building health systems. And to me, that was really congruent with the mission of AMPATH, which is the tripartite mission of advancing education and research and clinical care. And I knew from Pat that the fellowship program would be starting off, and I think to me, having been in Rwanda and Malawi and realizing how essential building an oncology workforce is, being a part of helping build a fellowship as part of an academic partnership was really exciting. And then also doing very necessary clinical outcomes research and trying to do trials and trying to bring access to care in many systems that are very resource constrained. So that's kind of how I ended up here. 

Pat Loehrer: That's awesome. So tell us a little bit about your breast cancer work. What exactly are you doing at the moment?

Jennifer Morgan: In Malawi, during my fellowship, we looked at the outcomes of women with breast cancer and really looking at late-stage presentations and the fact that in Malawi, we were only equipped with surgery, chemotherapy, and hormone therapy, but not radiation. You see a lot of stage four disease, but you also see a lot of stage three disease that you actually have trouble curing because it’s so locally advanced, really bulky disease. And so that first study showed us the challenge of trying to cure patients– They may not have metastatic disease, but it can be really hard to locally even treat the disease, especially without radiation. And so that’s kind of what we learned.  

And then, using an implementation science framework, we were looking at what are the barriers to accessing care. And I think it was really interesting some of the things that we found. In Malawi, that has a high HIV rate, is that the stigma around cancer can be far more powerful than the stigma around HIV. And so, we are seeing a lot of women who are ostracized by their communities when they were diagnosed with cancer. And really, they had been on, many HIV-positive women, on ARVs for a long time living in their communities with no problem, and so HIV had kind of been destigmatized, but we’re seeing the stigma of cancer and the idea that kids are as a death sentence was a really prominent theme that we saw in Malawi. 

So some of these themes, not all of them, but some of them are very similar in Kenya, and so what I’m helping work on now is there’s been this huge effort with AMPATH called the Breast and Cervical Cancer Screening Program, where around 180,000 women have been screened for breast cancer in a decentralized setting which is so important - so in counties and in communities. We're looking at who showed up to this screening and why did women only get breast cancer screening and why did some of them only get cervical, and why did some get what was intended - both. Because I think many people on the continent and then other LMICs are trying to do breast and cervical cancer co-screening to really reduce the mortality of both of those cancers. And the question is, I think: is mammography a viable screening mechanism in this setting or not? That’s a real question in Kenya right now. And so we're going to be looking to do some studies around mammography use and training as well. 

Dave Johnson: So, I have a question for all three of you. What lessons have you learned in your work in Kenya or Malawi that you've brought back to the States to improve care in the United States?

Pat Loehrer: One is that the cost of care is ever present there. And so one of the things that we need to think about here is how can we deliver care more cheaply and more efficiently. It goes against the drug trials that are going on by industry where they want to use therapy for as long as they can and for greater times. And there are a lot of common things like access to care is a big issue there, and it’s a big issue in our country. So we have used in IU some community healthcare workers in rural parts of our state as well as in the urban centers so that they can go to people's houses to deliver care. 

Terry was involved with a wonderful project. It was a supplement from the NCI, which looked at barriers to care and abandonment of therapy. And just by giving patients and their families a small stipend that would cover for their travel and their food, the abandonment rate went down substantially, and they were able to improve the cure rate of Burkitt's Lymphoma. It’s probably about 60% now. And so those are issues that I think we see here in our state, where people can’t come to IU because of the cost of parking, that’s $20 a visit. The lesson there is that we really need to get down to the patients and to their families and find out what their obstacles are. 

Terry Vik: My favorite example, since I deal with kids and parents, is how striking parents are the same worldwide. They all want the best for their child. They all want anything that can be done to potentially cure them, treatment, they do anything they could. And I think the hardest thing, as Pat said, is the financial burden of that care. And the other thing that I bring back to my fellows in the US is that you don't have to do Q4-hour or Q6-hour labs to follow somebody when they start their therapy. Once a day, every 3 days, works quite well also. And just the realization that things can be done with a lot less stress in the US if you only decide to do it.

Dave Johnson: Jenny, any thoughts from you on that?

Jennifer Morgan: I think for me, decentralized cancer care is so important. Even being back on the oncology wards in Indiana in December, I saw a couple of really advanced patients who were really unfortunate, and they had tried to go through the system of referrals and getting to cancer care. And unfortunately, I think there are disparities in the US health system, just like in Kenya, and maybe on different scales. But cancer care that's accessible is so important, and accessible versus available, I think we a lot of time talk about therapies that may be available, but they’re not accessible to patients. And that’s really what we see in Kenya, what we see in rural Indiana. There are a number of grants that talk about reciprocal innovation because some of these things that we do in Kenya to minimize burden on the system are things that can be done in rural Indiana as well. And so, partnership on these issues of trying to improve decentralized care is important everywhere. 

Pat Loehrer: And again, from the perspective as a medical oncologist, we see patients with late-stage diseases. We could eradicate the number one cause of cancer in Sub-Saharan Africa, cervical cancer, from the face of the earth just by doing prevention. We don't do enough in our country about prevention. The other dimension I guess I wanted to bring up as far as multidisciplinary care - when we think about that in our country, it’s radiation therapy, surgery, medical oncology, but one of the lessons learned there is that the fourth pillar is policy. It’s really about cancer policy and working with the government, Ministry of Health to affect better insurance cover and better care and to work with a different discipline in terms of primary care, much more strongly than we do in our country.

 Dave Johnson: Are you encountering similar levels of vaccine hesitancy in Kenya as you might see in the States, or is that something that’s less of an issue?

Pat Loehrer: I’ll let Terry and Jenny answer that.

Terry Vik: I think there is some degree of vaccine hesitancy, and not so much that it's fear of the vaccine, but it’s fear of the people pushing the vaccine. If it’s coming from the government or if it’s coming from outside drug companies or outside physician recommendations, it’s less likely to be taken up. And if it’s coming from within their own community or if it’s their chiefs and their community leaders they respected, then I think there is less vaccine hesitancy certainly in a lot of things we do in pediatrics. So I think there is hesitancy, but it’s coming from a different source than what we see in the US.

 

Jennifer Morgan: I would agree, and I think also COVID has changed the game on vaccine perceptions everywhere, and I don’t think Kenya is spared from that either. So it may take a few years to see really what’s going on with that.

 

Pat Loehrer: Jenny and I were at this conference, it’s a Cancer Summit in Nairobi a couple of weeks ago, and we saw this little documentary there. And this notion of misinformation, as we’ve seen in our country, is also common over there. They were interviewing a number of men and women from Northern Kenya about prostate cancer, which is a very serious problem in Kenya. The notion was that even doing PSA screening caused infertility, and so the men and women didn't want their husbands to get screened for prostate cancer because they would become less fertile by doing that. So, again, there are lessons that we– as Jenny mentioned from the top about anthropology, I think we’re all connected, we all have different ways of viewing communications in health, but I do think that we can learn from each other substantially.

Dave Johnson: I mean, it's remarkable work. How is it funded? 

Pat Loehrer: Well, I've been fortunate to be able to work with some friends who are philanthropists. We've had strong support as we've told our story with various different foundations. And we've been very grateful to Pfizer, who are very helpful to us in the early stages of this - Lilly Foundation, Takeda, Celgene. And I think as we basically share our vision of what we're trying to accomplish, we've been very humbled by the support that we have gotten for us. The U54 helps support some of the research. We have D43 we're doing through Brown University. So we plan to increase our research funding as best as we can. But this is active generosity by some wonderful people. We have a $5.5 million cancer and chronic care building in which a large sum of it came from Indiana University and the Department of Radiation Oncology. Dr. Peter Johnstone helped lead that. There was a Lilly heir that gave us quite a bit of money. An Indian Kenyan named Chandaria also donated money. So it's a matter of presenting the vision and then looking for people that want to invest in this vision. 

Well, I just want to say, from my perspective, I am more of a cheerleader than on the field. But Terry, I know you spent a tremendous amount of time on the ground in Kenya, and Jenny, you're living there. I just wanted to say publicly that you guys are my heroes.

Dave Johnson: Yeah. I think all of our listeners will be impressed by what they heard today, and we very much appreciate you both taking time to chat with us. 

So at this point, I want to thank our listeners of Oncology, Etc., an ASCO Educational Podcast. This is where we'll talk about oncology medicine and beyond. So if you have an idea for a topic or a guest you'd like us to interview, please email us at education@asco.org. To stay up to date with the latest episodes and explore other educational content, please visit education.asco.org. 

Pat, before we go, I have an important question to ask you.

Pat Loehrer: I can't wait.

Dave Johnson: Do you know how snails travel by ship? 

Pat Loehrer: As cargo!

Dave Johnson: Awesome. You got it. All right. Well, Terry and Jenny, thank you so much for taking time to chat with us. It's been great. I'm very impressed with the work you guys are doing. Really appreciate your efforts.

Terry Vik: Great. Thank you.

Jennifer Morgan: Thank you.

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