David J. Kerr, MD; Eduardo L. Cazap, MD, PhD


October 10, 2011

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United Nations Summit on Noncommunicable Diseases: A Critical Look

David Kerr, MD: Hi. I am David Kerr, Professor of Cancer Medicine for the University of Oxford, and President of the European Society of Medical Oncology. Welcome to Medscape Oncology Insights. I am taking the opportunity to report to you from the United Nations Summit on Non-communicable Diseases (NCDs). I am absolutely delighted that my great friend and colleague -- and mentor in many ways -- Dr. Eduardo Cazap, who is President of the Union for International Cancer Control (UICC), is joining me. This is one of those pivotal moments in time when we have a high-level meeting (only the second time in the history of the United Nations [UN]) for which heads of state are gathering to discuss health. It has happened once before, with AIDS, and now we are talking about NCDs.

The statistics are truly staggering and astonishing. In 2008, we know that there were 36 million deaths from NCDs, two thirds of the world's total. We know that a quarter of those occurred in people younger than 60 years of age, placing a very remarkable economic pressure on low- and middle-income countries. So we have come together, nongovernmental organizations (NGOs) and government heads of state, to see what we can do to solve this. Your leadership as President of UICC has been of paramount importance. Do you think anything other than good words and good intentions will come from this meeting, Eduardo?

The Impact of Collective Effort

Dr. Eduardo Cazap: Yes. We are doctors, and usually our leading organization is the World Health Organization (WHO). The reality is that literature recommendations are only recommendations. This is a different situation. In this case, the UN has made a political declaration[1] that has an impact over all 194 participating governments. They will have the responsibility to report and implement actions following this political declaration, so this a turning point in the history of chronic diseases.

Dr. Kerr: One of the most remarkable things is the fact that you are now here, a cancerologist through and through, but we are also working with our brothers and sisters in cardiovascular medicine, diabetes, and respiratory medicine. So for the first time, as a medical community, we have our collaborative act together. Rather than competing with each other, we are working hand in hand, trying to influence our political leaders. How important a part of the process do you think this is, the sense of collaboration and collectivism?

Dr. Cazap: Of course, I think that cancer is the most important disease, but as you mentioned, the NCD Alliance comprising the 4 leading organizations (the UICC, the International Heart Federation, the International Diabetes Federation, and the International Union Against Tuberculosis and Lung Disease) is an organization working together with the same objective. I would like to add that besides this important issue of the collaboration between colleagues, there is a critical aspect that we need to collaborate on outside the medical profession. This is an issue not only of health or disease; this is an issue of human development. During the speeches today from presidents, ministers of health, NGOs, and several different constituents of the civil society as a whole, everybody agreed that every component of the society has its own responsibility in this enormous tsunami of future risk for society as a whole.

Multipronged Strategy for Cancer Control

Dr. Kerr: I think you and I are allowed to use the word "epidemic" because such is the size of the health burden; that's how it feels. The thing that impressed me most about the approach taken collectively by UICC and our other colleagues is the huge degree of overlap in the risk factors when we look at cancer, cardiovascular disease, and so on. You and I have spent half a lifetime -- a career -- treating cancer patients, developing new drugs, and being involved in research, but as I become older, I am turning into a public health doctor. I am keen to do something around prevention: lifestyle, diet, exercise, tobacco control, the harmful effects of alcohol. If we come together in this, it looks as though we may have an opportunity to influence better health for our children and for those who are yet to come. I think prevention is important too.

Dr. Cazap: Yes, the old criteria are no longer valid. At the time that I graduated from medical school at the University of Buenos Aires, the whole curriculum was diagnosis and treatment. At the time, in 1975, when I became a medical oncologist, our area was cell kinetics and drugs. At that time, my boss and my old professor, Dr. Estevez, who was the founder of medical oncology in Latin America, started the concept of cancer control. Cancer control means education, primary prevention, secondary prevention, of course proper diagnosis, treatment, rehabilitation, end-of-life and palliative care, and morphine access. This is the whole spectrum, and I added to this the concept of global cancer control because every country, even the richest countries, needs international cooperation in this effort. So yes, prevention is a critical component, but together with prevention is education: public education, education of our politicians, and medical education, because we need to change the curriculum of the medical schools.

Tailoring the Strategy to Fit the Need

Dr. Kerr: That sense of a spectrum of cancer control going all the way through from raising awareness to end-of-life care -- I couldn't agree with you more. You provided very strong leadership suggesting that we need to build around the pillars of all 4 components. We cannot focus solely on prevention and completely ignore treatment. We cannot focus solely on policy and tobacco control without looking at end-of-life care. When we do clinics in Dar es Salaam or in Accra, or in the poorer South American countries, we are still seeing patients. The cancer burden is still there and we need to find a way to deliver cost-effective cancer treatments also. That's a challenge to us. It's at a time when our own countries are finding it difficult and are buckling under the weight of the cost of cancer care. With research and working with our brothers and sisters in low-income countries, we must come up with alternative, low-cost -- but still effective -- treatments.

Dr. Cazap: That is a very important point, but I am afraid that there is a little bit of confusion, because we have different levels of analysis of the problem. Of course, we are doctors. We want the best for our patients, regardless of anything, whether we have evidence or not; but another level is the medical society criteria or guideline or recommendation. That is usually based on the evidence, like a gold standard -- the best possible intervention. But we have another 2 levels that are also important in this concept: (1) the national level, because each country has a healthcare system and its own resources, and each country must define its own cancer plans and NCD strategy according to its own resources, and (2) the global level. For example, for cervical cancer prevention we have Pap smears that, in some very rich countries, might be performed twice a year, and that is unnecessary. In medical society recommendations, a Pap smear should be performed every 2 years, but the recommendation of the WHO is a gynecologic examination and a Pap smear once in a woman's lifetime. I am not saying that any of these 3 levels is better; each is different because each situation has a different perspective and a different context.

Research Networks: A Global Reach

Dr. Kerr: It's the notion of taking the best of Western medicine but tailoring it and adapting it flexibly to meet the needs of those countries and to meet their income level and so on. That brings us to the idea of research, because if you and I work with our colleagues from lower-income countries, we find them utterly dedicated, utterly indefatigable, but hungry for new knowledge and wanting to participate in research networks. It seems to me that there is a lot of room that we would be able to build north/south and intercontinental research networks.

Dr. Cazap: Yes. That is also a point that is very close to my heart and to my interest. It is not logical that today 95% of the research in the world is pharma driven. This is not bad, but we need to promote independent research, we need to promote publicly funded research, because, of course, it is natural that the interest of pharma is to approve a drug. But we have other types of research beside drug approval: epidemiologic research, basic research, translational research, and public health research. That means to evaluate interventions not only from the drug perspective, but also from the public health vision.

Looking to the Future: Cost and Targets

Dr. Kerr: Listening to heads of states this morning in the Grand Assembly Hall of the UN was a privilege for us both. Two things came out and I would be interested in your comments. Great support for this UN resolution, which was beautifully crafted, but 2 insistent questions came up: (1) Can we establish a global fund to help support our brothers and sisters in low-income countries? (2) And what about measurements? What about targets? Do you have any strong feelings about either of those?

Dr. Cazap: Yes, the issue of cost. This week, there was a news release from the World Economic Forum.[2] The estimated cost of all NCDs for the next 10 years for the world will be around $35 trillion.

Dr. Kerr: Trillion.

Dr. Cazap: Mental health alone would be $17 trillion. But if we invest $12 billion in NCDs, it will save $7 trillion in costs. But this is not a question of money; this is a question of proper allocation of resources with a good strategy.

Dr. Kerr: Thinking about targets, should we set ourselves a specific target? Should we say to the world, "By 2025 we want to reduce NCD deaths by 25%"?

Dr. Cazap: This is a weak part of the political declaration.[1] As you know, this is a political document, not a medical statement or a paper, so it was necessary to have some flexibility at certain points because the document was approved unanimously. Not a single country was against the document. This was possible because some sensitive things were not included. That will be our work for the future: to move forward, trying to reinforce the areas in which this declaration is not as favorable as we would like it to be.

Dr. Kerr: As always, we finish on a positive point. We are looking to the future, united and strong and with a sense that there is something that we can do about it. Eduardo, thanks for joining us for this Oncology Insight. Thanks to the audience for joining us also. This is David Kerr signing off from the UN Summit, in New York, on NCDs. Thank you.