Cancer 'Groundshot' Has Pragmatic Aims

Nick Mulcahy

March 01, 2018

A "cancer groundshot" could have a greater public health impact on global cancer outcomes in the next 10 years than any would-be innovations from high-tech moonshots in United States and other affluent countries, according to an essay published online February 28 in Lancet Oncology.

The term "groundshot" refers to using cost-effective and proven measures in the prevention and treatment of cancer — on a global scale. Currently, it is an idea in search of collaborators and commitments, say the essay authors, led by Bishal Gyawali, MD, from the Anticancer Fund, in Strombeek-Bever, Belgium, and an oncologist at the Civil Service Hospital, Kathmandu, Nepal.

The phrase was coined by Dr Gyawali in a late-2016 blog post in reaction to the hype generated by moonshot advocates.

"I'd rather support [an effort] that focuses on smoking and obesity reduction campaigns, promotes exercise and healthy diet, and encourages research that can be immediately applied to every global community. 'Cancer groundshot' is the term. Please feel free to use it," he wrote on ecancer.org

The groundshot is a "parallel" initiative with various moonshots in the United States, United Kingdom, and Canada and is not a competitor, write Dr Gyawali and his coauthors, Richard Sullivan, MD, PhD, from King's College London, United Kingdom, and Christopher Booth, MD, from Queen's University, Kingston, Ontario, Canada.

But they also say that the high-tech moonshot concept, with its emphasis on immunotherapies, big data, and precision oncology, is "not an effective strategy" globally.

"I like the idea of the cancer groundshot because there are already strategies that could be implemented with huge impact on some cancers," said Jose Jeronimo, MD, chief technical officer, Global Coalition Against Cervical Cancer, Arlington, Virginia, who was asked to comment.

The essay authors cite cervical cancer as one such malignancy that is primed for a groundshot.

They explain that more than 85% of cervical cancer cases worldwide exist in low-income and middle-income countries, where most women present with advanced disease. In high-income countries, such patients would be offered the expensive monoclonal antibody bevacizumab (Avastin, Genentech/Roche) plus two chemotherapy regimens. In 2014, this combination, compared with chemotherapy alone, was shown to improve median overall survival in this setting (17.0 vs 13.3 months; P = .004).

A groundshot would not emphasize that approach to cervical cancer. Instead, funds and efforts would go to human papillomavirus vaccination and cancer screening. The vaccine "can prevent most cervical cancers," and "screening can detect disease at an early stage at which it can still be successfully treated," assert the authors.

Moonshot-like research projects in the United States and elsewhere focus on developing costly, high-tech targeted therapies, such as monoclonal antibodies, to improve overall survival — that's a major goal, point out the essay authors.

Dr Jeronimo agreed that "expensive drugs" are no help to anyone who is not relatively affluent. "Those drugs are difficult to access in well-developed countries, and impossible to get in developing countries," he observed.

In comments to Medscape Medical News, Dr Gyawali suggested the cancer groundshot is also a vision of what not to do.

For example, he said that 90% of all patients with HER2-positive breast cancer in low- and middle-income countries do not receive trastuzumab (Herceptin, Genentech/Roche) because of affordability. Yet, despite such deprivations, cancer clinics in some of those countries "have started to implement artificial intelligence (Watson for Oncology)." One of those places is India, as reported by Medscape Medical News.

The groundshot discourages "flowing with the hype of high-income countries" and encourages "judicial allocation of limited resources," he said.

Pillars and Funding

Another pillar of a groundshot is drug "repurposing," which would ideally involve countries of all wealth levels.

The authors explain that there is a need to test relatively inexpensive drugs, such as aspirin and metformin, which are already used or approved for other indications, in patients with cancer; evidence suggests efficacy. But drug companies have no incentive to test unpatented drugs. However, if experts from high-income countries, who have the technical know-how to run clinical trials, advised physicians from low- and middle-income countries, it could be accomplished.

A cancer groundshot would also "ensure access" to proven interventions, say the authors. They ask, Why spend more money on highly technical innovations in certain cancers that already have effective and established prevention, surgery, radiotherapy, and chemotherapy? Invest in what already works, they suggest.

Access to palliative care and effective pain relief is also a cornerstone of the groundshot.

The entire initiative requires more planning and work than moonshots; in fact, it represents radical change, the essayists state. "If the global oncology community is serious about improving cancer outcomes now, a revolution around the reality of cancer is needed," they conclude.

Who would pay for all of this? Dr Gyawali believes that the money will come but only after a change in consciousness.

"Once the idea is acknowledged, funding wouldn't be a problem. Once the sexy concepts of moonshots or artificial intelligence or precision oncology et cetera were introduced, there were billions of dollars pouring in from every direction," he said.

The same applies to the groundshot, but with lesser amounts of money because there is no profit motive.  

"If international not-for-profit organizations, local government policymakers, and philanthropist organizations/people can be convinced, we can take this idea forward to the implementation phase," he said.  

The essay authors and Dr Jeronimo have disclosed no relevant financial relationships. Dr Jeronimo's organization, the Global Coalition Against Cervical Cancer, receives partial funding from BD Diagnostics and the Centers for Disease Control and Prevention.

Lancet Oncol. Published online February 28, 2018. Abstract

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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