Forget Moonshot: Cancer Patients Right Now Need 'Groundshot'

Roxanne Nelson, RN, BSN

June 21, 2022

CHICAGO — While the federally supported "Cancer Moonshot" aims to eradicate cancer in the future, back on Earth, a "groundshot" initiative could tackle issues faced by cancer patients right now — both globally and in the US — by making better use of services that are already available.

The term "cancer groundshot" was coined in 2016 by Bishal Gyawali, MD, PhD, in a blog post written when he was working at Nagoya University, Japan. He then elaborated on it in an opinion piece in 2018 while he was working at Anticancer Fund, in Strombeek-Bever, Belgium.

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, he argued. He explained that the term "groundshot" refers to using cost-effective and proven measures in the prevention and treatment of cancer — on a global scale.

The idea caught on, and Gyawali continued to develop the concept. He is now an associate professor in the Department of Oncology at Queen's University, Kingston, Ontario, Canada.

He was invited to chair a session on the concept at the annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago in June.

Addressing the audience, Gyawali recalled how he first came up with the "groundshot" idea.

In part, it was a reaction to the headlines and hype surrounding the Cancer Moonshot initiative, launched in 2016 under the Obama administration. Its major focus was a high-cost research strategy that included genomics, precision therapy, immunotherapy, and artificial intelligence.

Individuals and institutions began to develop their own versions of Moonshots, aside from the one initiated by the federal government. "But one day, I read a news item about two institutions suing each other because they were debating about who owned the term 'Cancer Moonshot,' " he said.

"We seem to have forgotten the destination and got entangled in the journey itself. It actually does not matter who owns the term 'Moonshot.' What matters is whether we are helping our patients and how better our patients' lives are globally as a result of our efforts," he said.

That was the impetus for his original blog post, in which he proposed a parallel "cancer groundshot" program that would ensure that all interventions are accessible to patients globally. "The philosophy behind cancer groundshot is that we already know several interventions that work ― curative services that work," he said, "but these interventions are not accessible to everyone. Access to proven treatments must therefore parallel development of new therapies."

Gyawali noted that globally, fewer than 25% of patients with cancer are able to receive safe, affordable, or timely surgery, which often is curative. "And sometimes, people argue that we can't spend on building newer surgical facilities," he said. "But actually, it's more expensive not to spend on curative services like surgery."

Another major issue is the lack of access to cancer drugs in low- and middle-income countries (LMICs). Many of the drugs are not approved in these countries, because the industry has less financial incentive. "Most of the low-income countries also do not have the regulatory capacity to assess all of the newer cancer drugs," he explained.

New cancer drugs are expensive, and affordability issues are widespread globally, but in LMICs, even older generic drugs are often out of reach.

In a survey conducted in Nepal among patients with acute leukemia who were receiving treatment in a public government hospital, Gywali and his team found that 87% of patients had to sell their house, land, or livestock to support treatment for acute leukemia. "And 73% of our patients had to sell their property, borrow from friends or relatives, and also had to ask for money from charities," he said. "So the bottom line is that, yes, modern cancer drugs are expensive, but in LMICs, even old generic cancer drugs are unaffordable."

This lack of access to cancer drugs in LMICs is a challenge, and it should be prioritized, he argued. "Participation in clinical trials, in theory, may help improve access to cancer drugs in LMICs, but not all clinical trials are worth participating in.

"LMICs should carefully choose the 'groundshot-type' trials, where the results can change cancer outcomes," he added. "And collaboration and bidirectional learning may be a win-win to both LMICs and high-income countries."

In Your Own Backyard

Barriers to cancer care are not limited to LMICs.

High-income countries such as the United States have their own challenges, noted Robin Yabroff, PhD, MBA, scientific vice president of health services research at the American Cancer Society.

The US leads the world in healthcare spending, but that does not always translate into clinical success. Yabroff highlighted a recent study that compared cancer-related healthcare spending and mortality rates in the United States to those of 20 other high-income countries. The US spent twice as much on cancer care as the average high-income country, but its cancer mortality rates are only slightly better than average.

"I think it really highlights the opportunity for improving cancer care delivery in the United States, which is one reason why I really like this concept of the ground shot of thinking of highly effective but underutilized cancer control interventions," she said.

While there are many underutilized interventions, Yabroff focused on three for which decades of research support their effectiveness: tobacco-control policies, cervical cancer prevention and screening, and health insurance coverage.

However, these interventions vary widely with respect to how they are applied across the United States, and there are striking geographic differences across the country.

Cigarette smoking is currently responsible for about 29% of cancer deaths in the United States, especially from lung cancer, and is linked to 82% of deaths and 81% of cases in the United States, she noted.

Not surprisingly, the highest lung cancer mortality rates are found in the areas where the prevalence of cigarette smoking is highest — the southeastern and midwestern states. "And so when we see patterns like this, it really drives us to think about if there are there state-level policies that potentially are related to what we're seeing in terms of cigarette smoking," she said. "And, in fact, there are a number of effective but underutilized federal and state tobacco control policies, including tobacco advertising bans, health warning labels, comprehensive smoke-free legislation, public smoking restrictions in work sites, restaurants, and bars, and state cigarette excise tax."

Despite recommendations for higher taxes on cigarettes, the average tax is only $1.91. "And in some states, excise tax is under $0.20 a pack, including many of those states with the high prevalence of cigarette smoking," she emphasized.

Cervical cancer is another "groundshot" opportunity because it can largely be prevented or detected early. More than 4000 women still die every year in the United States from an entirely preventable cancer, Yabroff emphasized. She also pointed out that the region with the highest cervical cancer mortality are the southeastern states, similar to that for lung cancer.

Preventive methods are underutilized, such as human papillomavirus (HPV) vaccination, which can prevent almost all cervical cancers as well as a number of other cancers that are caused by HPV infection. "Yet, a recent study showed that 40% of eligible children and adolescents were not up to date with HPV vaccination in 2019," she said. "Screening can identify precancer, prevent invasive cervical cancer, and lead to early-stage disease when diagnosed. However, 16% of eligible women were not up to date with cervical cancer screening in 2019."

Health insurance is a third issue, and perhaps the most important for the US. Before passage of the Affordable Care Act (ACA), almost 50 million people in the US lacked any sort of coverage. One provision of the ACA was with regard to the expansion of Medicaid, but the ACA became highly politicized, and some states opted not to take federal incentives to expand income eligibility. "Medicaid expansion is associated with reduced disparities in cancer stage and survival," she said, but she noted that "as of 2022, 12 states have yet to expand Medicaid income eligibility." Among these 12 states, seven are located in the southeastern part of the country.

"And once again, I want to draw your attention to these states in the southeastern part of the United States. Those are also those states that have high cancer mortality rates, high lung cancer mortality rates, high prevalence of cigarette smoking, and high cervical cancer mortality rates," she said. "So the concern is that there are growing disparities based on residence ― the state of residence and whether you live in a state that opted to expand Medicaid income eligibility or not. And this is a growing disparity that's entirely preventable."

This is "shocking," she emphasized, "especially in a high-income country where we have incredible disparities and we know of effective interventions that can reduce those disparities."

Upside and Downside of Technology

What role does technology have in addressing global cancer challenges? Miriam Claire Mutebi, MMed, MSc, a breast surgical oncologist based at the Aga Khan University Hospital in Nairobi, Kenya, explained that while judicious use of technology is "key," it is also not a panacea for dysfunctional systems.

Kenya has a population of about 44 million. About 90% of the population has phone coverage. "And in contrast to 2021," said Mutebi, "we are seeing about 130% phone penetrance, with 67% of smartphone coverage ― but then how does this translate into the health space and, more specifically, into oncology?"

The COVID pandemic resulted in an exponential increase in telemedicine and telehealth services and an increase in the number of apps for a wide range of services. "There was an increasing acceptance of these modes of healthcare delivery," she said. "And I think one of the silver linings, despite the disruptions caused by lockdowns and continuity of care, there was an exponential increase in the strategies to expand care, with patient navigators using technologies to call patients and find out if they were still adhering to their treatment and taking their medications."

There was a rapid shift to virtual tumor boards and patient support groups and also an increase in the platforms for e-learning for oncology residents and students. Some of the initial responses were very favorable, she said. Residents and students appreciated the convenience of the blended learning models and the ability to tap into the collective expertise of a global faculty. "And interestingly enough, quite a number of patients felt that with the telemedicine models, they had more time with the clinician, and the oncologists were more focused on them rather than trying to clear the queue," she said.

Mutebi cautioned that the downside cannot be ignored. There is a danger that technology can worsen disparities. For example, some patients may not have access to a smartphone or data bundles or a data program. "And perhaps from an education and training perspective, really looking at the loss of some of the haptic skills that you can only get with direct patient interaction," she said. "It is also important to take a step back and evaluate what components are required for having successful technology in the global oncology space.

"However, in keeping with the ethos of the groundshot, we need to look at pragmatic approaches," said Mutebi. "Rather than trying to reinvent the wheel, what are the existing technologies on the ground? And how do we coordinate these efforts so that it is a system effort rather than individual little bits and pieces trying to complement but not necessarily changing or shifting the entire system in the direction that we need it to?"

In summary, Mutebi emphasized that technology "is a double-edged sword and should be used wisely and should be contextualized."

The speakers have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2022: Special session: Cancer Groundshot: Addressing the Global and National Inequities in Cancer Care. Presented June 3, 2022.

Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.

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