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Dr. Joe Harford is Director of International Affairs of the U.S. National Cancer Institute (NCI), the world's leading cancer research body. In Europe recently to attend an international cancer conference, Dr. Harford visited the PACT programme office to discuss NCI training courses in cancer prevention. Here he talks about the worldwide cancer crisis and NCI's international mission.
Can you tell me about NCI and its international mission?
NCI is the largest cancer research oriented entity in the world. We're part of the U.S. Department of Health and Human Services and the National Institutes of Health. We spend just short of US$5 billion a year on cancer research-related activities. The focus of that covers the entire continuum of cancer, from prevention through early detection, treatment, end of life and palliative care. We have five extra-mural divisions, meaning they give grants to researchers around the world — mainly in the U.S., but we also have foreign grants and contracts. And we have two intramural divisions, meaning those that do research on the campus in Bethesda, Maryland, and on the adjacent campus in Frederick, Maryland. They cover cancer epidemiology and genetics, as well as basic and clinical research.
The International mission is framed in the National Cancer Act, which includes mention of international activities. The framers of the Act recognised that cancer research done anywhere can help people everywhere, including the American people.
We also have a couple of projects that have been characterized as ‘health diplomacy’. Perhaps the most prominent is the Middle East Cancer Consortium. It involves Cyprus, Egypt, Israel, Jordan, the Palestinian Authority, and Turkey and was signed in Geneva in 1996 by the Ministers of Health of each government. We also have an all-Ireland Cancer Consortium that involves Ireland-Northern Ireland and the U.S. through NCI. That activity came directly from the Good Friday Peace Accords. There is an old saying in the Middle East: “The enemy of my enemy is my friend.” All of us have cancer as an enemy and that is a bond of friendship, which can be used effectively to improve overall understanding and put some of the political differences behind us.
Do NCI's international activities focus more on low-income and developing countries?
The amount I mentioned includes foreign grants and foreign contracts, domestic grants and domestic contracts which have a foreign component. It also includes training activities on the NIH campuses. We have about 1000 international visitors each year, for shorter or longer terms. A lot of them are there for two or three years at a time, doing post-doctoral work in the laboratories of the Center for Cancer Research. So, most of our visitors tend to come from higher-income countries. But, having said that, my office tries to build capacity for research in places where it's currently lacking, so that does put the focus on lower-middle income countries. So the international activities of NCI include both high end synergy of research types of activities, as well as building research capacity.
So NCI's 1000 visitors are predominantly research workers?
Yes, the NCI is a research-focused entity, so in that sense there is a distinction between our focus and that of IAEA, which is more on care and building up of infrastructure. Obviously, the two do overlap, because clinical trials are a big part of our portfolio in clinical research, and in order to do clinical trials one must have a clinical infrastructure. So, well trained nurses and well-trained doctors — some of the things the IAEA is focusing on — will, I think, funnel into clinical research.
How serious is the cancer burden in low-income countries?
Already, over half of the cancer burden is in what is referred to as the developing world and that burden is increasing faster than the rate of rise in the developed world. One of the big reasons for this is the uptake of so-called western lifestyles, which involve tobacco use, diet and physical activity.
Lung cancer is now the number one cancer killer of women in the U.S. It's overtaken breast cancer. Overall smoking prevalence has been coming down in the U.S., but there's about a 20 year lag before the benefits of that kick in. There are countries of the world where more than 70% of men and fewer than 5% of women smoke, but that ratio is changing. Therefore there's an opportunity in many developing countries. If we can design and test and implement anti-smoking interventions, especially directed at the female population, we could prevent what's happened in the U.S. and the consequent lung cancer from ravaging these other countries.
I often say that the three most important features of cancer in low and middle income countries is one, late presentation, two, late presentation and three, late presentation. Our progress against cancer in terms of survival improvement in the United States has certainly been aided by improved therapies. But a major component of that improvement and survival is down-sizing or down staging of the tumours to earlier, more treatable stages. That hasn't occurred yet in most developing countries where late presentation is an issue.
How important is cooperation between NCI and other international organizations and agencies?
People tend to think it's a small world because we can get on a plane and fly from here to there. And we think that what happens in one country effects what happens in another. But, in fact, it's not a small world. It's a very large world. And it's a very big job that we have to do in regards to cancer. I don't think there's any one agency or entity that could possibly tackle the job in an effective way on its own. In fact, even collectively we're still having a hard time meeting the growing burden of cancer, which is the result of demographic changes, changes in lifestyle and the like. Even if we pool all of the resources of all of the entities that are working in cancer it's still not sufficient to the task. It's a big, big job.
What is your opinion of the PACT approach to tackling the cancer crisis?
I think the creation of the PACT initiative is to be applauded. It has served to bring together groups to work in a way that they weren't working previously. The notion of anchoring more comprehensive cancer control around places where radiotherapy is being delivered is, I think, a very good idea.
The various partners in the PACT activity each bring different strengths to the table. The IAEA has a long history of working in the area of radiotherapy in these countries. The World Health Organization obviously has a long history of working throughout the world, too. The NCI's focus is research. We believe that if you're going to do effective prevention, if you're going to do effective treatment, if you're going to do effective palliative care, you need to base that on evidence that comes from research.
Are you optimistic that we will eventually beat cancer, or bring it under control?
Cancer is actually a group of diseases that we collectively call cancer. We know, looking at the response of a tumour to, say, chemotherapy, that while it can be very effective in one cancer it may not be so in another. So you have to keep trying to find agents that will work on the various sites. I think we're probably going to move towards a situation where more and more cancers will be treated like a chronic disease. Using the example of diabetes, someone can have diabetes, but it can be under control and can be treated. They can have a normal lifetime and die of something else. In the same way, a person may die with cancer but not from cancer. The progression of the disease is slowed. The distinction between that and a cure is fairly subtle, because the person may have to continue medication or treatment, in the same way that a diabetic continues. NCI's primary role, not just in PACT but overall, is to help contribute to that evidence base upon which health interventions can be based.
In what ways is NCI working together with PACT?
This is the second year of a programme that we initiated with PACT to bring folks nominated by PACT on scholarships to Bethesda for the summer curriculum for cancer prevention. So far, about 20 to 25 individuals have been nominated, not only from the six PACT countries but also other IAEA Member States. We organize their visas, housing etc. and bring them to Bethesda for four weeks of Principles of Cancer Prevention. Some stay on for a fifth week of Molecular Prevention. The four week courses involve 85 lectures in areas of cancer prevention and give participants an opportunity to interact with NCI staff. Just as importantly, I think, it also gives them an opportunity to interact with one another in this context. Bonds are built that will continue as they go back to their home countries. And, within a country, it creates a cadre of like-minded or like-experienced folk in cancer prevention. Ireland is a great example of this. Over the past eight years, Ireland and Northern Ireland have sent close to 200 individuals to this course. And the same can be true of, say, Tanzania. We had three participants from Tanzania last year and maybe another one or two are coming this year. So our major contribution to the PACT activity thus far has been in the area of education and training, in the form of this summer course.
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