The way forward in cancer diagnostics and care

Article published in Le Temps, December 3, 2018

In Switzerland, every year more than 35’000 people are diagnosed with cancer; more than 16’000 die of the disease.¹ Globally, cancer causes one in eight deaths. The starting point for care is sobering: the reported efficacy of treatment is as low as 25 per cent across all cancer types. Over 200 cancer types render the disease complex to identify, and hard to treat. Each cancer requires unique diagnosis and treatment.

In spite of all these challenges, the prospect of cancer as a disease that can be managed more like a chronic disease is finally moving into sight. The advent of immunotherapy with checkpoint inhibitors and immune stimulators, targeted therapies with antibodies and radiopharmaceuticals, cancer vaccines, cell therapies, and oncolytic viruses would have been the stuff of science fiction only two decades ago. Now we need to be similarly ambitious about the areas where we still need the step-change such as pancreatic cancer, or diagnostics and screening, and philanthropy is a big part of the solution. The way forward is a smart division of labor with governments and markets.
 

A first problem we need to solve is awareness enabling prevention

Roughly eighty per cent of cancers are now diagnosed in low and middle-income countries. Notwithstanding, our understanding of cancer remains spread very unevenly. There is lots of research on high-income countries but a lot less knowledge about the situation in developing countries.

The single most effective and cheapest way to improve the chance of survival is early discovery. Yet when diagnosed, a patient in a developing nation is likely to suffer from advanced disease. Together, the lack of diagnostics, healthcare professionals including surgeons, and poor infrastructure conspire against the patient’s health. Cultural frameworks sometimes need to be factored in too. For example, the African Union reports that Somalia has one of the lowest levels of awareness for breast cancer on the continent.² Culturally, the disease that attacks vital but private parts of the female body is treated in shame. Plus, most oncologists in Somalia are male. To protect their privacy, victims shy away from seeking medical help until the breast cancer becomes attached to the cloth and starts to discharge. But then it is too late.

Building capacity and a platform for exchange in the global south is a job best done by non-profit organizations, and they need philanthropic support to do so. For example, the Union of International Cancer Control’s (UICC) core vocation is to integrate cancer control into the world health and development agenda. UICC does so by working with its 1’100 members: the world’s major cancer societies, ministries of health, research institutes and patient groups. Next to member contributions, it is philanthropic funding that enables the organization to constantly build capacity by offering new services to their members and act as effective advocates. To bring these insights to the donor community, we recently partnered with UICC to release a new edition of the Lombard Odier Donor’s Guide to Cancer.

Second, we are not done with research

Today’s cancer research infrastructure and talent development has consistently benefitted from the generosity of a wide range of philanthropists, including U.S. shipping magnate Daniel Ludwig, whose Ludwig Cancer Research has committed more than USD 2.5 billion to cancer research since 1971.

While an enormous figure, it can seem small compared to global spending on cancer medicines with therapeutic and supportive care, which rose from USD 96 billion to USD 133 billion from 2013-2017.³ A numbers-only view would however not do justice to the importance of individual genius in engineering the breakthrough against cancer. That’s why at Fondation Philanthropia, among other things, we also finance (post-)doctoral scholarships at Institute Gustave Roussy, one of Europe’s leading cancer research institutes and hospital.

Investing in people is a good idea because one cannot underestimate the power of new, disruptive mindsets in the medical community. Take the advent of the immuno-oncology paradigm. Rather than attacking a patient’s tumor with drugs, immunotherapy seeks to stimulate the human immune system, so it can recognize, attack, and ultimately kill, tumor cells – a task our organisms routinely perform well when they successfully fight bacterial or viral infections. Arcane a decade ago, today, immuno-oncology is the fastest growing segment within the oncology field. Immunotherapy has enabled step changes in treatment, such as Chimeric Antigen Receptor T-Cells (CART), which are engineered receptors that combine a new specificity with an immune cell in order to target cancer cells. The doctor removes T-cells from the patient, genetically alters them, and then puts them back into the patient so they can attack the cancer cells in the body.
 

Advances in genomics will further enable the personalization of such cancer treatment, and 3D cell printing will provide the necessary organoid generation capability, e.g. by printing to mimic organ functions to better predict the effects of novel treatments in humans. As gene editing techniques become industrialized and applied to the oncology space, reprogramming immune cells so they can target and destroy tumor cells will at some point become a standard process.⁴ If it is not the raw talent who once learned the ropes on a Ph.D. or post doc scholarship to crack challenges such as personalized cancer vaccines, identifying via gene sequencing of patients’ tumor cells or priming the patient’s immune response against specific components of cancer cells, then who will?

Third, we need to fix access and cost. Here, philanthropy has a major role to play

With rising spending on healthcare generally placing ever increasing pressure on public budgets and global oncology spend forecast to rise by 53 per cent from 2015 to 2020, the approach to patient care is in urgent need of a fundamental transformation.⁵ Spending is heavily concentrated. The top 35 drugs account for 80 per cent of total spending; on the other hand, over half of cancer drugs have less than USD 90 million in annual sales. List prices of new cancer drugs at launch keep rising: the median annual cost of a new cancer drug launched in 2017 exceeded USD 150,000, compared to USD 79,000 for the new cancer drugs launched in 2013.⁶ New models are needed to keep cost within reason: the forecasted doubling of healthcare expenditure in OECD countries as a share of GDP by 2060 is not financeable on a sustainable basis. Driving access while containing cost necessitates combining new and better drugs and medical devices with the use of real-world data, artificial intelligence and mobile apps to improve patient engagement and therapy targeting. Here again, philanthropy can play a useful role in helping to pilot new solutions. For example, kicked off with philanthropic seed funding, the Romandie Oncology Network has introduced a tumor board: in this formula, doctors and other health care providers with different specialties interact regularly to review cancer cases, and share knowledge to get individual patients the best possible individual cancer treatment and care plan.
 

Contribute to the Breakthrough

Aging, urbanization, and environmental pollution are taking their toll: the incidence of cancer is expected to grow to more than 21 million new cases of cancer worldwide by 2030. This is in part due to population growth and demographics – but also a result of our changing lifestyle and nutrition.

As a consequence, next to doing the same more efficiently we also need breakthrough innovation. Philanthropy and innovative finance will be a part of the solution equation. Philanthropy is at its best when it acts as society’s risk capital; building new institutions of high ambition and scale can be a powerful catalyst to crowd in the market and government. Just consider the advances in the field of infectious diseases that became possible by the creation of the GAVI Alliance and the Global Fund, with the decisive support from the Bill and Melinda Gates Foundation. It is time we be similarly ambitious in the field of cancer.

¹ Swiss Confederation, National Institute for Cancer Epidemiology and Registration, and Swiss Childhood Cancer Registry, 2011, “Cancer in Switzerland: Situation and development from 1983 to 2007.” 
² African Union, 2015, “Breast cancer: The number one killer cancer in Somalia”
³ IQVIA, 2018, “Global Oncology Trends 2018:  Innovation, Expansion and Disruption” Institute Report May 24, 2018 
⁴ Barrangou, Rodolphe, 2015, “The roles of CRISPR-Cas systems in adaptive immunity and beyond” Current Opinion in Immunology, 32: pp. 36-41
⁵ KMPG, 2018, “Future of Oncology”
⁶ IQVIA, 2018, “Global Oncology Trends 2018: Innovation, Expansion and Disruption” Institute Report May 24, 2018