Low- to middle-income countries (LMICs) carry nearly 70% of the global cancer burden according to the World Health Organization (WHO).1 Fragile healthcare systems, inadequate resources and expertise, and high costs have made it difficult to fully implement recent advances in lung cancer care.
During the 2023 World Conference on Lung Cancer, several experts addressed these concerns during Plenary 5: Transforming Discovery into Treatments in Lower- and Middle-Income Regions. The session, which took place Tuesday, September 12, featured presentations on overcoming the barriers that LMICs face across the spectrum of lung cancer care—from diagnosis and biomarker testing to managing early-stage and advanced disease. The session is available on-demand for registered WCLC 23 attendees through December 31.
Mariam Jamal-Hanjani, MD, PhD, Thoracic Medical Oncologist at University College London Cancer Institute, presented the results of TRACERx, a longitudinal study in the UK of more than 800 patients with stage IA–IIIB non-small cell lung cancer (NSCLC). Comprehensive genomic sequencing, clinical data, and multi-site tumor sampling enable researchers to investigate spatial and temporal disease heterogeneity to better understand the biology and evolution of lung cancer.
Dr. Jamal-Hanjani focused on how TRACERx is enabling researchers to map patterns of dissemination and identify traits that make tumor clones more likely to metastasize.
“These types of studies can provide a greater understanding of which cancer cells metastasize and what dictates metastatic potential,” said Dr. Jamal-Hanjani. “TRACERx demonstrates the value of longitudinal sampling to understand how lung cancer evolves in real-time in the context of selection pressure provided by treatments.”
She hopes that studies like TRACERx can help clinicians in LMICs by identifying markers of metastatic potential and poor prognosis to help make treatment decisions and guide drug development in limited-resource settings..
Alan Sihoe, MBBChir, a cardiothoracic surgeon practicing in Hong Kong, discussed advances in surgical treatment. While Dr. Sihoe focused on the surgical management of early-stage disease, he stressed that the principles apply across all treatment modalities.
New technologies and techniques, including robotic-assisted thoracic surgery and next-gen keyhole surgery, have transformed thoracic surgery during the past 10 years. Continued research is under way in areas such as 3D and robotic technologies.
Bringing these newer technologies to LMICs may not be financially feasible in some settings. Surgeons must consider whether newer technologies bring proportionate value in terms of improved outcomes, considering the increase in cost and resources.
Dr. Sihoe’s work has shown that simple, cost-effective changes can improve surgical outcomes just as much, if not more so, than technological improvements. Considering all aspects of surgery—from pre-operative optimization and nutritional supplementation to intra-operative analgesic regimen and post-operative mobilization schedules—can provide substantial improvements in surgical outcomes.
This is not a one-size-fits-all approach. Every institution must tailor their protocols based on their resources and patient needs. When it works well, the improvements in patient outcomes are far greater than anything you would see with technology improvements.”
Dr. Sihoe also discussed how value can also be increased by applying new surgical technologies to broader settings. He used the example of technology reducing post-operative pain allowing for patients to more quickly get to adjuvant therapies and also saw the value added potential of applying new techniques to the ct screening population.
Anil Tibdewal, MD, a thoracic radiation oncologist at Tata Memorial Hospital, Mumbai, India, discussed approaches to oligometastatic disease.
Many LMICs face significant challenges in managing oligometastatic disease, Dr. Tibdewal said. Lack of MRI and PET/CT machines make it difficult to diagnose oligometastatic disease. In addition, many countries do not have enough experienced radiologists. This is especially important in countries with high rates of tuberculosis (TB), where experienced radiologists are needed to differentiate between malignant tumors and TB lesions.
In terms of treatment, lack of availability and long turnaround times for next-generation sequencing can limit the ability of patients to receive targeted therapies. In addition, Dr. Tibdewal stressed that high costs, lack of radiation and surgical expertise, and poor health insurance coverage mean that many patients in LMICs do not receive state-of-the art treatment.
Dr. Tibdewal showed several clinical studies demonstrating the benefit of local consolidation therapy after systemic treatment in patients with oligometastatic disease, but he noted a need for more robust data in LMICs.
“We have real-world evidence showing we can improve progression-free survival by treating oligometastatic disease,” he said. “As a clinician in a lower-middle-income country, I know the importance of generating data in LMICs using our own patient population.”
Dr. Tibdewal called for more robust phase 3 data, particularly in LMICs, increased collaboration with institutions in LMICs, increased patient diversity in clinical trials, and improvements in biomarker testing to better identify oligometastatic disease and stratify patients who are most likely to benefit from treatment..
Finally, Ross Soo, PhD, a senior consultant in the Department of Haematology-Oncology at the National University Cancer Institute Singapore discussed the barriers to novel cancer treatments and clinical trials that LMICs face.
Dr. Soo’s research[1] has shown that rates of pathological diagnoses of NSCLC vary significantly across regions in LMICs, and rates of biomarker testing are often quite low. Access and reimbursement are also significant challenges. Many agents considered standard of care in high-income countries are often not reimbursed in LMICs, he said.
Dr. Soo called for more clinical trials in LMICs. “There is currently an imbalance in cancer research and cancer therapy between LMICs and high-income countries,” Dr. Soo said. “But we’ve seen that clinical trials and research are feasible and impactful in LMICs.”
A 2021 analysis of oncology clinical trials across low/middle and high-income countries showed that randomized-controlled trials in LMICS were more likely to identify effective therapies and have a higher effect size than those conducted in high-income countries. These trials are also less likely to be industry-funded and are more likely to be published in journals with a lower impact factor.
Dr. Soo described several strategies to improve access to novel agents and clinical trials in LMICs across individual, organizational, and national levels. His suggestions include increasing the number of high-quality cancer registries; educational initiatives for healthcare providers and patients; value-based, tiered pricing and compulsory licensing to improve affordability; and strengthening research capacity via training initiatives, partnerships, and improved infrastructure and collaborations.
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