The Growing Global Cancer Divide

The Growing Global Cancer Divide

Don Pollard

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The chances that you will get cancer and die from it depend on where you live. In wealthy nations, the war on cancer is far from over, but personalized medicine and novel treatments like immunotherapy have significantly improved cancer survival. The opposite is true in poorer nations, especially in sub-Saharan Africa where cancer deaths are rising fast, including from cancers that are preventable or treatable with routine measures. In advance of World Cancer Day, speakers discuss developments in cancer treatment and prevention, and the prospects for closing the global cancer divide. 

This meeting is made possible by the generous support of Bloomberg Philanthropies.

FINK: Good morning, everybody. Thank you for coming this morning, and welcome to today’s Council on Foreign Relations meeting “The Global Cancer Divide” with Cary Adams and Harold Varmus.

I’m Sheri Fink. I’m a correspondent with the New York Times and I’ll be presiding over today’s discussion.

This meeting is made possible by the generous support of Bloomberg Philanthropies.

So you can read more in your bios, but Cary Adams has come here all the way from Geneva and is the chief executive officer of the Union for International Cancer Council (sic; Control.) And in this role he focuses on global advocacy and uniting the international cancer community to reduce the global cancer divide that we’ll be talking about today and promote greater equity.

Harold Varmus came from a little—a little closer this morning. He’s currently the Lewis Thomas University Professor at the Meyer Cancer Center at Weill Cornell. And he’s also served as the director for the NIH and the National Cancer Institute, during which time—very relevant to our discussion today—he founded the NCI’s Center for Global Health. And Dr. Varmus has also worked on global health issues with a number of international organizations, including the U.N., the World Health Organization, and the Bill and Melinda Gates Foundation.

So we will commence. And I think it would be great just to lay out for us—and many of us may be familiar with this already, but—what is the global cancer divide. Give us a sense of why we need to talk about this today. I know you’re both focused on solutions, but what is the problem?

ADAMS: Go ahead, Harold. Please.

VARMUS: Well, the—if you look at what’s happened to health in poor countries, there’s been what we call an epidemiological transition. There are more people living to advanced age. There’s better control of infectious disease. And as a result, the populations are aging, and people in poor countries and middle-income countries are seeing higher incidence of diseases that are noncommunicable in general—although frequently cancers in these poor countries are caused by infectious agents, but we’ll return to that—and the incidence of cardiovascular disease, diabetes, renal disease, and importantly cancers are rising dramatically. That epidemiological transition, of course, is posing new problems for control of disease in these countries and moving us to expand global health efforts in ways that are nontraditional. Traditionally, we focus on malaria and HIV and tuberculosis and infantile diarrhea and many other infectious diseases. And now the challenge, which has been recognized by the U.N. and by our government and by many others, by organizations that Cary runs, to be a new way of thinking about delivering health care to—and prevention methods to poor countries.

FINK: And, Cary, can you expand on that? Are there any statistics you want to mention, or?

ADAMS: Yeah. So those of you who are familiar with the numbers, I mean, the numbers of cases of cancer increase year on year. Latest figures for last year was 18.1 million new cases and 9.6 million deaths. And the reason the divide is being talked about is because if you go back to 1970, about 15 percent of new cancers were in low- and middle-income countries, and now it’s about 60 percent and it’s growing. It’ll be 70 percent by 2015. And in those countries, where you’re seeing the population growth and you’re seeing the aging and the bypassing of the communicable diseases, what you’re seeing is countries which do not have the infrastructure to actually respond to that dramatic change that we’re seeing over twenty to thirty years. And as a result of that, that means the chances of survival in those countries are much lower than in the developed world, and that’s where the divide is happening. So, unfortunately, the problem that we need to solve is occurring in the place where we can’t solve it, so that’s the challenge.

FINK: So, you know, I think there can be a question or maybe a lot of people’s first question would be, well—two things, I guess. One is we focus a lot of infectious diseases in these countries. You mentioned that, in lower-income countries. Those are still a problem. Those haven’t—we haven’t gotten a handle on them yet, so why think about cancer too?

VARMUS: Well, I think there are a number of answers to that. First of all, there has been a fair reduction in the impact of infectious disease in these countries, so it’s not as though we’re not controlling them. They have come under appreciable control.

The second thing is that we do have methods that can be used to try to reduce cancer mortality. Some of the numbers that Cary was mentioning are particularly impressive because the increases in cancer deaths worldwide are going to—those increases are going to occur almost entirely in low- and middle-income countries, not in the advanced countries, where cancer is still obviously a problem. We all worry about it and we haven’t conquered the number of cancers that exist, but there is an additional reason for thinking very carefully about cancer in a country-by-country manner because, as I’m sure our conversation will reflect, the diversity of cancers encountered in any single country, likely to vary. So one of the most important features of all this is not going to the latest pharmaceutical product, but just trying to understand cancer at a fundamental level in each country and know what is there, what the challenges are, what kinds of preventive strategies and screening strategies and affordable therapeutics are available for the kinds of cancers that are dominant in each of those countries.

FINK: And what would you say about that question, the pushback or people saying, oh, you know, there are these other big problems, and why should we focus on cancer, isn’t that more expensive?

ADAMS: Well, I don’t see it as an either/or. I think, you know, a government of any country has an obligation to look after its health of its citizens. And the fact that the makeup of diseases which those citizens are addressing at any point in time means that the government has to respond to that change.

And, yes, there is—there’s a need to address the communicable diseases. I mean, some countries in Africa, I mean, cancer is the fifth or sixth in terms of the number of deaths per year. But it’s growing rapidly as the population is aging and adopting a lot of Western lifestyles.

So I don’t see it as an either/or. I think it’s a both. And I think it’s been an unnecessarily siloed approach which we have adopted at a global level when actually we’re talking about a human being.

For those of you who have ever been to a palliative care unit anywhere in the world, when you’re sitting there, you know, with someone who’s eighty, ninety, they don’t have one disease. They’ve got diabetes. They’ve got a cancer. They’ve got, you know, a series of problems which are being addressed. And so that’s when it all comes together as a challenge, I think, for society.

There are differences, obviously, between the makeup of the cancers, as you hinted earlier, in developing countries compared to, say, America and Europe. I mean, 25 (percent) to sometimes 40 percent of the cancers will be driven by viruses and infections, and that’s where the problem is very different to address and to some extent a little bit easier to address than—

VARMUS: There are opportunities created by that.

ADAMS: The opportunity is there to make a significant impact in a relatively short period of time because the solutions to the infection- and virus-driven disease—cancers like cervical cancer, stomach cancer, colorectal cancer—they are—liver cancer—they’re in our grasp. We can do something.

VARMUS: And I think we also need to—

FINK: And having to do with prevention as well, right?

VARMUS: Well, that’s what I was going to make a point about, that we need to remember that even the cancers that are most prevalent and the major causes of mortality, lung cancer in particular, are not most effectively battled by using new immunotherapies and the most expensive targeted drugs. Those are definitely advances in this country that matter a great deal to patients who have cancer now, but the biggest single thing we do to reduce mortality from lung cancer is put in programs for cessation of tobacco use. And those programs can actually be financially beneficial to countries if they exert taxation as a means for controlling tobacco use. That has a dual benefit of raising revenues. Can be a difficulty in countries that are producing tobacco for commercial gain, but the savings in health care expenditures can be very significant. And we can attribute in this country where we reduced cancer mortality by about 1 ½ percent a year, almost half of that is—over the last fifty years is due to reduced tobacco use.

FINK: So these are good points. So, first of all, on the prevention side, that can be very cost effective or even financially beneficial. And then you both kind of highlighted something that was interesting. You mentioned very fleetingly palliative care and you mentioned, you know, other benefits of tobacco control. So some of the kinds of infrastructure that you may be building if you’re targeting cancer could be more broadly helpful for other diseases. I think you both made that point.

VARMUS: Well, I think we probably didn’t make it as strongly as we should have about—

FINK Make them. (Laughs.)

VARMUS: And I hold myself responsible for that. But—

ADAMS: I’m happy to let you take the blame for it. It’s OK. (Laughter.) I don’t know what I was saying, so that’s fine.

VARMUS: But we need to recognize that chronic diseases are not just cancer, that cardiovascular disease is actually deeply affected by tobacco use. And when we think about the rise of chronic disease in general—noncommunicable diseases, as the U.N. likes to call them—we need to think about measures that we take that influence not only cancer rates, but rates of other diseases. And certainly high on that list would be cardiovascular disease. Tobacco control has a great impact on reducing those conditions as well.

FINK: And you brought up palliative care, which is, if you’re building that up, then you were saying there are a lot of people who need that, those services.

ADAMS: But I think that it goes broader than just the palliative care space. I mean, the investment’s been put in place for HIV/AIDS, for example, in some low- and middle-income countries. There are a lot of organizations.

Now, building on that core infrastructure to reach out, for example, for childhood cancer, because if you’re interacting with families—with mothers and children—then, of course, that infrastructure can provide services for screening as well as for treatment for other diseases. So it’s not just an enormous expense of putting a radiotherapy machine in place, pathology, surgery, and things like that. You can build on a lot of infrastructure that exists at the moment. This is not just completely incremental.

FINK: And then how do we prevent—you know, if there’s a big push to address cancer, how do you prevent the siloing of those efforts?

VARMUS: Well, I think Cary was raising this issue. You bring in some of the infrastructure that many of these countries lack—pathologists, surgeons in particular—you do—you bring benefit for control of other diseases as well. I’m fond of pointing out how few countries in Africa have adequate surgical provisions—anesthesia machines, people who can conduct general surgery. You don’t need to have someone who’s an expert in taking out the pancreas; what you need is people who can do general surgery. When you do that, you benefit not only a cancer patient who has early cancer and needs removal of part of the colon, but you also provide a means of treating people who’ve had automobile accidents, which are incredibly common in poor countries. You have minor—what might be construed in this country as minor conditions—twisting of the intestine or pneumothorax, common conditions that can be lethal without surgical control. And building that hospital infrastructure is—

FINK: So that’s another example of multiuse.

VARMUS: Right. Exactly.

FINK: And then, also, but—so you—we talked about prevention and then we talked about surgery. So a lot of people might think it’s all about the drugs, right, but it’s—there are other ways to address cancer. You just mentioned two of them.

ADAMS: It’s certainly not about the drugs. I mean, the drugs are very important, and particularly those drugs that are off patent and on the essential medicines list of the World Health Organization’s. They’ve gone through rigorous appraisal to say these drugs work for certain cancers, and we would argue that countries should take that list and basically introduce that into their system, assuming they have the pathology and know what cancer one has and they did the associated—

FINK: Is that a new thing, that WHO includes cancer drugs on its list of essential medicines?

ADAMS: Yes. WHO has an essential medicines list, and there’s a process which we introduced three, four years ago to keep that constantly updated because it hadn’t been updated for about ten or fifteen years. And now, I mean, this year I think there’s five drugs being put forward to be considered to go onto that list, and these are effective drugs addressing the cancers that are more common, and they’re also cost effective. And the majority are off patent, which means that they’re generic and therefore they’re cheaper.

But a lot of low- and middle-income countries look to WHO for their inspiration. So they’ll look at the essential technologies list, which is a new list that came out two years ago which says what technology you should have to address cancer. And also, they look at this essential medicines list, and that provides them with a sensible baseline to start. And I agree that it’s not appropriate for them to go for the latest immunotherapy, but certainly they should have the basic drugs in there, including for example something like morphine—

VARMUS: Sure.

ADAMS: —you know, which 92 percent of the world’s morphine is only received by, like 10, 15 percent of the world’s population, and it’s just not available. And for those of you who have been close to a loved one in the last few weeks of dying of cancer, you probably couldn’t imagine that happening without morphine. I mean, it’s just—it would be impossible. But the vast majority of deaths that occur through cancer in low- and middle-income countries, there is no opioids or morphine or basic palliative care available.

VARMUS: But I also think that we ought to be taking some of these newer drugs and pushing hard on the drug industry to make them available in—at low cost when they are demonstrated to be effective.

FINK: Are there examples of where that has happened with cancer drugs?

VARMUS: Well, I think you could—I find it useful to look at what we’ve done in the control of AIDS through PEPFAR—PEPFAR, the—President Bush’s President’s Emergency Fund for AIDS Relief. There was a lot of reluctance to think that in poor countries in the world you’d get people willing and able to take complicated antiretroviral therapies on a complex schedule, but in fact adherence was very high. Companies were willing to work to restrict these—the low-cost versions of these drugs to poor countries. And this has made a tremendous change in the health in actually the most deeply affected African countries.

FINK: Right. And there were deals to make drugs lower.

VARMUS: Yes, absolutely. And that—

FINK: But are there examples yet with cancer?

VARMUS: I think it’s—you got to look at the history of cancer drugs in a—in a more historical fashion. So in the 1960s there were efforts made in Uganda to try to study cancer, and one of the cancers that was discovered was a cancer called Burkitt’s lymphoma which affects children usually under the age of six or so and manifests by a large lymphoma growing usually in the jaw or near the jaw. And it turned out that one of the very first chemotherapy drugs, Cytoxan, was remarkably effective. And Uganda became a site—Uganda, Tanzania, a few other local countries—became sites where the National Cancer Institute went to learn how to use chemotherapies in these—in these poor populations. Now, that drug initially was—

FINK: But did the population actually have access to it outside of the trial?

VARMUS: Yes. This drug now, of course, is long off patent and rather inexpensive, so it’s a good example of one of those drugs that are—

FINK: I just want to go back—

ADAMS: Another example is I think each of the pharma companies have access programs for their core drugs in low- and middle-income countries and price differentials. And actually, a couple of years ago, rather impressively, the pharma industry came together a brand called Access Accelerated and made a joint commitment to help get drugs in, get medicines into lower-and-middle-income countries and to beat down some of those barriers. And we’ve been working with that organization for the last two years to make that happen.

So I think, you know, we shouldn’t discount, you know, the actions of the private sector in trying to resolve the problem, but they can’t do it on their own. You have to get government engagement. If you don’t get government engagement, national cancer control plan, commitment to registries, investment, and pathology, all of those, really the drugs don’t mean much.

FINK: Right. And just to go back because I want to make sure to be clear. So the WHO is considering adding these to its list or already has added some?

ADAMS: It adds every year. There’s a submission process—

FINK: But there are cancer—

ADAMS: There’s a submission and there’s, I think, about forty drugs on that now.

VARMUS: Yes. Many of them are chemotherapies. You know, chemotherapies are difficult drugs. They sometimes cause dire side effects. But they are often very effective. And then there are drugs like imatinib, known as Gleevec, which will—is about to come off patent, but can be negotiated to be delivered at relatively low cost. That is a lifesaving drug. It changes a disease that affects several thousand people in this country, probably a hundred thousand, fifty thousand worldwide, chronic myeloid leukemia, into a disorder that doesn’t change life expectancy. And that drug will be made available if it’s on your essential medicines list.

ADAMS: But I don’t think we should go down the medicines line completely.

VARMUS: No, and I—

FINK: Yes. OK, right. So we’ve talked about—

ADAMS: Fifty percent—50 percent of cancers need to have radiotherapy.

FINK: Right.

VARMUS: And one that we have not talked about, for example—

FINK: So prevention, prevention, we’ve talked about surgery and you just brought up radiotherapy. Do you want to say more about that?

ADAMS: Let Harold go first.

VARMUS: Well, I think I want to come back to this question that both Cary and I have alluded to, which is that whereas in this country, a relatively small number of cancers are related to infection, that in poor countries, between 10 and 30 percent of cancers are related to infection.

FINK: So those would be cervical?

VARMUS: Well, let me just dissect this a little bit. So, yes, some directly caused by viruses, like hepatitis B virus, for which we do have a vaccine. The most important thing that I think both Cary and I would like to emphasize is the opportunity presented by human papilloma viruses which are responsible for almost all cases of cervical cancer, which is a cause of one of the two leading causes of mortality among women, breast cancer and cervical cancer. And there is an opportunity because we have an excellent vaccine that right now is priced normally too high for most poor countries to afford, but can be made affordable through programs like the Global Alliance for Vaccines and Immunizations, can be made affordable by concerted efforts that come from advocacy groups, from countries that are willing to make investments in global health. And that can basically reduce cervical cancer rates dramatically and in conjunction with some low-cost screening methods and surgery for early-diagnosed cancers can reduce one of the major causes of death in poor countries to virtually zero.

FINK: Great examples.

Do you want to talk about radiotherapy?

ADAMS: Yeah. I was just going to make the point that 50 percent of cancers require radiotherapy. And radiotherapy unfortunately is not available in low-and-middle-income countries generally. There are many countries that have one machine or two machines and they don’t have the technical capacity to actually work these machines as well.

But again, looking at where the industry is going—because there’s basically only three big producers of radiotherapy: Varian, Elekta, and Accuray. And Varian a couple of years ago launched a much smaller, less powerful machine, which is more effective, which is being produced directly to go into low-and-middle-income countries. So that’s a great example of where they see a commercial opportunity to solve a problem that we need solved.

So, again, governments need to buy them, they’ve got to get their capital to actually buy them. They’ve got to put the infrastructure around it to make it work, build it, and the bunker, everything else. But I do see that there is a movement to actually solve the problem of radiotherapy in low-and-middle-income countries.

FINK: What are—before we get to solutions, because I want to talk about some more and you’re peppering them in your answers, which is great—but what would each of you say is the biggest obstacle to addressing this cancer divide?

VARMUS: Well, I think it’s—I think you’ve got to dissect the problem a little more carefully and talk about what is the cause of high-end cancer rates in different countries, so the problem does vary. Some places, you’d say getting HPV vaccine, human papilloma virus vaccine, into use would be one of the most important things you could do to effect some control.

FINK: But obstacles, like, what’s stopping it from—what’s stopping us from having less inequity?

VARMUS: Fundamentally, the most difficult problems are having enough trained doctors on the ground to make accurate diagnoses, and that includes pathologists, people who can deliver treatment. The second thing, just general resources and attention by national governments. Cary mentioned earlier the importance of having national cancer plans. Many countries have them, but they’re really not very good plans because they really haven’t carefully taken into consideration what the—what the cancers are in that country because they don’t have pathologists, they don’t have—so it’s very hard to put your finger on one thing.

Getting national support and international collaboration to help countries deal with the problem, political commitment to saying yes, we have cancer in this country and we can do some things about it, both prevention and treatment, that we give hope to people. We have—we get some easy successes, and there are some relatively easy successes that can be had, you know, inspires people to say yes, we can improve our health systems in fairly fundamental ways. But laying out a plan with political commitment to do something about it, developing some partnerships.

The National Cancer Institute, for example, depends very heavily on the motivation at virtually every NCI designated cancer center in this country to develop some relationship with hospitals in other countries. There are hundreds of projects being undertaken abroad.

FINK: So we’re going to get to the solutions, but what’s your one—

VARMUS: Yeah. Yeah. It’s hard to divide the solutions from the problems.

FINK: That’s just one obstacle. What’s your one obstacle?

ADAMS: My one—I’ve been taught never to say “the one thing.” So I’m going to say I’m going to echo—

FINK: Good. You’re both resisting the challenge, that’s good.

ADAMS: I resist it, yeah. You can’t get me to do one. I’m going to do one at the end if I feel like it, but I’m not going to do it now. (Laughter.)

Without doubt, political will. Political will is so important. If the government backs it, irrespective of low-income country or middle-income country, if they back it, either they can fund it or they can find funding for it from the international community, but they’ve got to have a good plan.

FINK: Why is there a lack of political will?

ADAMS: Why is there—

FINK: Lack of political will.

ADAMS: Well, I think I would say that there’s a growing political will. I mean, the context of where we are today compared to ten years ago when I first came into this space, ten years ago, the number and quality of national cancer control plans around the world was not particularly good, the investment was not particularly good. But the NCD movement over the—that’s noncommunicable disease movement—over the last ten years with a series of quite large commitments being taken by all countries at the U.N. here, but also at the World Health Assembly, has raised the temperature on what are you doing about it and, you know, you should have a plan. And not just at the global level, but it’s actually inspired cancer organizations in country to advocate for, well, hold on a minute, you signed up for the World Health Assembly on the cancer resolution last year, where’s our plan, we should have a plan, you’ve got to do something. So I think that—

FINK: More accountability then.

ADAMS: There’s more accountability. And the quality of that plan, we reviewed something like a hundred and thirty plans at the end of last year. And we could see an improvement in the quality from the previous review over a five, ten-year period. There’s definitely more engagement from governments. They see it as a growing problem. They recognize there’s international support available through international organizations, like my own and others. And they are investing more because they see that—they know how to invest.

So they’ve learned from what’s happened in the development. They know there’s vaccinations available. These weren’t available twenty years ago. They know—

FINK: And are we seeing—are we seeing any—

VARMUS: So we did have HPV, human papilloma virus, vaccine—sorry, sorry, we did have hepatitis B vaccine.

ADAMS: Yeah, but not HPV.

VARMUS: Right.

ADAMS: So, yeah.

FINK: Are we—are we seeing any numbers, though? Are we seeing any—kind of just ask you to—

VARMUS: If there were—if there were one thing—if there were one thing, I would say it’s reluctance for governments to take on tobacco control.

FINK: You had—you had ten things. (Chuckles.)

VARMUS: Well, but if there were one thing to put at the top that we haven’t mentioned.

FINK: Tobacco, OK. But getting back to the—

ADAMS: I was going to say that as my end.

VARMUS: Oh, go. Sorry, sorry, sorry, sorry.

ADAMS: You shot me down. That was going to be my one thing. We can share the one thing.

FINK: But you both had a chance to give your one things, now you’re coming in with your one things?

ADAMS: No, no, because I was going to say at the end, because I want to get—I think the political engagement is on point because the political engagement requires country-to-country engagement and that’s where the U.S. comes in in longer term to help support those governments because that’s the relationships that we want in place.

But my one—my one thing, OK—(laughter)—

VARMUS: Our one thing.

ADAMS: I feel pressure to do this—our one thing is the issue—

FINK: It’s silly to ask for one thing.

ADAMS: —is the issue of tobacco, is the issue of tobacco. We, as a—as a community, as a generation, are allowing—while we’re doing all this hard work to get cancer control plans in place, vaccinations down to a certain price, getting screening in place, we are allowing the industry to go into low-and-middle-income countries and kill people. That’s what we’re allowing.

VARMUS: And it’s not just going into. I mean, Indonesia, almost 65 percent of men smoke. And, of course, Indonesia has an economy that’s partly based on tobacco production and cigarette production. They supply tobacco to lots of places in the world. So getting government the commitment to combat tobacco use is not the easiest sell.

ADAMS: Yeah, it’s not complicated, but it is something which, you know, the community itself in that country has to argue against.

And I look at Jordan, for example, where my president, Princess Dina Mired, who’s the president of my organization, she resigned, and the King Hussein Cancer Center, which didn’t exist fifteen, twenty years ago, is absolutely fantastic and can cope with the cancer burden of that country in its entirety at top-quality level. But at the same time, they have smoking rates of 70 percent. So there’s a dilemma in the country. You know, you created something and then you’re, you know, overwhelming it with demand in the future from a—from a cancer which currently is not very easy to treat, but very expensive.

FINK: Right. So we’re going to go to questions in just a moment, but I just wanted to ask, are there—are there some places where we’re seeing numbers suggest that the battle is starting to be won or that the divide is starting to go down? Are there some places you would point to where not only in sort of implementation of some of these steps, but where we’re actually seeing better numbers, better outcomes, fewer deaths, however you want to measure it? But what would be—

VARMUS: I think your emphasis on—

FINK: Pick your one place.

ADAMS: The one place.

VARMUS: Your emphasis on the—on the kinds of measures, important because there are lots of ways to do these measurements. In Rwanda, for example, the uptake of human papilloma virus vaccine is higher than it is in the U.S. and that’s because the government has really bought into it, they have organized vaccination programs, they have support for low-cost vaccine, and the rates are remarkably high and I’m quite convinced that we’ll see over the next twenty years a remarkable decline in mortality from cervical cancer as a result. So that’s one way to measure things.

ADAMS: I think it’s difficult with cancer to say, you know, you do that and it’s all solved. I mean, we know the incubation period, for example, on tobacco use and lung cancer is twenty, thirty years. Vaccination, the value of cervical cancer—the impact on cervical cancer of HPV is ten, twenty, thirty years in advance. So you’ve got to look at the early indicators. Are there countries who are clearly on a pathway to an improved life and healthy society in the future? And there are.

I would use Zambia as an example. Got a great plan, put in place registries, investing in the plan through to 2021, doing a screening, vaccination programs. All the early work they’re putting in now will yield benefits because the science and the evidence supports that. So I think it’s important to look at the decisions being taken today by governments around the world and say, will it lead to a reduction in incidence potentially? It depends on the growth of the population, the age of the population. Will it improve the mortality incidence ratio? I think it will, so more people will survive.

So sort of, you know, that being at .78, you might get down to .38, which is Australia or .42, which is America. Can we do that so that, you know, the vast majority of people survive a cancer rather than die from it?

FINK: And having good mechanisms—

ADAMS: And I think the preconditions are being put in place by many countries.

VARMUS: Maybe we should point to our own country.

FINK: Right. Having good mechanisms, too.

VARMUS: You know, in our own country, we reduced tobaccos incidence—tobacco use from about 42 percent in the 1960s to under 20 percent now. And that reduction accounts for almost half of the reduction in age-adjusted mortality from cancer overall, even though the major effects are on lung cancer.

FINK: That’s powerful. And then you both raised numbers. To have numbers, you have to also do research and be able to track these things.

VARMUS: You have to have national commitment, which Cary mentioned earlier, to do registries, to make diagnoses, and gather the numbers and see what the consequences of these measures are.

ADAMS: And let me give you an example of that. So in Chile, they put in the registries—this is working and has been many years—but they’ve got gallbladder cancer in women at 12.8 women per one hundred thousand when the global average is 2.8. So imagine, when you’ve got that data coming through, you can then build a response which is absolutely uniquely qualified to solve the problem you face as a country. And that applies to whether it’s in Taiwan where you’ve got the—(inaudible)—where they’ve got oral cancers.

You know, once you’ve got the data, then you can decide what the response will be and you’ll be far more effective in investing in the right services to support your people.

FINK: That’s a very good point, the variability in which cancers you want to be targeting.

VARMUS: Yeah. It doesn’t mean you solve these problems because the problem in Chile continues.

But I think the other thing that we haven’t spoken much about is international cooperation to try to deal with these problems. And a good example raised by—a point you stimulated with your comment just a moment ago, that in East Africa there’s now a very high incidence of esophageal cancer. And investigators and clinicians from a wide variety of countries have built an esophageal African cancer consortium which, you know, represents a step in the right direction. It’s not—it doesn’t mean that we have solved the problem, but having concentrated attention paid to this high rate of esophageal cancer is going to lead to improvements.

FINK: That’s great.

I’d like to open it up now. At this time, I’d like to invite members to join our conversation with your questions. And a reminder, this meeting is on the record. Wait for the microphone, speak directly into it. Please stand, state your name and affiliation. Please limit yourself to one question and—(laughter)—see, one question, and keep it concise to allow as many members as possible to speak.

So wow, OK. How about back there please?

Q: Good morning. Thank you for an interesting talk. I’m Ruth Oratz from NYU Langone Cancer Center.

Women’s cancers present a major public health issue. Women are 50 percent of the population. Breast cancer, as we know, is the most common cancer in women. And yet, in some of the countries we’re talking about, I think there’s another significant barrier to taking care of women with breast cancer, and that is awareness and education. In many parts of the world, women are unaware of the signs and symptoms of breast cancer, there’s inadequate screening, they don’t have access to simple diagnostic tools. And we do have for probably half of the breast cancers simple oral medicines that could be very effective.

I’m aware of a lot of on-the-ground NGO and private organizations to try and raise awareness and educate women around the world, but can you talk about some of the political and more organized global efforts to address breast cancer worldwide?

VARMUS: Do you want to start?

ADAMS: I can start that. I agree entirely with you. And this is a—it’s not just breast cancer. It is most cancers, there’s a lack of awareness of the symptoms, the signs. There are cultural barriers which prevent individuals even wanting to declare that they have cancer because they are shunned by society, male or female. And it’s a cultural issue beyond just being a medical issue. So I agree entirely with what you said.

I think the case study I would use at a national level—and then I’ll talk more broadly about the international initiatives—was, as I said, when Jordan put its King Hussein Cancer Center in place, Princess Dina always talks of the story about, you know, they put the cancer center in place, they built it up, the competence, they worked with St. Jude’s in the USA, they got fantastic training, education, pathology, got the kitty and the money, everything. And about 70 percent of all women turning up with breast cancer turned up stage three, four. And as a result of that, it was very depressing.

And Princess Dina and her foundation and many others decided to reach out to the community to change the culture of society because women were presenting because there were sudden concerns about whether they would continue to be married, whether their daughter would be married in the future, if someone else could touch their breasts and would their husband allow. A whole series of things which are not specific to Jordan, they’re quite common in the region and beyond.

And by reaching out into the community and running a breast cancer awareness campaign for many, many years, they’ve now got the presentation level to stage one, two at about 70 percent, which means far more women survive, fare more advocates, far more fundraising. And it has a complete cycle, it really has made a big difference.

In terms of the international organizations and breast cancer, there are many. And actually, most countries that we have a member in, a cancer organization, breast cancer features as a major part of their work. So I think there’s a lot of international awareness as well as awareness within countries on this. And I do see it as an opportunity where, particularly on this cancer, where the major difficulty is not necessarily the treatment, it’s the presentation level. If we can get three, four down to one, two, then there will be a lot of people surviving the disease.

VARMUS: Yeah. I obviously concur with all the things that you’ve just heard.

There is also room for technical improvement, for making more accurate diagnoses. Mammography is obviously a tool that can be more usefully employed. There are new efforts to use sonograms to try to make better diagnoses earlier on. Because moving from stage three and four to early-stage cancer is obviously critical. You do that, you obviously need to have surgical support. And in some of the Middle Eastern countries, that exists, but in many of the poorest countries in the world, you don’t have the necessary surgical support for taking care of these—of these patients.

FINK: Yes?

Q: Hi. I’m Eugene Huang, I’m with the Council on Foreign Relations.

Both of you identified the issue of tobacco use as a cause of this global cancer divide. But I was struck by the fact that neither of you mentioned or even alluded to the environmental factors, like pollution. I was curious, to what extent—

ADAMS: Sorry?

Q: Pollution.

FINK: Pollution.

Q: To what extent that this divide reflects the divide in terms of access to clean water, air, and safe food.

VARMUS: I think you have a hard time convincing most people that we have identified elements in water, for example, that are responsible for cancers. There is one clear example and that’s schistosomiasis, which is a very rare cause of cancer worldwide. But in general, while people obviously would like to have clean water and clean air for many reasons, the link to cancer is, in my view, not as strong as it is as strong as the link to smoking, to heredity. We haven’t talked about some of the more sophisticated approaches to anticipating the need for prevention based on risk factors, but that is a major factor in this country and will be abroad as well.

So while I’m completely supportive of the idea of having clean water mainly to reduce the risk of childhood infections from gastrointestinal disease, for example, from contaminated water, the link to contaminants and water and cancer is not well established, in my view.

ADAMS: Can I just answer as well?

FINK: Right there. Oh, sure.

ADAMS: There is a report that’s come out, I think last week from (Lancet ?) and the (inner-city ?) alliance on the environment and air quality and NCDs more generally, because it’s not just the lung cancer, it’s lung disease, heart disease, COPD, things like that. So I think there’s a lot more focus on that.

Now, whether you can say that’s a driver of the divide, I’m not too sure.

VARMUS: I wouldn’t say so.

ADAMS: I would probably say not.

I think it’s just unfortunately there are some major cities in the world that have awful air quality. But in the big numbers and the big scheme of things, I don’t think it really changes it too much.

VARMUS: But we did—we should emphasize that chronic obstructive lung disease is one of the major chronic diseases that’s accounting for this increased burden of disease that’s related to noninfectious causes.

FINK: Go ahead.

Q: Hi. I’m Craig Charney of Charney Research.

Dr. Varmus, I have to say I was stunned by that response because while you chose to focus on water, you seem to be neglecting the fact that air pollution is not only extremely severe in many of the newly industrialized cities, but that there are published estimates of the excess mortality that is associated with it.

In addition, what hasn’t been mentioned thus far is occupational safety and health. Because in fact, with the massive growth in the working class of these countries and of industry, when industrial protections remain primitive and the enforcement of such laws, as I saw when I worked in South Africa, are virtually nonexistent, workers are exposed to extremely high concentrations of toxic and cancer-causing chemicals as well.

So I’m wondering if what we’ve just seen actually is one of the other causes, namely a tendency on the part of the medical establishment to look away from some of the industrial causes of cancer.

FINK: What say you? (Laughter.)

VARMUS: Well, I would—I’m not—I’m not debunking the idea that there is a relationship between industrial pollutants and chronic lung disease. But I think that the evidence for—we’re talking here about cancer primarily and the link of those two, cancer is much less well established, if established at all, than the link to use of tobacco.

Q: (Off mic.)

VARMUS: Well, which ones do you mean? I mean, there certainly is exposure to asbestos is a huge problem, minimized in this country because of asbestos control, but historically a big one.

FINK: Right, with the link to mesothelioma, a specific cancer.

VARMUS: Right, sure, of course. But that was not the question.

FINK: But not lung cancer, not, like, industrial pollutants are not contributing to lung cancers, other types of lung cancers?

VARMUS: The evidence—you may know the evidence better than I do, but the—but the link to tobacco is extremely well established, the link to specific pollutants much less well so.

FINK: Do you want to add anything?

ADAMS: I’m not familiar with the research on that. And I would—I would suggest that if it is a particular issue in South Africa, I would hope that the cancer organization in South Africa is aware of it and therefore talking to the government about how to resolve it. But I’m not aware of any specific research in that area.

FINK: Thanks. Yes. Back there please? Then you.

Q: (Off mic.)

FINK: Oh, please wait for the microphone.

Q: Yes, thank you. Hi. I’m Joan Kaufman from the Schwarzman Scholars program and Harvard Medical School.

And I have a question about, you know, what’s happening with, you know, advances in genomics and the big data, AI, and high throughput analysis, you know, which is, to some degree, changing the field of pathology and may obviate the need for, you know, surgical facilities in some countries where it’s very hard to find surgeons and pathologists, but you can do a saliva test and, you know, do, you know—

VARMUS: Yes. I’m happy to speak to that, yes.

Q: Yeah. And, you know, that seems like it’s going to really change the field of diagnosis of cancer in many places in the world, you know, sort of an easier reach in some way than other types, training medical workers and things like that. So could you talk to where the—where the cancer diagnosis field is going through these types of, you know, mobile technologies, the advances in genomics, high throughput data, and all that stuff? Thanks.

VARMUS: Sure, happy to do that. Yeah. No, one of my jobs here is in the New York Genome Center and I’m deeply involved myself in relationship of genetic variation in cancer. And I think we first of all need to make some distinctions between the inherited genetic risks that people have that can be determined by looking at the DNA of normal people that don’t have cancer to assess their risks of certain kinds of cancer. And we know that there are genes that predispose to colon cancer and mutations that predispose to breast cancer and ovarian cancer and so forth. And those are important.

The other set of genetic alterations that are incredibly important in establishing a diagnosis, as you’re pointing out, are the mutations that occur during life that account for the vast majority of cancers that we see in response to the natural immunogenic events that occur as we live our long lives and changes that occur as a result of exposure to the mutagenic factors present, for example, in tobacco smoke. And those are, as you say, deeply influencing diagnosis.

If you take a patient with lung cancer, anywhere in the world, most profoundly looked at in the U.S. and Europe, you can take a diagnosis that was once meant—once made under the microscope to be adenocarcinoma of the lung and say this is an adenocarcinoma with a mutation in gene X, Y, or Z for which therapies will differ. So these are incredibly important developments. And happily, while the preponderance of the evidence thus far does come from U.S. and Europe, happily many other countries are involved in taking on these challenges. And there is data now in relatively small amounts coming from many countries around the world, especially from those that do have an advanced scientific infrastructure—India, China, and parts of South America, for example.

How is that going to change the need for surgeons and pathologists? Not tremendously in the beginning. We’re still going to need the fundamental tools that are used to treat cancer and to anticipate the need for surveillance.

At the New York Genome Center, for example, we’re undertaking a new project trying to address the risk factors that account for cancers in the understudied ethnic populations. So I think there is a response in the scientific community to do all this. It is expensive. It’s hard to translate into changes in care immediately. And there, I think from both Cary’s point of view and mine, there are many things we need to do in the poorest countries right now that we can’t wait for the full flowering of the genetic approach.

FINK: But I think—I think there might be two different things that you’re talking about here. One is getting, like, very into the personalized characteristics of a particular tumor and how you might use a particular approach to treat it. But then it seemed to me you were getting at some possibilities of more like rapid diagnostics or things that—

VARMUS: Well, that’s phase two. You’ve got to understand what the—what the analysis that you may make with a—you know, with a handheld—

FINK: But are there—yeah, is there something like that now?

VARMUS: It’s not available yet.

FINK: OK.

VARMUS: You can obviously take a blood sample quite easily, but you have to have a place to take that blood sample and do the analysis. And blood is not the only thing. There is an advanced technology that is coming into use in the U.S. and Europe of taking samples from blood where you can see circulating tumor DNA, and follow the course of infection—a course of treatment, and perhaps even make early diagnosis ultimately.

That’s a very advanced technology but, really, most of the DNA-based diagnostics are involved with analysis of tumors themselves.

FINK: So you’re still having to go in, do the surgery, and look at that.

VARMUS: Well, do a biopsy, but nevertheless, that is something that is not going to be available in the near future.

FINK: Did you want to add—Cary wants to add something.

ADAMS: Yeah, I’d take that question in a slightly different direction in that what we’ve seen over the last few years is the use of, I mean, very basic things like iPhones in the hands of community nurses who are able to therefore offer earlier diagnosis to get someone into the system in a community setting, get them into the city.

That’s a very simple use of technology, and it seems like quite—

FINK: How does it work?

ADAMS: Oh, basically it just—it provides—I think the application has loads of questions and answers, and you go through it, and it says this person should be referred. I mean, it’s that simple because you can’t get, you know, primary health care out into rural environments.

VARMUS: Let’s be clear. You’re not using that for DNA sequence-based diagnostics, no.

ADAMS: No, not at all, not at all. That’s why I’m saying—

VARMUS: There are—there are simpler tools for diagnosing infectious disease and malaria.

ADAMS: I’m taking a slightly different direction. Are we seeing—

VARMUS: Yeah, but I want to answer her question. (Laughs.)

ADAMS: —the use of technology in actually helping low- and middle-income countries, and that’s one example. Another example would be the remote pathology is certainly something we’ve seen, and we know that the American Society of Clinical Pathology, for example, are helping some cities around the world by introducing that. So it goes through to them. I don’t know the technology—

VARMUS: Well, the—

 FINK: Tell us about—

ADAMS: I don’t know the technology of that.

FINK: Tell us how that works—

ADAMS: I don’t know the technology of that.

FINK: —because that sounds very interesting. So basically I’m imagining that that would be—you know, a sample would be taken somewhere, and then you could image it, and then it would be read by somebody at a distance. Is that the idea?

VARMUS: Oh yes.

ADAMS: Yes.

VARMUS: It’s called telepathology.

ADAMS: Yeah—

VARMUS: I was at the hospital in Rwanda and they were—we were looking at a slide in Rwanda, and someone sitting at the Mass General Hospital was on the phone looking at the same slide. And this kind of thing, you know, it’s still specialized, it’s not practiced everywhere, but it does reflect a potential to expand—

ADAMS: It does.

FINK: Well, I was going to say—

ADAMS: And I think—I hope that was the point you were trying to make.

FINK: —but that—they have been talking about that for—

ADAMS: I may have misunderstood, but I—that’s the point you’re trying to make, that we don’t have to put in place the developed countries’ system, and processes, and training.

VARMUS: Right.

ADAMS: We can deliver a lot of that remotely because of technology, and that does give me hope that now we can put what would notionally be someone who is not overly qualified to become better understanding of the situation therein.

VARMUS: But—

FINK: That has been talked about for so many years. How come it—

VARMUS: Yeah.

ADAMS: Yeah.

VARMUS: That’s the point that I was going to make—

FINK: (Laughs.) How come it’s—

VARMUS: —that for twenty years the Gates Foundation has been interested in handheld diagnostics and making these rapid-in-the-field diagnoses, and I think, you know, the technology is there to try to develop, and in some instances it’s happening, but it’s slow, very slow, and I don’t want to give the impression that now it’s possible to go out in the field and diagnose early-stage lung cancer with a handheld device. It just doesn’t happen.

ADAMS: It’s not going to happen.

FINK: Yes. And the mic is coming.

Q: Yes, quackery complicates cancer prevention and treatment in the U.S. I wonder if you would give us a little bit of a tour of quackery around the world and how it affects meeting your objectives.

ADAMS: It’s a word I don’t understand. What does quackery mean? (Laughter.)

VARMUS: Come on.

ADAMS: This is an American word I don’t understand. Explain what you mean—please explain.

Q: Well, there are a lot of beliefs about causes of cancer and treatments of cancer—

ADAMS: Oh, yeah.

Q: —which are widely used, widely believed, but are thought to be ineffective by people at Memorial Sloan Kettering. (Laughter.)

ADAMS: Well, I—we have to be respectful for the different ways in which different cultures address cancer. We were in Malaysia for the World Cancer Congress last year, and we ran sessions on complementary medicines, which are traditional medicines helping and supporting chemotherapy, radiotherapy, and the value they bring. They were very interesting sessions. We’re not discounting them, but at the end of the day, at UICC, we’d like to revert to science and evidence, and that’s where we go.

But there are certainly a lot of different ways in which different cultures around the world try to bring in older complementary medicines or traditional medicines into treatment of cancers.

VARMUS: But Jesse (sp) is worried about whether they work, and we do need to examine whether they are effective because we don’t want to be making investments in these things. You know, it’s—I understand the need to respect traditional medicines and try to test the ones that do show some level of promise but, you know, the financial motivations, the preying on people who are dying of cancer gives a result of heartbreak and bankruptcy.

FINK: But turn that upside down. Is there any pushback in some countries against what we would consider here effective treatment? Like are there—is there a fear of quackery—

ADAMS: I think it’s more the price which is the pushback; it’s not actually the whether it works or not. It’s the cost which is the barrier for most countries to take on the latest drugs and things like that, so it’s not that they don’t believe; it’s just that—

VARMUS: No, I think what she’s asking is whether other countries are committed to combatting the quackery, and I would say—

FINK: No, no, I think—I was asking more just—there’s such a lack of trust in health systems in many countries and fears that if you’re going to vaccinate me with the HPV vaccine that you’re going to be infecting me with something, or like how much is there a desire to not—

VARMUS: The cost is much more of a problem.

ADAMS: Yeah, the cost is the more—there is—there is pushback around the world on HPV, but I think that is reducing over time as the evidence mounts that actually there is no negative consequences.

VARMUS: And it is important to point out there—

FINK: There was pushback here, too—

VARMUS: —there are—well, there’s—

FINK: —at first.

VARMUS: —pushback at the individual level because there’s an anti-vax movement and they—often parents are presented with the option of what seems to be vaccinating your kids against something that they are going to contract through sex, as though—

FINK: As though you are encouraging—yeah.

VARMUS: Right, so instead of saying, do you want to protect your daughter against cervical cancer and your son against oropharyngeal caused by these viruses, this is presented as a way of combatting the result of a sexual contact which their children, of course, will not have until they are married and happy.

FINK: Right. (Laughs.)

OK, let’s get some more. You over there.

VARMUS: Our own cultural barriers.

Q: Henry Greenberg, Mailman School.

Going back to tobacco, with e-cigarettes that satisfy the addict and do not cause chronic disease, wouldn’t be a wonderful leadership step by the United States to ban combustible tobacco and just end it? Let the addict use e-cigarettes, no mob emerges like in Prohibition—

VARMUS: Why do you say that?

Q: —it will solve the problem. Why not ban it?

VARMUS: I’m fine with that. I don’t agree that we wouldn’t have a black market, though.

Q: (Off mic.)

VARMUS: I’m supportive. I’ll follow you. (Laughter.)

FINK: OK, so—

ADAMS: There are more countries banning e-cigarettes, by the way.

VARMUS: (Laughs.) Yeah, that’s right.

ADAMS: Just so you are aware. It’s one of those dilemmas that we face in the world, are they good or are they bad?

VARMUS: It’s interesting. No, but one of the reasons most of us are unhappy about e-cigarettes is because they lead to tobacco use. And if you banned tobacco, and if you’re going to do that effectively, maybe—(laughs)—we could live with vaping.

FINK: Yeah. Back there, please.

Q: Thank you. My name is Phun Nguyen (ph) from Vietnam Television.

I have a question for Cary Adams. The theme of the World Cancer Day this year is “I am and I will.” Can you explain the theme and the reason why you chose the theme?

ADAMS: Sure. I’d almost forgot we were doing this because it’s World Cancer Day on Monday. (Laughter.) It’s so interesting, yeah, so those of you who want to do something on Monday, it’s World Cancer Day.

The theme is “I am and I will,” and it’s a great theme that everyone can adopt to use for themselves on the day, so I am a father, and I will ensure my children never take up a cigarette. I am a CEO of an organization and I will ensure that we deploy good health practices in my organization. I am—so you can use it however you want.

And the press release associated with that is informing people about the need for early detection and to make sure that we bring those staging down as much as we can. But it’s an annual event. This theme will run for three years. Go to worldcancerday.org, or those of you who do tweeting and things like that, look on the Facebook and LinkedIn pages. There will be thousands of events taking place around the world. The media have picked up on it already, and I would encourage you all to take a moment during Monday to reflect on what you can do to help the cause of cancer globally.

FINK: Because we only have a couple of minutes left, let’s just get all the questions on the table. So we’ll start with you, and then over there. And try not to answer them until—(laughs)—

Q: OK. George Gavrilis, Columbia University. Thank you.

So I wanted to understand what your vision for the future is through maybe you painting a picture of what it would look like in a small village in a remote area of a poor country. What would it look like ten, fifteen years from now if you had an ideal—but also realistic—success? What would cancer services look like in a cluster of villages?

FINK: Great. And I’m writing these down so I’ll remind you.

Let’s take two more. You over here have had your hands up. Oh, sure—

Q: Sorry.

FINK: And then you—and then you. You can have one, too.

Q: Gerald Liu from Princeton Theological Seminary.

Most people smoke for pleasure, or to make themselves feel better, or for social reasons. How do we address the health risks of tobacco without making it a punitive measure on the working classes? And secondly, isn’t the biggest obstacle the fact that cancer treatment is a multi-billion-dollar industry? So could we look at the rising cancer rates in the rest of the world as an opportunity to disentangle cancer treatment from, (like ?), capitalism? (Laughter.)

FINK: OK, and then you over here.

VARMUS: Hang one minute. (Laughter.)

FINK: And I’ll—I’ll repeat the questions. Yes?

Q: Betsy Fuller from Bloomberg Philanthropies.

I just wanted to ask Cary specifically what the biggest barrier is to population-based registries. I know there’s a lot of hospital-based ones, but more about population-based registries.

FINK: OK, so I’m going to repeat the three. Vision for the future—I can’t read my writing—(laughs)—smoking—

ADAMS: That was a very complicated question.

VARMUS: That’s a philosophical seminar at Princeton.

FINK: Multi-billion-dollar industry, and Cary, barriers to population-based registries. Have at it.

ADAMS: OK. I’ll do the registry one.

VARMUS: That’s the easy one.

ADAMS: Yeah. (Laughter.) I was asked first so I have the easy one.

Most population-based registries start of as a hospital-based registry, and then a government or a state decides they want to expand that, and it grows from there with other hospitals and more training for those hospitals to collect the data.

So it sort of grows and expands, and to help that growth and expansion, our colleagues at the International Agency for Research on Cancer in Lyon are there to support countries, to support states or cities actually develop their cancer registry processes, which of course relies on pathology in the first instance anyway, so there’s a whole series of, you know, preconditions in order for it to grow.

And a lot of people get confused that population-based registry means every part of the country has to be covered. That’s not true. Statistically you need to get to a certain percentage, and once you are there, then you can say with some certainty what the cancer burden is within that community and how big that community may be.

It’s certainly something which we’ve seen great progress in in the last seven or eight years, and I’m hopeful that will continue in the next five to ten years. It’s not a heavy investment overall, to honest. In the context of a national cancer control plan, it’s not the heavy capital investment that other parts of it are.

VARMUS: We do need good pathologists to make sure the registries are correct, and I think increasingly we’re going to want to add in some genomics to this effort because genomic technologies are being practiced in lots of countries, and getting a sense of what kinds of mutations are driving cancers in even the poorest countries will be useful.

FINK: Can you define what a registry is? I’m not sure everybody knows.

ADAMS: Oh, a registry is the data collection point of all the cancers which have taken place in that country. Once a cancer has been diagnosed, then it’s registered with the cancer registry through to either successful treatment or, unfortunately, to the death of the individual.

VARMUS: But I would—I would urge people to have a look, if you haven’t, at Global Burden of Disease websites to see just how different the distribution of cancers are in different countries and how important it is for countries to know what kinds of public health measures and treatments to be available in those parts of the world.

ADAMS: And it’s also important—

FINK: We have—

ADAMS: —because if you take on new policies, you want to know what the impact it has over time, and you need to build up, you know, ten years’ worth of data to really get to understand the nature of the cancers you are addressing.

FINK: A very important question.

All right, so we have 60 seconds left—

VARMUS: OK.

ADAMS: I can do the village one.

FINK: —so you can answer one of the others—

ADAMS: I love the village one—

VARMUS: Would you like to?

ADAMS: I can do the village—you can do the Princeton one over there, actually. (Laughter.)

VARMUS: I’m saving that for after the hour.

ADAMS: Oh, really? OK. OK. That could be a meeting afterwards.

VARMUS: We’re going to go out for coffee and talk about it.

ADAMS: The village, well, I—there’s no answer to your question. (Laughter.)

VARMUS: That’s easy—that’s an easy answer. (Laughter.)

FINK: (Laughs.) Thank you, everybody.

ADAMS: That’s an easy one. The reason I say that is my organization set up an initiative called the City Cancer Challenge a couple of years ago, and we’re working with cities to create—

VARMUS: That’s cities; he wants villages.

ADAMS: Oh, I know, but I’m saying we want the cities to actually work out what the right solution is for cities, and every city has been a completely different solution. And those cities are reaching out into rural communities with a completely different solution.

So I don’t think it’s a—you know, lift and drop and say, there you go; that’s how you solve that problem. It depends. And therefore I think the international community has to provide frameworks for them to understand what their challenges are and then just put in solutions that solve the problem they face.

VARMUS: In 15 years, no one smokes in that village. Everyone is vaccinated with HPV and HPV vaccines, and they all have access to a tertiary cancer care hospital if they have cancer.

FINK: Great. Any last points you really want to make that haven’t come out?

VARMUS: This is an international problem with local solutions, and we need to incentivize people to recognize that we can make progress against these diseases, even the poorest countries. Fifteen or twenty years ago, we thought we couldn’t make real progress against HIV in Africa and other poor countries. George Bush proved, through PEPFAR, we can do that, and with resolve and international collaboration, we can make real progress against cancer.

FINK: Cary?

ADAMS: I would just like to say that, in my experience traveling around the world, that there is an overriding philosophy maybe that the developed countries have got to teach the low- and middle-income countries how to do things. There’s a lot of learning you can get from those people. They are brilliant, they are amazing, they are innovative, they’re entrepreneurial, and that can be brought back. So I see it as a knowledge exchange—not to just see it as that we’ve got to solve the problem in another part of the world.

FINK: So thank you very much, and thanks to our wonderful speakers, Cary Adams and Harold Varmus. Great discussion. (Applause.)

ADAMS: Thank you, Harold.

(END)

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