American Society of Clinical Oncology’s Global Oncology Leadership Task Force: Findings and Actions

In response to rising cancer incidence and mortality rates in low- and middle-income countries and the increasingly global profile of ASCO’s membership, the ASCO Board of Directors appointed the Global Oncology Leadership Task Force (Task Force) to provide recommendations on ASCO’s engagement in global oncology. To accomplish its work, the Task Force convened meetings of global oncology experts, conducted focus group discussions with member groups, did site visits to South America and India, and met regularly to analyze the findings and develop recommendations. Task Force findings included global concerns, such as access to care, and specific concerns of middle- and low-resource settings. The need to strengthen health systems and the importance of alliances with a range of international cancer stakeholders were emphasized. Task Force recommendations to the ASCO Board of Directors were based on a three-part global oncology strategy of professional development, improvement of access to quality care, and acceleration of global oncology research. Specific areas of focus within each of these strategic pillars are provided along with an update on areas of ASCO activity as these recommendations are implemented.


INTRODUCTION
Cancer incidence and mortality in low-and middleincome countries (LMCs) have been rising steadily over the past several decades. In 2012, the International Agency for Research on Cancer (IARC) estimated that approximately two thirds of all cancer deaths and nearly 60% of new cancer cases occur in LMCs. Furthermore, IARC has projected that by 2030, new cases of cancer in LMCs will be nearly double those in high-income countries, and more than twice as many cancer deaths will occur in LMCs than in high-income countries. 1 Cancer has become more broadly recognized by the global community as a global health priority, as evidenced by the historic 2011 United Nations High Level Meeting on Non-Communicable Diseases. 2 These epidemiologic trends are reflected in the increasingly global profile of ASCO's membership: Approximately one third of ASCO members practice outside the United States, and of these international members, one quarter practice in LMCs, which represents a significant and growing constituency. Thus, the ASCO Board of Directors has made it a priority to consider their needs and interests.
The Global Oncology Leadership Task Force (Task Force) was formed by the ASCO Board of Directors to provide recommendations on ASCO's engagement in global oncology. More specifically, the Task Force was charged with identifying ASCO programs and services that have the potential to address unmet needs in oncology communities outside the United States as well as other cancer-related issues that the international cancer community is not fully addressing. The Task Force collaborated with ASCO's International Affairs Committee and other ASCO committees to evaluate ASCO resources and opportunities to leverage other relevant components of ASCO toward global goals. The Task Force was chaired by Gabriel Hortobagyi, MD, and staffed by Doug Pyle, Vice President for International Affairs.

METHODS
To accomplish its work, the Task Force performed the following activities from July 2014 to March 2016: 1. An initial conference call to collect input on the Task Force's agenda; The Task Force wrote a white paper that outlined its finding and recommendations, which was presented to the ASCO Board of Directors in June 2016.

Global Oncology: Global Concerns
Although definitions vary, global health has been described as an "area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide." 3 Global oncology is a more recent term that generally refers to the application of the concepts of global health to cancer and implies an approach to the practice of oncology that acknowledges the reality of limited resources in most parts of the world.
Although its mandate covered a wide range of issues, geographies, and practice settings, the Task Force identified common themes and concerns among the diverse stakeholders consulted. These themes included the following: · Professional development: support for the highest quality of specialty training, continuing professional education, and career development in global oncology. This includes: + The need to train allied health care personnel (eg, nurses, community health workers) in aspects of oncology care to leverage the existing health care workforce, particularly where the specialist workforce is severely limited; + The need for optimal training and postgraduate education of oncology specialists worldwide; + Recognition in high-income countries of global oncology as a field for formal professional development and as a legitimate, research-oriented academic field. · Quality of care: + Access to care: while the affordability of care relative to available resources varies, concern about the rising cost of care is certainly a global one.
+ Quality standards and patient-centered outcomes.
+ Cultural barriers to quality improvement such as resistance to the use of narcotics for pain control or a public perception that cancer is an untreatable disease. 4 · Research: shared interest in research and concerns about regulatory and funding challenges associated with cancer research.
These common concerns offer opportunities for collaborative efforts around the world to develop optimal solutions to these challenges, which in all cases should be context-specific, taking into account the local environment, resources available, financial considerations, and other factors. Global oncology requires a paradigm shift from a model of taking knowledge generated in a developed location and disseminating it to a less-developed location to a multipolar model where solutions are generated and shared across multiple settings. Indeed, during the Global Oncology Summit, reverse innovation was highlighted as an opportunity to accelerate discovery by researching innovative approaches pursued in LCMs that could be globally applicable.

Resource Stratification: Middle Resource and Low Resource
The Task Force heard significant commonality in terms of issues and concerns, and deliberations also highlighted significant distinctions among practice settings that were driven in part by the varying resources available. In these discussions, countries typically are categorized as high income, middle income, and low income. On a national economy basis, the World Bank defines middle income economies as those with a gross national income (GNI) per capita of . $1,045 but , $12,736, low income as a GNI per capita of < $1,045, and high income a GNI per capita of > $12,736. 5 The stratification of cancer control interventions by resource availability was pioneered by the Breast Health Global Initiative. 6 Although useful as a framework, within countries categorized as middle income (eg, India, Brazil), low-resource rural settings can coexist with urban areas with highly advanced facilities. Furthermore, a country may have a middle-resource economy but have a high resource health system or a high resource economy and an underdeveloped health system. MRCs were also a theme of the Global Oncology Summit at ASCO's headquarters in Alexandria, VA, in January 2016. Generally, MRCs appear to offer an infrastructure conducive to ASCO having a significant impact, including established systems for medical education (eg, oncology specialty training) and health care delivery systems and relatively stable and growing economies with a growing middle class that places a priority on health, political stability, and governance.
The visits to the MRCs revealed an overall high credibility level for ASCO and its meetings, guidelines, and products. The interest in standards may be partly due to variability in oncology training and professional certification in some MRCs (eg, at the time of ASCO's visit in 2015, oncology training in Argentina could be obtained through a 5-year residency or through a shorter university course certification, but more recently, the Argentine Ministry of Health reportedly initiated a harmonization effort with respect to oncology training) and an interest among oncology training programs to establish quality standards and differentiate their programs on the basis of quality. ASCO and the European Society for Medical Oncology actively support medical oncology training worldwide and recently released updated recommendations for medical oncology training. 7 Similarly, the Task Force perceived in MRCs a growing and dynamic private hospital sector that sees quality and certification as market differentiators. For example, private hospitals in India promote their adherence to the Joint Commission International certification. ASCO's Quality Oncology Practice Initiative (QOPI) and, even more so, QOPI Certification, offer an opportunity for ASCO to respond to this organic, market-driven interest in quality standards. ASCO also heard top-down interest in programs like QOPI from government authorities in support of ministries of health efforts to improve health care quality and reduce care disparities.
Representative of nearly 40% of the world's population and . 20% of its cancer population (on the basis of 1-year prevalence data 8

Health Systems Strengthening
The Task Force discussed the need for ASCO programs to be integrated within existing health care systems of the countries in which they are being implemented. Such an approach makes ASCO programs more relevant and adaptable to address the realities of that health care setting, ensures that the program will have a sustainable impact that is aligned with other efforts to improve the health care system, and considers critical components of the cancer care delivery system on which oncology depends.
The collaboration between ASCO and CAP is an example of a systemic approach to programming. Under this collaboration, ASCO and CAP are developing tools and resources to assess pathology capacity and address pathology gaps in four pilot countries (Haiti, Honduras, Uganda, and Vietnam) with an aim to improve pathology capacity in LMCs. In proposing this collaboration to CAP, ASCO perceived a critical deficiency in the cancer care delivery system, and through an alliance is working with partners to address that deficiency.
With the assumption that this collaboration will be successful, ASCO could consider a collaboration with sister societies to address other gaps in cancer care delivery in LMCs.
The integration of programs within an existing health care system also means adaptation to and leverage of available resources. In LRCs and even MRCs, a critical lack of formally trained medical oncologists and other oncology specialists exists, which necessitates the consideration of an unconventional oncology workforce to enhance overall cancer care capacity. In middleresource settings, organ specialists (eg, pulmonologists who treat lung cancer) are key constituents. In low-resource settings, health care delivery is focused on a primary care workforce. The Dana-Farber experience with training primary care providers in Rwanda to deliver cancer treatment has already been mentioned. In India, a similar program internally initiated by an ASCO member provides generalist training to reach outlying communities. The scarcity of trained nurses in most LMCs also is a key component of the health care workforce shortage in these settings, and an opportunity to work with the Oncology Nursing Society (ONS) was identified.
Finally, the Task Force discussed the value of integrating the range of programs and products in ASCO's portfolio on a national level. Although various ASCO international programs commonly are linked in a particular country, this process remains relatively informal. For example, past IDEA recipients often organize ASCO international courses in their countries and apply for innovation grants. The Task Force suggests that ASCO could achieve more through a country-focused approach that engages national governments and health systems more formally and that more consciously draws on ASCO offerings in a planned manner.

Alliances
A consensus existed among Task Force members about the importance of strategic alliances in supporting and extending ASCO's international efforts. ASCO collaborates with a strong network of oncology societies to organize programs around the world, and these will continue to grow. In addition, the Task Force identified seven other alliances that could be further developed or initiated: 1. International agencies such as the WHO, IARC, and other United Nations bodies: Work with these agencies will align ASCO's international programs with broader international initiatives and amplify their impact. Possibilities for collaboration between ASCO and the Infectious Diseases Society of America were suggested during the Global Oncology Summit given the expertise of the infectious diseases community in conducting large-scale international programs and the relative frequency of infection-related cancers in lowresource settings.
5. US academic cancer centers that conduct global oncology programs: The Global Oncology Summit, which had a large representation from these academic centers, highlighted the potential synergies between ASCO and these centers. One was in the development of global oncology as an academic field, and many representatives from these centers expressed a need for the field to be more formally recognized, research to be better funded, and barriers to fellows who pursue an interest in global oncology to be addressed (including the provision of protected time for faculty to engage in global oncology activities) and saw a role for ASCO to align these needs with its other professional development activities. Another synergy was in collaborations where academic centers perform intensive programs in LMCs (eg, Rwanda, Kenya). ASCO could collaborate with, learn from, and help to disseminate promising models from these initiatives.
6. Public advocacy organizations: ASCO has the opportunity to enhance its role internationally through partnerships and its international members to raise public awareness about cancer as a disease, its potential curability, and the importance of early diagnosis and timely and effective treatment. This could be expanded to include education of the local media and political decision makers.
7. Individual oncology leaders in the countries. Although substantial gains have been made through the IDEA program and, more recently, international member participation in the Leadership Development Program, there is an opportunity to expand ASCO's leadership development capabilities and experience internationally, possibly through local leadership training in conjunction with national society partners. These leaders would be critical for engaging their own governments and professional societies in advancing quality care.

PUTTING THE FINDINGS INTO ACTION
ASCO offers a robust portfolio of international programs 10 that consists of three mutually supportive pillars: professional development, quality improvement and research. Each of these domains represents an area of ASCO strength. Each pillar requires active advocacy on the part of ASCO to key audiences (including the education of governments and potentially the public) and strong alliances with key stakeholders. Through this framework, ASCO is now pursuing a number of new initiatives to put the findings of the Task Force into action.

Professional Development
Promoting the recognition of global oncology as an academic field. ASCO will be engaging various stakeholders to support the transition of global oncology from an informal field of largely voluntary activity to a formal field with a strong research component and recognized value of oncology training and the practice of oncology. Such an initiative builds on ASCO's expertise that supports the professional development of domestic and international members, and ASCO's recent efforts to formalize global oncology through Journal of Global Oncology, the global oncology track at the ASCO Annual Meeting, and the Global Oncology Symposium.
Training of nonspecialists in oncology principles.
Recognizing that the demand for oncology services will exceed the supply of specialists in many LMCs for the foreseeable future, ASCO is reviewing models for the training of nonspecialists in oncology principles and cancers commonly found in their region or communities. ASCO can learn from approaches currently pursued in Rwanda, India, and Canada, and can build on its existing Cancer Control for Primary Care course to educate health care workers in underserved communities.

Quality Improvement
Accelerating QOPI Certification internationally. QOPI Certification has a significant potential to promote a global standard of excellence in cancer care and to motivate cancer practices to improve the care delivered. In 2016, ASCO awarded QOPI Certification to its first practice outside the United States: the Contemporary Oncology Team practice in Athens, Greece. Earlier this year, certification was awarded to a practice in Brazil, and based on this experience, ASCO will promote QOPI Certification in other countries.
Supporting improved cancer control in LMC cities.
As new investments in the cancer care infrastructure are made in middle-resource (and some lowresource) settings, ASCO can offer trusted, scientific guidance on the essential elements for an effective quality cancer center and cancer care delivery. ASCO is proud to be a founding collaborator with UICC on the City Cancer Challenge launched in January 2017. With 54% of the world's population already living in cities, which is expected to rise above 66% in the coming decades, C/Can 2025: City Cancer Challenge will address the urgent need for fully functional, comprehensive cancer solutions in urban areas to reach the majority of the world's population. The first three cities who have committed to the challenge are Asunción in Paraguay, Cali in Colombia, and Yangon in Myanmar. These key learning cities will provide insights on how the international community, local civil society, and public sector can best work together. ASCO and its member volunteers will be contributing technical assistance to the program and linking the program requirements with relevant ASCO programs and resources.
Extending ASCO international programming beyond oncology. Through an alliance with CAP, ASCO is extending its programs in LMCs to include pathology capacity development, which links CAP pathology expertise and tools with ASCO's international network and programmatic expertise. This alliance with CAP can be a model for ASCO to collaborate with other organizations in other cancer control domains (IARC in registries, ONS in oncology nursing).

Research
Making global oncology a formal component of the ASCO Annual Meeting. The ASCO Annual Meeting serves as a platform to highlight global oncology issues and research, to promote a dialog about these topics from different perspectives, and to raise awareness of these issues among attendees. This has been realized through the Global Oncology Symposium that was organized with the 2015 and 2016 ASCO Annual Meetings, and now the Global Health Track that was started with the 2017 Annual Meeting.
Creating Conquer Cancer Foundation research awards for global oncology. ASCO's philanthropic affiliate the Conquer Cancer Foundation (CCF) offers a grants and awards program that includes the Young Investigator Awards; Career Development Awards; and for research in LMCs specifically, International Innovation Grants. In response to the need and interest in global oncology research that the Task Force identified, the CCF is now developing new research awards to support formal and robust global oncology research. The CCF Global Oncology Grants Task Force has defined award criteria and terms and announced the first awards at the 2017 ASCO Annual Meeting.
Deepening of CCF involvement in global oncology. As ASCO's philanthropic affiliate, CCF can further raise awareness of the critical need for additional resources for global oncology interventions and the impact of these interventions on patient care around the world. The global oncology mission may resonate with new donor sources, and high-profile forums, such as the World Economic Forum meeting in Davos, Switzerland, may raise public and philanthropic awareness of international cancer issues. In fact, the UICC has established a productive collaboration with the World Economic Forum and launched the City Cancer Challenge at Davos this year.
In conclusion, by publishing the findings of the Task Force and reporting some of the follow-up actions, we hope to inform the dynamic discussions of today on the alarming challenges in global oncology and the ways to address these challenges. The planned actions by ASCO as outlined in this article are intended to address some of these challenges, but ultimately, a suitable response will require many actions by many organizations in all sectors of our global community. The leadership and membership of ASCO look forward to this collaboration and to realizing the improved patient outcomes that we all envision.