The Lancet Asia Medical Forum - Asia and Cancer Management in the 21st Century

21 Apr 2007

By Mr Khaw Boon Wan, Minister for Health

Venue: Suntec Convention and Exhibition Centre

Distinguished guests

Ladies and Gentlemen

Introduction

This is the second time the Lancet’s Asia Medical Forum is being held in Singapore.  We are delighted.  

Over the years, Singapore has invested heavily to build up our biomedical sciences capabilities and remains committed to stay the course.  We have developed Biopolis as a key, focal infrastructure that is now the leading biomedical research hub in this part of the world.  We have attracted world renowned scientists who have brought with them critical expertise, leadership and inspiration, and helped us overcome capability gaps to jump-start our efforts. We are investing in our own talent, sponsoring bright, young Singaporeans for their PhDs at the best institutions around the world. As a logical extension of our work thus far, we are moving into translational and clinical research, with cancer as one of the priority areas. 

That a world leading scientific journal like Lancet is once again holding its Asia Medical Forum in Singapore, focusing this time on cancer management, is a reassuring affirmation for us, that our efforts have not gone unnoticed, and that we are on the right track.

The Fight Against Cancer

With an aging population, the incidence of cancer in Asia will increase rapidly.  This will put tremendous burden on patients, their families, and the healthcare system in each country.  Singapore will not be spared.  Cancer is already our top killer and we are bracing ourselves for the disease burden to increase as our population ages.

I am neither a clinician nor a scientist, and the audience here knows much more about the science of cancer than I do.  But being in the healthcare business, I have to confront the issue of cancer management with my clinical colleagues.  Let me share some aspects of this difficult issue from the perspective of a layman. 

Battle Victories

More than 3 decades have passed since US President Nixon declared war on cancer in his 1971 State of the Union Address.  He had then pledged US$100 million “to launch an intensive campaign to find a cure for cancer”, promising more funds for his campaign.  Since then, the US alone has spent more US$200 billion on cancer research. 

There have been significant battle victories.  Dramatic improvements in cancer management have been achieved in the areas of prevention, early detection and treatment. 

Smoking, which has been identified to be responsible for more than 30% of all cancer deaths, has declined in developed countries thanks to smoking cessation programmes and public education.  Rates of new cases of lung cancer have consequently seen declines.  Similarly, our Hepatitis B vaccination programme, introduced in 1985, has led to better prevention of liver cancer here.  More recently, the development of an effective vaccine of the human papilloma virus promises to significantly reduce the incidence of cervical cancer.

Major strides have also been made in detecting cancer earlier.  For example, improved mammograms for the detection of breast cancer, routine colonoscopy to detect colon cancer, and tests to detect prostate cancer have helped us find these cancers at earlier stages, when they are more curable.  Research in molecular genetics can now identify individuals with higher genetic risks of developing cancer.

In addition, developments in molecular biology and chemistry have led to the discovery of effective therapies.  Many cancers, previously considered death sentences, are now curable. Childhood leukemias, Hodgkin’s lymphomas, and testicular cancers all have cure rates that exceed 80%.  Mortality from chronic leukemias has fallen dramatically.  For the first time in recorded history, the mortality rates for breast and prostate cancers have also fallen, with early diagnosis and effective treatments. 

Battle Woes

For all the victories in battles against cancer, however, the war is far from over.  Critics point to how, even though we have won some battles, we are losing the overall war. 

The research community has had its fair share of criticisms.  There may be new discoveries being made with the promise of new, more effective tools against cancer.  But the translation of these discoveries into real benefits for patients has been slow, if at all. 

Others have criticized the fragmented nature of cancer research.  A March 2004 Fortune article, for example, highlighted what it termed, a “dysfunctional cancer culture”:

“A groupthink that pushes tens of thousands of physicians and scientists toward the goal of finding the tiniest improvements in treatment rather than genuine breakthroughs, that fosters isolated (and redundant) problem solving instead of cooperation, and rewards academic achievement and publication above all else.” (“Why We’re Losing the War on Cancer [And How to Win It]”, Clifton Leaf, 22 March 2004, Fortune)

Drug companies commercializing new treatments have also come under fire because new cancer treatments come at a huge price tag, even though survival gains are generally measured in additional months of life, not years.

Only recently, the LA Times carried a report on a controversial debate in the US, centering around a new generation of hyper-expensive cancer drugs which can cost as much as US$100,000 annually, but help extend the lives of most for only a few months: 

“The drugs’ sky-high costs compared with their relatively small health benefits have sparked arguments among policymakers and medical professionals about what to do with the growing number of people who are depleting their life-savings on the drugs or, worse, who cannot get them at all.  More broadly, they ask, is this the best way for society to spend its increasingly limited healthcare dollars?”  (“Setting the Price for Putting Off Death”, 18 March 2007, LA Times)

Although this debate is taking place in the US, the issue is relevant elsewhere, particularly in Asia where incomes are still low.  The looming cancer crisis because of our aging population will hit those hardest who can least afford it: the elderly and the medically under-served. 

It will be a great challenge for governments, because healthcare is viewed as something which cannot be denied to anybody regardless of whether he can afford it.  Politically, governments will find it difficult to defend attaching a dollar value to life, no matter how short.  There will be immense pressures to make new treatments available at whatever cost, even though society as a whole may not be able to afford it. 

Some countries have tried to address this issue with the setting up of institutions to determine the cost-effectiveness of drugs to be used by public healthcare institutions.  The UK established the National Institute for Health and Clinical Excellence (NICE) to decide which drugs the National Health Service could use.  Similar organizations operate in Australia and Canada.  In the US, there is discussion now on a proposed Comparative Effectiveness Board (CEB), which would review the evidence on how well drugs work and whether they are cost-effective.   Along the same lines, Singapore set up the National University of Singapore Centre for Health Services Research in collaboration with the RAND Corporation.  Among other things, the Centre will study issues such as cost and effective utilization. 

Other countries have resorted to more controversial measures.  Thailand, for example, issued compulsory licences under the WTO’s TRIPS Agreement to allow generic versions of anti-AIDS drugs.  The Thai Health Minister explained that the government had to resort to this in the face of a ballooning healthcare budget.  He has indicated that it is considering further compulsory licences for drugs in critical need but the state cannot afford to buy.  This will include cancer and more AIDS medications. 

The drug companies are understandably unhappy.  Development of a new drug can take decades, and cost hundreds of millions of dollars.  Having made such an investment, the drug companies expect to earn adequate returns and have their intellectual property rights properly protected.  But the practical concerns of governments, particularly the predicament of developing countries like Thailand, are real and cannot be ignored.  If affordability is a concern in developed countries like the US and UK, the challenge facing poorer developing countries must necessarily be much more daunting. 

A complete solution that satisfies the budgetary concerns of countries and the commercial considerations of drug companies has yet to be found.  But this is one issue, though unrelated to science, which needs to be addressed for it will have a critical impact on cancer management, and indeed, healthcare in general.  

Marching Forward

Against this backdrop, what can we do moving forward?

Greater Collaboration

One thing is clear: we not only need more investment in basic, translation and clinical research, we need greater collaboration to push the research outcomes quickly to patients. 

Unfortunately, research has always been plagued with accusations of work done in silos and even deliberate with-holding of information.  Much has been said about this, for example, in the context of avian influenza and the threat of an influenza pandemic.  Holding back of information by scientific agencies sadly occurs, even as some scientists call for the release of more data on the H5N1 virus.  More recently, Indonesia’s refusal to share H5N1 samples for vaccine research had grabbed headlines, with the world heaving a sigh of relief when the WHO finally worked out a compromise with the Indonesian government.  We need to rise above this mindset. 

I am optimistic the cancer research and clinical community can do this, based on Singapore’s own experience.  For example, through the Singapore Cancer Syndicate, under A*STAR, we have successfully established a national programme in cancer research that straddles basic and clinical research, and brings together research groups on cancers that have significant mortality in our population.  By harnessing the resources of the research community, co-operating and working together instead of competing against each other, this has led to significant advances in discovering new treatments.  The programme has extended beyond Singapore’s shores.  The Syndicate has funded a paediatric oncology study in childhood leukaemia involving 4 paediatric oncology centres in Singapore and Malaysia, resulting in improvements in patient survival.

Singapore institutes have also successfully established collaboration initiatives with various foreign groups.  These include the Karolinska Institute of Sweden, the Max Planck Society of Germany, the Australian National University’s Australian Phenomics Facility, RIKEN of Japan and the International Cancer Biomarker Consortium (ICBC) of the Fred Hutchinson Cancer Research Centre in Seattle. 

Focus on Asia

We will all gain if the international research community expands such collaboration networks across the world.  In particular, focus must increase on Asia as a key node in these networks.  As life span increases across Asia with economic development, the burden of cancer will inevitably increase.  Projections by the World Health Organization indicate that the number of new cancer cases in Asia will increase by more than half, to 7 million, by 2020.

The ethnic diversity in Asia presents a unique challenge.  Expressions of diseases between the different ethnic groups are different.  The spectrum of cancers and the response to cancer drugs have also been found to be different in the various Asian populations.  There is thus an urgent need to better understand the underlying science causing these differences, which may give us new insights to approaching cancer and its treatment.

Asia is well-placed to participate in these research efforts.  Though much of the progress in the past century in cancer research has come from the West, contributions from Asia are rising and will be even more significant in this current century.  Asian researchers are already populating major laboratories and contributing mindshare in the study and cure of cancer. 

In Singapore, our concentration of research and medical talent in cancer is significant and making an impact on cancer research and the delivery of care to Singaporeans.  Singapore’s survival statistics for childhood cancer, for example, is among the highest in Asia.  One of our local researchers has defined how Asians metabolize certain anti-cancer drugs differently and how these doses must be altered to provide safe treatment.       

With our built-up capabilities and depth in cancer research, Singapore is keen to do our part in wider regional and international work to tackle cancer management in Asia.  Our population, with 3 major ethnic groups of Chinese, Malay and Indian, gives us a unique ability to carry out longitudinal cohort population studies. Early-phase trials in multi-centre research could be hosted here, with the later phase studies involving larger populations done in China and India.  I believe our scientists here are raring to go.   The government will cheer them on.

Beyond Science

But even as we push the boundaries of scientific research, we need to deal with non-scientific aspects of cancer management.  For research to truly benefit mankind, we cannot ignore the economics and politics of treatment costs.  The challenge is finding innovative ways to make cancer treatment affordable, especially for regions like Asia, with minimal market intervention and distortions. 

I do not have specific solutions, but I am greatly encouraged by the pockets of creativity seen in initiatives targeting the poor, providing low cost solutions for the masses.      

In India, for example, the Aravind Eye Hospital, which performs low-cost or free cataract surgeries for poor Indians, has grown to become the largest single provider of eye surgery in the world.  Aravind does not depend on donations, and does not accept government grants.  It is totally self-sustaining, notwithstanding the fact that 70% of its patients pay nothing or close to nothing.  

They achieve this through creative, innovative processes.  For example, they put 2 or more patients in an operating room at the same time.  Their doctors developed equipment to allow the surgeon to perform one 10- to 20-minute operation, and then swivel around to work on the next patient, who is already in the room, prepared, ready and waiting.  The surgeons are so productive that it costs US$10 to conduct a cataract operation compared to over $1,600 in the US.     

To be sure, it may not be possible to simply replicate the Aravind model for cataracts to cancer treatment.  But I believe that if bright minds are put to it, we will be able to find creative solutions applicable to cancer management.  We owe it to our patients to give it our best shot.

Conclusion

At the end of the day, prevention is better than cure.  If nothing else, it is cheaper and less painful.  We have made significant progress on the prevention and detection fronts.  We must fight to maintain and build on these achievements, and avoid backsliding.  The war on cancer is not the sole domain of the scientists and clinicians, but laymen themselves have significant roles to play, leading healthy lifestyles, with sufficient exercise and proper diet, and avoiding cancer risks.  It is an uphill task to change mindsets and habits, and perhaps the first exercise of creativity is to find novel ideas to promote healthy lifestyles, based on solid scientific evidence from research. 

But good work can never be done in isolation. There is a need for cross fertilization of ideas and exchange of views. Hence, the need for conferences like the Lancet Asia Medical forum, which brings together many leading cancer experts, researchers and public health administrators from around the world to discuss the many challenges posed by cancer.  

I wish you an interesting and fruitful conference.