Cancer Topics - Oncology Practice in Low-Resource Settings

Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. This ASCO Education podcast will explore oncology practice in low resource settings.  Dr. Thierry Alcindor, a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston, Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance and Dr. Sana Al Sukhun, an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan will discuss the barriers they face providing cancer care in low resource areas in the US (1:48) and Jordan (11:52) and the one challenge that is key to solve in order for proper treatment to be administered in the US (29:07) and Jordan (31:42). Speaker Disclosures Dr. Sana A. Al-Sukhun: Honoraria – Novartis; Speakers' Bureau – Novartis, Roche, Pfizer; Travel, Accommodations, Expenses – Roche, BMS Dr. Richard Ingram:  None Dr. Thierry Alcindor: Consulting or Advisory – Merck, Bayer, BMS, Astra Zeneca, Astellas Scientific and Medical Affairs Inc.; Research Funding – Epizyme, EMD Serono, Karyopharm Therapeutics, Springworks, Astellas Pharma, Deciphera Resources  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at [email protected]. TRANSCRIPT Disclosures for this podcast are listed on the podcast page. Dr. Thierry Alcindor: Hello, dear ASCO audience, welcome to this episode of the ASCO Education podcast. Today, we will examine practicing oncology in a low-resource setting. Managing cancer patients is a multifaceted challenge. Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. I'm Dr. Thierry Alcindor. I'm a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston. Joining us are Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance. He is, as well, the current president of the Virginia State Oncology Society. We are also very pleased to be joined by Dr. Sana Al Sukhun. She is an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan. She is also the past president of the Jordanian Oncology Society.  So, I'll begin with Dr. Ingram. You have experience with patients in the Appalachian region of the US by practicing medical oncology in rural northwestern Virginia for the past 25 years. Can you describe this unique region for our listeners and detail some of the challenges you face when providing care there? Dr. Richard Ingram: I have been practicing here in Northwestern Virginia for the past 25-ish years, and have seen over time barriers to care that I think could be applied anywhere. And, I think we'll hear some interesting stories today from our colleague from Jordan also, in that regard. The main barriers I think are somewhat slightly stereotypical but real where I am. There is a diverse population here, meaning a big geographic area and a somewhat underpopulated area. So, resources are scattered and scarce sometimes and located in concentrated areas. So, patients have difficulty with access to cancer screening, imaging, and sometimes downstream or tertiary care where I am. I have patients that will travel an hour and a half to two hours one way i.e., a three to four-hour round trip - sometimes over some difficult terrain, meaning some difficult roads out our way, both with mountains and some geographic challenges just to get to us. You can imagine the difficulty that is with either coordination of care with a multidisciplinary patient having to see multiple providers or more practically, a patient receiving radiotherapy on a daily basis. And, this not only is time but money because you're trying to make a decision about follow-up appointments and missing work at an hourly wage versus working that week and paying your bills. I have patients currently who are working around that. I have several concurrent chemo-radiotherapy patients - currently, actually two I saw this morning - in clinic, both of which live in a town called Petersburg, West Virginia, which is about an hour and 45 minutes one way. So, three and a half hours from us. And, we've had to connect them appropriately with resources around transportation to make sure they stay compliant with their care.  You have this empathy and drive to care for patients and try to apply the same care you would across the continuum. That socioeconomic status is not unique to Appalachia but I think is somewhat emblematic in our area - lovely, hardworking people and diligent in their craft. But, when you have barriers such as cancer diagnosis and now superimposed strain and stress on your family life and work life, it can throw things out of balance.  A similar patient of mine that I saw today actually in clinic, same area, same concurrent diagnosis, their big access issue is that they're also the primary caregiver for some grandchildren that are staying at home. They've taken in their grandchildren and, not unique to Appalachia, but somewhat in that we have a lot of multigenerational families living together. So, you're trying to help that person get through their therapy and still be the homemaker for grandchildren and try to battle their cancer diagnosis and at the same time not bankrupt them financially from a socioeconomic standpoint. Dr. Thierry Alcindor: What's the insurance coverage pattern like? Dr. Richard Ingram: In my area, about half to 60% of our patients are on either uninsured or they are on public insurance, whether that be Medicare or state Medicaid or exchange programs. From the private sector, there are private plans, but a lot of those are self-funded, meaning they are local municipalities, teachers' unions, first responders, and then a small pocket of what you and I would call traditional commercial insurance coverage. And so, for us, we for a lot of our patients have built relationships, for instance, we know this gastrointestinal group will take that insurance of a Medicaid or uninsured patient and this one won't, or vice versa. So, there is some fragmentation of care if you're not very conscious and deliberate at the medical oncology and radiation oncology side, which is in my practice about making sure the patient can get access to care. Dr. Thierry Alcindor: I understand. So you talked about the lack of adequate or complete primary care coverage. Do you have enough medical oncologists? Dr. Richard Ingram: Excellent question. I appreciate that. Yes. So we do, in that my group does and my region does. So we are very strong, as I like to say, the end of the funnel. You know, I consider cancer care screening a funnel you've got to screen through. I imagine you have a giant funnel of trying to screen through patients for the screening program appropriately and then the positive screens come out at the end of the funnel.  At the end of the funnel, we can receive these patients and take care of them and provide all of the touch points of surgical, radiation, medical oncology, genetic counseling, survivorship. My biggest passion and what I've tried to do in the Appalachian Community Cancer Alliance is raise awareness on the screening and getting the screening activities out into these rural communities so we can get stage migration to an earlier stage of cancer. Still take care of the people who develop positive screens and downstream disease, obviously, but it'd be nice to start getting stage migration to the left, meaning to earlier stages for patients.  What we really have out here is a lack of primary care doctors and stability of primary care doctors because it's a very difficult area to practice primary care with geography, very difficult area, with the payer mix and the socioeconomic status, and a difficult area for people to desire to live in when you're trying to practice primary care, not surrounded by every specialist. A rural primary care provider really has to be, in essence, a true solo practitioner in Appalachia. They have to have a broad skill set because they just don't have a cardiologist sitting next door or a neurosurgeon immediately available.  We have a full complement of surgical oncology specialists, radiation, three-dimensional stereotactic, clinical trials, genetic counseling, eight medical oncologists, a well-equipped ICU, and care. But our catchment area we serve is a geographic radius of two to two and a half hours, of which there's not much in between. There are some rural clinics, some community outposts, some critical access hospitals. And really creating that infrastructure of navigation has been the key success in our area of trying to navigate a patient through the system and trying to support these single clinics or smaller critical access hospitals from afar, support them intellectually with cognitive capabilities over the telephone to help work a consult up and trying to navigate the patient in.  But again, the physical or the geographic, or distance barriers are real, and the socioeconomic barriers are real. Even once we can make a link with the primary care doctor and be more than willing to see the patient, sometimes just physically getting them to us can be a challenge. Dr. Thierry Alcindor: So what is the Appalachian Community Cancer Alliance doing to improve cancer screening, cancer care outcomes in the region? Dr. Richard Ingram: Excellent question. So the Appalachian Community Cancer Alliance started organically. So myself, as president of Virginia, got together with other state presidents, West Virginia, Tennessee, South Carolina, North Carolina, Kentucky, and said, “Gosh, what could we do collectively? Or what are our collective issues and problems?” Because we kind of serve a similar population and geography. And out of that was born kind of a homebrewed alliance, which formalizes the Appalachian Community Cancer Alliance.  And I want to kind of just start with a quick story, and then I'll explain where we launched. I had a patient that really resonates with me personally. So it was a patient I met in the emergency room, happened to actually be kind of mid-pandemic. I was on call, very nice patient, presented with severe dyspnea orthopnea platypnea, came to the ER, had a large pleural effusion lung mass, medial spinal mass, worked them up, ended up being metastatic non-small cell lung cancer stage IV. Got them plugged into treatment and took care of them.  And then when I had a moment, I went back through their files as we usually do when we're taking a history and I had noticed that they had had a low-dose chest CT several years earlier at a community center out in their rural area of West Virginia. And I asked the patient about it and he kind of recalled getting the CAT scan. But bottom line, the area had set up a screening program but had not set up an actual mechanism or a flow of navigation. And/or if they had, the patient was unaware. So basically, the patient dutifully went through a screening program. There was the pandemic, there was a turnover of staff and it wasn't the patient was forgotten, but the patient never got navigated to work things up. And lo and behold, that positive low-dose CT screen turned into stage four cancer years later.  So I wanted to focus on cancers we could make an intervention with in Appalachia and what was formed was called the Lung Cancer Screening Task Force. That was our first successful endeavor of the alliance. So this task force was formed after about a year and a half or so of work of the states I mentioned. It has become its own task force that reports to the alliance and we're very proud of it because it has been recognized in President Biden and Jill Biden's Moonshot Initiative for Cancer. It's actually obtained funding and we've worked backward to work on a navigation program as well as screening in the most underserved and lowest-screened areas in Appalachia. Dr. Thierry Alcindor: Well, that sounds exciting. Like, I feel that there is a nice infrastructure as well as projects coming along and I'm quite eager to hear from Dr. Al Sukhun whose practice is based in Jordan.  Dr. Alsukhun, in 2022 you gave a presentation where you highlighted how low-income countries had experienced greater increases in breast cancer incidence and mortality compared to high-income countries in the last decade. What challenges are patients and doctors facing and what should be prioritized? Dr. Sana Al Sukhun: Interesting question. First, thank you so much for inviting me to take part in this very interesting discussion. Pleasure to join, listen, learn, and reflect. Indeed, I've enjoyed listening to Dr. Ingram very much. He was speaking about his area and indeed discussing most of the issues, believe it or not, we face in different parts of the world referred to as countries with limited resources. When you refer to limited resource environments or countries, you're really referring to two different types of limited resources: very low-income countries or middle-income countries. The challenges are a bit different. The first challenge we generally face is access to the application of knowledge. For example, in Jordan, we have access to the knowledge. We have excellent infrastructures, we have an excellent health workforce. The problem is the application of the knowledge, application of what we have learned to help our patients. However, the challenge in different limited resources goes across the theme of a multidisciplinary approach. It starts from prevention, early detection, where, as you mentioned, we are facing a significant increase in the number of cases diagnosed with breast cancer. The proportion of patients diagnosed with breast cancer in countries of limited resources is 62% of the worldwide new cancer cases. Why do we have such a significant increase in the number of cases? Most countries undergoing what's called socioeconomic transition, they are facing increasing risk factors to develop breast cancer. One of those which is significant not only when it comes to breast cancer but to most kinds of cancers is indeed a significant increase in the proportion of the population suffering from obesity. The highest absolute increase in the prevalence of obesity worldwide over the past couple of decades has been seen in the Middle East, Central Asia and North America. That by itself is a significant risk factor for the development of breast cancer and other long lists of cancers.  In addition, of course, to smoking. For example, last year, unfortunately, and I'm not proud to say Jordan ranked among the highest in terms of smoking prevalence among men in the region. So these two important risk factors, in addition to the westernization of lifestyle, less physical activity, you know, all these risk factors, most important is awareness that these risk factors are important in terms of attributing to cancer. This is not common knowledge across all countries. We do not have enough campaigns across all countries to emphasize the importance of prevention. Then comes early detection. When it comes to early detection, you know, the challenge is not homogeneous. For example, in Jordan, a couple of decades back, most cases with breast cancer were diagnosed at an advanced stage. Barely one-quarter to one-third of cases were diagnosed at stages I to II. Right now, almost 60% of the cases diagnosed annually are really stage I or II early breast cancer. Thanks to the campaigns from government, non government organizations, NGOs, college society, all people are working together to emphasize the importance of prevention and early detection. That was quite successful in Jordan, and as you can see here almost two-thirds of cases are diagnosed early. However, contrast that with neighboring countries. I'm referring to Iraq, Sudan, Yemen, and if you notice I'm mentioning countries with conflict. Those countries not only suffer from limited resources but also instability. And when Richard was referring to the access transportation challenge, indeed, we in Jordan treat so many of the patients diagnosed with cancer coming to Jordan seeking treatment from Iraq, from Yemen, from Sudan, that by itself is a challenge. And at the same time, it reflects the status they suffer from, they suffer from lack of health workforce, lack of enough oncologists. Very few, if any, oncologists are available there. And not only you're referring to oncologists, you need pathologists, enough well-trained pathologists, surgeons, radiation oncology service. Those are quite limited when it comes to many of the surrounding countries and many countries actually with limited resources.  For example, in Africa, same challenges, the multidisciplinary approach that's quite vital for the proper treatment of patients with cancer is indeed also lacking in many countries. The infrastructure takes not only having hospitals but also a multidisciplinary workforce. Then when it comes to treatment, you are faced by a common belief across many cultures that a diagnosis of cancer is equated to a death sentence. Very few, if any, believe that they can be treated from cancer or at least live with cancer in some situations. With breast cancer, patients with metastatic breast cancer deserve to be treated and can survive for years with excellent quality of life as well, still contributing to their society. Especially more than 50% of patients in countries of limited resources when diagnosed with breast cancer, they are younger than age 55, which is ten years younger than patients diagnosed in countries of high income. So they are still in the prime time of their life. They are needed by their family, their society. That's a huge actual economic impact on society and not only on the family. So these are issues to be tackled, to be emphasized across societies so that they can seek treatment when they have access to it. Dr. Thierry Alcindor: Can you tell us about access to cancer medicine, whether chemotherapy, targeted therapy, or immunotherapy? Dr. Sana Al Sukhun: We are living in a fantastic area where precision medicine has really revolutionized our approach to the treatment of many tumors. But at the same time, while we are talking about equity, improving access, it created another challenge and it created, unfortunately, disparity and made equity even more difficult.  Right now, we do have, there is a huge difference between access, availability, and affordability. Most of these new medications, whether basic chemotherapeutics or recently approved targeted therapeutics or immunotherapy are available, but the problem is they are not affordable. Some of them are available in certain institutions, while in the same country, other institutions, if the patient's insurance happens to be in another institution, they cannot access it. So even within the same country, across different institutions, so many of the recently approved targeted therapeutics or immunotherapeutics are not offered. So equity is lacking even within the same country, in many countries with limited resources.  Sometimes the irony is you will have the very highly-priced medications while out of the blue you are faced with the challenge of shortage of basic therapeutics, platinums, for example. And I learned from colleagues, the states suffered from a similar shortage the last few weeks. And you can imagine not being able to access platinum to treat your patients can make a huge difference and impact. Even if you have immunotherapy, you don't have it. That's ironic.  And another challenge, most patients with the availability of social media and Google, thanks to Dr. Google, you check Dr. Google, and the first option you get is very pricey options, immunotherapy, targeted therapy. So the patient comes to you and he's getting the recommendation of having basic chemotherapy, sometimes because the indication is chemotherapy, sometimes because they cannot afford- you offer them the higher price medications, but they cannot afford it still. You still advise chemotherapy because it does work, but the patients are under the belief that if they do not take the very pricey medication, they are doomed and they cannot be treated. So they put treatment off altogether.  These are conflicting concepts. They need awareness campaigns, they need explanation. Social media needs to do a better job improving what it markets. It usually markets the very pricey medications as life-saving, while talking about chemotherapy as something that really hurts patients, while in reality, sometimes this is all we have and it does make a difference.  Another challenge we face, our region, for example, it's a conflict region with so many refugees. To give you a very simple example, I had a patient coming from a Syrian camp, hemoptysis, worked her out, and it looks like lung cancer, and I managed - she cannot afford any kind of treatment - but I managed with the hospital to get the CT scan free. We got the biopsy, and the good news is that companies, pharmaceuticals can and do help. They offered to test the biopsy for EGFR, and it turned out to be positive. Of course, we have no access to EGFR-targeted therapy. So what can we do? Indeed, that patient, we offered her platinum, but at that time we didn't have platinum. Within a couple of months, she presented with a very advanced-stage disease. And unfortunately, we lost her before we could start treatment because platinum was not available. Not only EGFR inhibitors, but we're talking about the simple things. Basic chemotherapeutics are important, those we need to emphasize availability. We keep talking about cutting-edge therapeutics. They're very fascinating to use, to treat, they made a huge difference, but still, our old friend, basic chemotherapy can and does make a difference, something we need to talk about more and more.  Dr. Thierry Alcindor: I agree with you, and that's true of even high-resource countries. I mean, cytotoxic chemotherapy remains the backbone of treatment for many cancers, even in 2023.  But I'd like to ask you a question following up on what you just described so well regarding availability, access. Do you have research infrastructure that would allow you, like for example, they have done in India at Tata Memorial Hospital, to conduct research with lower doses of those expensive agents? I think that this is quite a promising direction for low-resource countries. What do you think?  Dr. Sana Al Sukhun: You touched on a very dear subject to my heart, actually. Right now we're working with ASCO discussing a policy, discussing clinical trials in limited resource environments. Indeed, this is one of the very important aspects that can improve truly access to medications and contribute to the knowledge worldwide. Unfortunately, there are so many barriers.  A short answer to your question is very few centers, if any, in the region do have infrastructure that can facilitate enrollment in phase three randomized trials. Investigator-initiated trials, particularly like the ones you're alluding to, more or less similar to the FinHer trial when we learned that short courses of trastuzumab six months versus twelve months can be reasonable for patients with a limited number of risk factors. Such trials, unfortunately, so far the infrastructure does not allow having such investigator-initiated trials. Not only the infrastructure, pharma needs to be more open for the support of such trials in these environments. Most governments in the region are still struggling with the concept of having human subjects enrolled in clinical trials. That needs awareness, not only at the level of the society or the patients or the physicians, by the way, who also, we struggle because we do not have protected time or appreciation. Dr. Thierry Alcindor: So you're talking with such passion about those challenges, and I feel that there is quite a lot of effort that you're putting in. So maybe you can tell us about the improvements that you have noted. Dr. Sana Al Sukhun: It’s interesting when you look over the past couple of decades how things have moved. Particularly in Jordan, having a cancer center, the first comprehensive cancer center in the region, really set a good example for Jordan itself where other institutions improved to try and compete, improve their services similar to what King Hussein Cancer Center currently has. Also, they managed to have an infrastructure for clinical trials. And as I mentioned, they do have some of the phase III clinical trials already running, participating in large multinational clinical trials. That’s a huge improvement, a huge step. Still, investigator-initiated clinical trials is something we are working with the government to support and start and encourage. Our screening program really succeeded and we are more or less similar to high-income countries when it comes to the rate of early detection. Still, we are working on improvement. We don’t have a national screening problem. We have a national awareness campaign problem.  Dr. Thierry Alcindor: Okay, so that's a lot of success.  Dr. Sana Al Sukhun: That's huge success. Not only that, in October, now you come to Jordan. It's not only one government-run program. You see all clinics offering mammography services, either free or 50% off for patients across the kingdom. That actually did reflect positively on neighboring countries. Egypt, for example, right now started the last couple of years a similar national awareness downstaging program with excellent numbers of cases caught up early. The region is really improving - I'm talking about our region in the Middle East - if it were not for the conflicts. That’s not the case when it comes to, unfortunately, countries with conflict, we all struggle. Jordan, Lebanon, even Syria, we all struggle with the refugee problem. Still, the refugees do not have enough funding, but a lot of NGOs are trying to help them. Along with what Richard described, you find many NGOs, they start themselves to help with access, to help with transportation, to help with medical fees for early detection. I believe we are moving far ahead when it comes to cancer, in particular over the past decade or so, as compared to many other diseases. Still, I believe we need contribution or cooperation between all stakeholders. That's what we still need. Dr. Thierry Alcindor: Okay, excellent. So I have a couple of questions that I would like to address to the two of you. Which barrier do you feel is the most difficult to solve when providing cancer care in low-resource settings? Is that the infrastructure? Is that the personnel who has not been properly trained? Equipment? Which would it be? Dr. Richard Ingram: Yeah. I appreciate it. And I really have been reflecting on Dr. Al Sukhun's heartfelt passion and comments. And thank you for sharing that, Sana. I think that's something we all need to be aware of. And a compliment to you and your team for being so inclusive in that region. I mean, cancer is a difficult enough diagnosis, but yet alone in a conflict zone, I can only applaud and empathize with you and a sincere tip of the cap to you and your team. That's incredible work. Dr. Sana Al Sukhun: Thank you. Dr. Richard Ingram: In general, you have to change the culture. You have to build trust in the process, the medical process, because that medical system may have let patients, family members, or neighbors down previously. So, I think building trust around screening and building trust around that there is an infrastructure that's going to take care of you if you have a positive screen.  I have several patients, but one comes to mind a very complicated trimodality disease, esophageal cancer. But the long and the short of it is, the patient presented to a rural outside emergency room with obstructive symptoms. The emergency room doctor was savvy enough to have some resources in their area but stabilize the patient. The test they could get; they could just get really kind of a barium swallow at the facility, saw there was a problem, but then called an oncology nurse navigator program that we've instituted in our region to cover this wide footprint. The nurse navigator was able to basically navigate this patient very successfully into a GI endoscopy program, which then got them in the cancer program and worked hand in hand with a social worker arm that we've instituted also to help assist the nurse navigation program. So the social worker was able to work on food insecurity, getting the patient actually applied for and got them Medicaid and got them transportation, barriers lifted.  So, it was a very successful anecdote compared to my unsuccessful anecdote earlier around lung cancer. So, to me, it's an example of a playbook that the Appalachian Community Cancer Alliance is trying to develop. So, maybe we can aggregate best practices in some way, shape, or form as the alliance and get those across the world, get those to Dr. Al Sukhun and the King Hussein Center in Jordan, and get it to wherever we need to in the world to help patients because the patient's problems are not unique to Appalachia. They're just unique to under-resourced and geographically spread out areas. Dr. Sana Al Sukhun: Absolutely. Dr. Thierry Alcindor: Yeah. That's well explained. Dr. Thierry Alcindor: Sana, which barrier would you say is the most difficult one for you?  Dr. Sana Al Sukhun: We all get involved and cancer is an emotional diagnosis. It's completely different from all other diagnoses. No matter what, all illnesses are challenging, but the word 'cancer', nobody can deny it. It still carries a lot within those few letters. So, good infrastructure, not only in terms of building - this is very important - it's also a multidisciplinary team within that infrastructure.  The other day, a patient came to the emergency room of the hospital across the street from where I practice. He was 25 years old, healthy, just some fatigue lately, and he collapsed. Actually, they found him pancytopenic. So, looking at the blood film, long story short, was highly suspicious for acute leukemia. The patient cannot afford admission to a private hospital, but he had insurance in the Royal Medical Services. In Jordan, we have different kinds of insurance depending on which section you belong to. It's more like the VA in the States. I talk to my colleague over there, tell them high suspicion for leukemia and he's like, "Send him right away." He was admitted simply because he had coverage; he had insurance. They do have also a good cancer center there. So, they had him admitted, had his bone biopsy done, diagnosed, and started treatment. That is an excellent example of how a good infrastructure, when available with good access to that infrastructure - so it’s infrastructure and good access to that infrastructure - can make a huge difference.  Dr. Thierry Alcindor: That's right. So, the two of you have offered plenty of potential solutions, which is, in fact, to a certain extent, the point of this podcast. But if you had to state what would be your first step, which one would it be? Rich? Dr. Richard Ingram: I think if I could not pick one thing but a collection of things, it really would be, top of mind, would be just an awareness that we have gaps in our infrastructure. Cancer care and navigation, even in the most resourced areas of probably the most resourced country in the world here in the United States, yet alone in some of our under-resourced portions of the United States. So you can only imagine in an underserved or under-resourced other part of the world. So I think awareness of the issues, awareness that we need to create a somewhat seamless infrastructure throughout the entire continuum from the screening of cancer to diagnostic studies to therapeutic studies to survivorship to palliative care and counseling. And then along the way layer in clinical research, which is the only way we're going to move the needle, and services such as genetic counseling along the way. So I would say awareness of the issues and then starting with the key stakeholders in your area, all coming around to the awareness of the issues, then you can start to build the infrastructure. And I think once you build the infrastructure, it will become easy to recruit and retain healthcare staff in a sound infrastructure - meaning I think that will get over the barrier of understaffing rural areas like Appalachia or other underserved areas in this country, in that if you have a great infrastructure, I think I know, as Sana alluded to, once you create this infrastructure, you as a provider want to practice there. You want to be part of something that has a great infrastructure because A) you're proud of the work done, B) the patient gets state-of-the-art comprehensive care, and C)  you're making a difference in your community. Patients aren't having to travel, patients are safe and have their arms around them with a program right in their backyard. Dr. Thierry Alcindor: Excellent. Sana, what would be your first step? Dr. Sana Al Sukhun: Thank you, Thierry, and thank you, Richard. You know Richard, every time you speak, you speak my mind. It just speaks for how much we are alike across the globe rather than we are different. We share the same challenges, we share similar barriers, and indeed solutions are more or less similar. After all, we're all human. If I were to think of one important thing, it's awareness. Awareness campaigns targeting the society, discussing the importance of early detection, prevention, and treatment. Awareness campaigns targeting all stakeholders, policymakers, number one, emphasizing the importance of infrastructure to be supported, to be environment-attractive for a good workforce to work together, build it forward, treat patients in a safe environment. Also targeting industry to collaborate with other NGOs in the society to support that infrastructure and empower it to start clinical trials for each community. Not only targeting the community needs but also the way you describe it, Thierry, using the new therapeutics in a society-adapted approach to improve access to treatment. Those infrastructures, once empowered and doesn't have to be one, once empowered, they can be infectious. They can contribute to elevating the medical care in different settings in each society. So, one good infrastructure can set the example for other institutions to improve their care and collaborate as well. So, it’s awareness campaigns putting all key stakeholders together including the society. Dr. Thierry Alcindor: Okay. Well, I think we had a very insightful and lively discussion so I would like to thank both Dr. Sana Al Sukhun and Dr. Richard Ingram for having joined us for a discussion about practicing oncology in low-resource settings. And for the audience to know, the ASCO Education podcast is where we explore topics ranging from implementing new cancer treatments and improving patient care to oncologist well-being and professional development. If you have an idea for a topic or a guest you'd like to see on the ASCO Education podcast, please email us at [email protected] and to stay up to date with the latest episodes and explore other educational content, please visit education.asco.org. Many thanks again. A pleasure to talk with you. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.