Colorectal Cancer and More Medical Diplomacy Acts: What is Better for Patients and Humanity

In the inaugural event of the Global Cancer Movement, initiated by OncoDaily, Dr. Ghassan Abou-Alfa delves into groundbreaking advancements in cancer research and treatment. This virtual session, held from December 6-8, 2024, brings together experts to discuss the latest in oncology, with a particular focus on immunotherapy, targeted therapies, and emerging clinical trials.

Congratulations again on the great efforts that you’re doing and thanks for the invitation. I’m going to go share my screen and admittedly, we’re going to talk about certain things reflecting rather than just like lecturing, saying this is what we should do or not do.

Yeah, so reflecting on what we’re going to talk about, I thought that maybe look at it from a medical diplomacy act because there are a lot of findings that really can help us really build this in.

But of course, understandable, ultimately, we’re still physicians, we’re still scientists. The aim exactly, as we just heard through the other discussions with Dr. Vansbrouwe and others, is how can we make sure that patients are cared for and cared for correctly? That’s really the bottom line of it.

So these are my disclosures and these are my contacts. I mean, many people ask and please feel free, if you want to take a picture of your QR code, you can connect with me. But Ong Daily does an amazing job.

I mean, I will say jokingly, Ong Daily, if you lose where you live, they can find it for you. So that’s really the great thing about this area. Thanks so much, guys, for all of this effort.

So I’m going to start a little bit with the story from why we’re talking about all of this. What triggered that specific talk and that specific subject is, at the moment, proudly, we’re looking into the next-gen sequencing for the first time ever in Armenia. And we’re analyzing it in a collaborative work between Sloan Catering and Armenia, trying to find out like really what is so different, if any, in regard to the patients in Armenia with colorectal cancer.

And you can look at it as a very simplistic question, like, you know, what should we do or what’s the answer? But the question is, you’ll in no time figure out that there are a lot of variables that you have to really pay attention to as you work with that nature. And just give a little bit of perspective what we have done so far so you can really get the sense.

And you’ll notice that I’m not showing any data on that yet, because, to be fair, we’re still finalizing it. And I want to be respectful to my colleagues in Armenia in regard to wrapping it up, because this is really their lead effort and we’re helping them and supporting all that. But nonetheless, we pretty much, patients are consented on a clinical trial in Armenia, in Yerevan.

And number two is that the tissue sampling and detailed material demographics are being shipped to Sloan Catering in New York. And from there, we’re doing natural sequencing and trying to analyze the data with our clinical medical oncology group here at Sloan Catering. Have we done that before?

Yes, of course we have. And actually, that’s the paper I’m showing you, because this is the first one ever we did was with the American University of Beirut, where we built a whole tissue bank for them, where pretty much any patients who will just come in, consent, they can have their tissue banked in the institution in Beirut, Lebanon. And the idea was, can we learn from it down the road for any specific purpose?

And as you can see, in our first effort that we published already in JCO Global Oncology, we found that certain cancers probably are going to be more pertinent, which implied right away for you, incidence in a specific population. And number two is, we were rather impressed with the readiness slash non-readiness of the patients to look into this. And interestingly, one third of the patients said no.

And when we asked ourselves and permitted, we asked permission from the IRB to ask even the people who denied getting on the clinical trial, will we be allowed to probe them only with one more question, why you said no? And I would say that we’re a little bit naive ourselves and our colleagues at the American University of Beirut, we thought that the questions could be, maybe I’m worried you’re going to take my data away. I’m worried that my religion will not permit me to do so.

Remember, we’re talking about an area in the world where really, it’s still very intensely religious and strong believers, and thought maybe culturally it’s not the right thing to do. Maybe I should need to protect my family, et cetera, et cetera. But interestingly, one of the answers that really was not really vetted out on our part, thinking it’s going to be an option that they will choose, and impressively almost two-thirds of patients said, because we don’t know what you’re asking us, as simple as that.

And this is really how much, to go back to what Verna was talking about, like how much education is critical, literally two-thirds of patients said, you know what, we have no idea what you’re talking about.

And this really will tell you about important, when I go on efforts of that nature, we can have to start right from the base, right from the ground in regard to, number one, is ensure patients do understand this for the merit, because that idea that cancer happened because it’s luck, it’s from God, it’s because I did something bad in my life, you know, we’re very good at blaming. Human beings are very good at blaming in every way possible.

But what about the genetic error that just happened because just an error, and that led to the development of a cancer, it’s not even there yet. And that’s really what’s important to rebuild this and try to understand this, where it might take us from. With this said, proudly, we have this on the side only to tell you an effort of that nature, we are like beyond the 1,000 tissues, and all the tissue remain lodged at the Medical University of Lebanon.

Only if we have any project that we are sharing or doing together, then the tissue will be brought into the American from the American Visitor Bureau to Sloan-Kettering, we do the analysis necessary and we ship it back. And for example, we lately, our colleagues in GU looked into bladder cancer that’s caused a secondary presumed side risk factor being cigarette smoking in the Western Hemisphere, versus Hubble bubble smoking in the Middle East, and the genetic alterations that occurred in either of them that’s already published. We kind of did not necessarily stop there, we kind of have been using that version, even though, as I said, the tissue bank is not happening yet, except at the American University of Beirut.

And probably they have direct access to our database, so they really can access and enter data immediately into Memorial website, on the website, I mean. And at the same time, we are ready to take projects wherever we are in the world to really study on these things. And that’s why, again, you see how we are evolving into the effort that we’re doing currently with Armenia.

For that matter, we did a similar one, this was just published literally, barely a few weeks ago, with Chile. Because as many of you know, in Chile, it has the highest incidence of gallbladder cancer in the world. And however, we don’t know really anything about sequencing in the patient in Chile.

So this study, we’re very proud, and this one of our superb fellows who trained with us before getting back to Chile, Sebastian Mondaca, and it shows the good and bad. It shows the good stuff that we did very well, and number two, it shows the challenges that we are going to have. And there’s something very important for all of us to recognize as we continue to make efforts of that nature.

Number one, we found out that after all the genetic analysis of patients with gallbladder cancer being of native Chileans versus Spaniards versus Western Hemisphere in the U.S. did not matter. They all have the same profile, pretty much, give and take. However, you notice very clearly here, if you look right on top of the right side of the screen, you’ll see that PUC stands for the Pacifica Universidad de Chile.

This is the Catholic university of Pacifica University in Chile and Santiago. And the other side is MSK cohort. And you can see, whoa, like we barely have any number of patients from Chile.

We had 23 only, while for Memorial Society, we have 237. So we’re like talking about 10% of the population. And just one more time, now you can see how the story bridge in between what we have done with the Americans of Beirut and how much patients will probably lack education and how much really we had chance of losing on about one-third of patients who really were approached for consenting.

And there you go, in Chile, we have only a sampling of 23 patients compared to 237 from Sloan-Kettering. We know we are a big center, but still gallbladder cancer has the highest incidence in the world in Chile. So that’s make us give a pause.

And we did challenge that the people are invited to look into about the ways that we can really circumvent those kinds of efforts and be able to really get more analysis and more data. Now, with this said, again, to kind of look at the challenge that we’re doing per se, one thing that I would like to really pause on is this case. By the way, this is from the legal equivalent of PubMed.

This is like, you know, from LexisNexis, it’s like a search database. You can, like, same way any of us would put in PubMed, you know, Dr. Cassie, the name, Corectal, you’ll find all what Dr. Cassie published on corrective cancer. Here, you can look what kind of case you’re really interested in.

You can look, for example, I want, like, a dog bite in the right hand, whatever, you can find it. And interestingly, in that database, the case that really stood out and pertinent to our work is Moore versus Regents of the University of California. And by the way, one thing in the law system, as you know, all over the world, the minute you are into the legal arena, everything is public.

There’s nothing more privacy anymore. So that’s why, actually, Moore is the name of the patient. And interestingly, here, as we know, when you put the case, is Moore the patient suing UCLA, University of California Los Angeles.

Why is that? Because, if anything, Moore had hairy cell leukemia. And when he got the hairy cell leukemia, some of you might guess and might know from your days as a general hematologist, oncologist, hairy cell leukemia, actually, treatment was, at some point in time, splenectomy.

You take the spleen out. And, if anything, Moore had the spleen out. If you give credit, UCLA took care of Moore very well, and they took the spleen out.

And then, in follow-up, they start taking blood work on Moore on a regular basis to check in, make sure everything is good, and they collected that data. One day, somebody woke up at UCLA and said, wait a minute, did we consent Moore for all that effort? And they said, oh, maybe not.

They went ahead and called Moore, the patient, told him, by the way, we did the following, we’re doing the following, this is all for you to make sure, understand your disease better, et cetera, et cetera, but we would like to consent you. By total serendipity, who was with Moore at home that day when he got the call? His friend was a lawyer.

And the whole question really brought up, like, whoa, this is my spleen, how come you guys are working on it without my consent, per se? Believe it or not, this is actually ended up a lawsuit, Moore against UCLA, that went all the way to the Supreme Court. And the question is, of course, to make it simple, who has right to that spleen and who has right to those bloods?

Is it Moore or UCLA? I wish we have an interactive discussion where I can get a probe on everybody, but I’m sure all of each one of you is thinking about, like, I take this side or that side. But for those who really said that Moore won because it’s, after all, Moore’s spleen, it’s Moore’s blood, they did not consent, interestingly, you’re wrong.

Actually, the court stood with UCLA. And this is their argument. By the way, can anybody tell, and you’re going to laugh at this one, anybody can tell me who has a freezer that knows how to maintain spleens at home?

What’s the experience that Moore has? Interestingly, UCLA won, not because, oh, yeah, you don’t know how to do it, or you’re wrong, et cetera. They got the slap on the hand, because after all, they should have consented more.

There’s no question about it, and the law is saying that you should have consented more. But interestingly, a beautiful statement that came from the Supreme Court, they said, that spleen and that blood, that kind of analysis is important for humanity. And they used the word humanity in that statement.

And in other words, even though UCLA was wrong not consenting, but at the same time, we really will tell them you should have consented, but still, however, they have more value from this tissue than not, and as such, it should really belong to UCLA as a custodian of the tissue, because ultimately, tissue is owned by the patient themselves, not by anybody, and try to really help better understand how hair cell leukemia would occur and happen.

Why bring this up? Because one of the challenges that we’re doing as we’re doing our exercises now, and this is one of the things that we have done with Armenia as well, like, okay, you’re sending tissue, we’re doing the analysis, like who owns what? And for that matter, we’re actually dealing with this issue, and go back to my dear friend, Verna, is we’re dealing with this in Africa.

And the question is, if I’m going to put this scenario here, I pick a call, and I just, I called my friend Verna, and I’m doing this only for illustration purposes, and say, hey, Verna, I’m doing this new research at Memorial, definitely, I think if you can understand, about 20 patients from Ghana will understand better exactly what’s going on here. Can you send me the tissue?

And you know what, I’m going to be nice, just I’m going to send you the shipping bill, don’t worry about it, and you know what, any publications, as you can see here, we need to do some research in red, we do the shipping, it arrives, we do the analysis, we publish on it, and of course, Verna’s name is on it, because after all, she was part of this.

But interestingly, let’s assume, let’s assume what we ask as a question really could lead to a new therapy. And basically, this actually is happening as we speak with what we’re doing with Armenia, because we’re doing actually a lot of deep analysis to check point inhibitors, potential targets in the Armenian population. And if we would just do that part, as you see, I put like a dollar sign with wings at the end, because yes, it’s money out of the window, because we didn’t do anything that will really help our patients and our colleagues in Africa for that purpose.

And as such, our vision is the following, is yes, we’re going to do a certain evaluation, we’re going to get some sponsorship for it, like whatever pharmaceutical company or whatever entity, we’re going to tell them, it’s going to cost you that much and start. And what’s this that much? That much is we do the shipping, we do the genetic analysis, we get to the publication.

But what’s interestingly, that money that we collected in the beginning is going to be in a custodian account. When a drug is developed, rather than patients in Africa, to give you a little bit of an example, we just published lately in JCO, as you’re well aware of, we did find out that only 5% of our colleagues in Africa, 5% out of 500 we interviewed have access to checkpoint inhibitors. And why is that?

Because they say it’s costly, we can’t afford it. And as such, rather than pay when you need it and really say we don’t have the money for it, because now the resource was paid for in advance, this is money that will remain owned by the people of Africa for the sake of getting the new therapies. As a such, Africa would have paid for the drugs not on a credit, but they paid on a debit, i.e. they pre-paid it per se.

So as you see, these are not necessarily a classic discussion that we all have, but rather these are, and I’m not implying in any way, shape or form, that these are like really defining answers per se, but these are an opportunity for us to start posing questions about those important questions, so hopefully we’ll know how to better serve our patients wherever they are. And proudly we’re doing this with Armenia, we’re doing and paying attention to all those details as we go, and hopefully we’ll have a little bit more details that we’ll publish at some time soon. Thank you.

And what we have done, and some of you are aware of that effort, back in 2022, and this is before the latest unfortunate event that humanity is still dealing with being in Ukraine or in the Middle East, we invited 72 of our colleagues from 36 countries that are in conflict. These colleagues, their countries, not themselves, but their countries don’t talk to each other.

And the question was exactly what you brought in, like can we really figure out a way to understand better about our patients, that way we can really better understand where genetic analysis is coming to play. I’ll give you an example why this is important. Interestingly, I’ll give you an impressive example that’s already published.

I give credit, like you can see how it really was built around. One of our colleagues, well-known in Israel, her name is Efrat Levy, she’s a well-known geneticist in Jerusalem. She worked with one of her colleagues who is also a geneticist in the West Bank, his name is Moin Kanan.

And together they found out that a understandable, and this is what we all know, that’s published and there’s plenty of data on, an Ashkenazi Jewish woman with a BRCA mutation, if they get that kind of specific alteration, what did they get? Most likely they’re not breast cancer. Interestingly, they found that actually, if you have the same BRCA mutation, by the way, this is very important for all of us, we’re all one people all over the world.

It’s not like BRCA happening, you know, here in Slovakia, we have BRCA families from China, we have BRCA families from Saudi Arabia, you name it. Interestingly, if you have a BRCA mutation in a Palestinian woman, specifically a Palestinian Muslim woman, it does not cause breast cancer, it causes ovarian cancer. And the question is, what’s more about this genetics?

We don’t know. So we proudly, when we met together, we brought in the question is, can we understand from this? Because we’re trying to understand if the divergence of population will stress out the genetic makeup of the tumors, and same time, could it be also the other way around?

And there’s a good example of conversions. Conversion is the best example in Singapore. 25% of the population of Singapore now is Chinese Malay mixed, and could be the conversions of population could lead to something else.

To that matter, and this is a nice story to kind of finish on a nice tone, as Gemma asked, who got really interested in our data? The United Nations. And if anything, we currently are working on, stay tuned, we don’t have that really announced officially yet, but at least there’s some probing on it.

We are actually hoping to have a opportunity for the next generation for our advanced medical students, residents, fellows, junior faculty, wherever you are in the world, to apply for a grant support that will look into any question that impact germ genetics, or environmental impact in areas of conflict. How can we really bring people together? And of course, we’re going to invite mostly people who are really coming from conflicting zones.

But we at Sloan Kettering want to be the middleman who can help out rich people together. So stay tuned. This is hopefully happening.

We don’t have any date yet, but I would say 25, 26, you’re going to see about the meeting in Geneva, and you’ll be invited based on the completion basis. And hopefully we’ll get something out of it for how to help understand cancers better, get better treatment for people. And of course, if it does contribute to peace, we’re not going to say no.