Advancing Pediatric Oncology v.2: Insights from Dr. Tezer Kutluk and Dr. Zainab Shinkafi-Bagudu

Prof Tezer Kutluk is a renowned Peadiatric Oncologist, Chairs the Turkish Childhood cancer registry, and a past UICC president. In this eposiode of ‘United Against Cancer‘, he speaks to HE Zainab Shinkafi Bagudu about the changing landscape of childhood cancer in Turkey, where there is a 70% survival rate.

Her Excellency Dr. Zainab Shinkafi-Bagudu is a global cancer advocate, a pediatrician, a UICC Board Member,  Founder of the Medicaid Cancer Foundation (MCF), and the Chairperson of First Ladies Against Cancer (FLAC). Dr Bagudu is working with the state ministries of health, education, and women affairs to implement programs to sustainably improve menstrual hygiene, girl-child education, economic empowerment of women, and put an end to gender-based violence. Zainab Shinkafi-Bagudu is a member of the Editorial Board of OncoDaily.

Tezer Kutluk is a Healthcare Consultant at Kutluk’s Consulting. He is the Past-President of UICC, Union for International Cancer Control. He graduated from Hacettepe University Faculty of Medicine in 1981 as third in his class. He completed his training at Hacettepe University Faculty of Medicine, Department of Child Health and Diseases in 1985. He became a pediatric oncology specialist in 1992. Previously he has worked at the University of Texas MD Anderson Cancer Center in Houston.

Zainab Shinkafi-Bagudu: Thank you so much. You went through a lot there. My next question was going to be in the last 10 years, what are the achievements?

You mentioned quite a lot. The fact that there has been a subspecialty training for pediatric oncology. The fact that you had universal health coverage.

The opening up of a lot of pediatric cancer with cancer centers that have the capacity to treat pediatric childhood cancers. However, the lack of human resources as well as clinical research and clinical trials and research is also a problem. You mentioned human resources, which is a point that resonates with me sitting in Africa, where we are seeing a lot of professional flights to high-income countries.

I have two follow-up questions from your first submission. The first one I would say is how do you see digital technology and the use of models like AI working in the general landscape of oncology in Turkey? Also, how have you been able to overcome the challenges of access in terms of local production?

Has that helped local production of the new generation medicines that we all know about, the chemotherapeutic immunotherapy agents and so on? Are you able to produce them in Turkey? I know that there is a lot of device manufacturing that comes out of Turkey and also frameworks and servicing of equipment, which spills over to countries in Africa a lot.

We get a lot of support for our medical devices from the Turkish companies. Let’s hear your responses to those two questions. The use of digital technology to combat human resources and then also local production. 

Tezer Kutluk: Accessing to the digital world is easy in Turkey, I would say. I know my colleagues in the Department of Radiology already started to use artificial intelligence in imaging. For example, they are able to use how to improve the digital images by using artificial intelligence.

But this is one area. I know many of our colleagues, not only in the Pediatric Oncology, all over the medical community in Turkey, has an interest in artificial intelligence, but still it’s in early phases, the early steps. You will not see that much research or initiative on that, but I think in the coming 3-5 years, we will see a lot of progress because Turkey is very open to the Western world.

So, the commercial relationships, the scientific relationships are very straightforward. So, we will not have a major problem, but definitely there is a central governmental scientific society. But the issue for these kinds of innovations and new things, implementation, is always a problem, even in the upper middle-income countries, because of having a priority issue.

So, sometimes it is slower than you expect. For example, I will give you an example. Turkey was doing really well on vaccine implementation, but I would tell in the past, Turkey is quite delayed to bring the hepatitis B vaccine.

Now, we don’t have any problem on vaccine, but sometimes it’s not because of the money, it’s not because you don’t have resources. Sometimes it’s a matter of the political priority, knowledge and advocacy, those kinds of things. In conclusion, you don’t see that many things in the digital technology, but I am sure the academia is very eager to invest more in the digital world.

The other thing is, Turkey is investing a lot on the medical devices, because recently we have well-established pharmaceutical companies, but still in the medium development level. So, we are not producing that much new drugs, but I know a few Turkish companies produced some of the classical difficulty on accessing type of medicines, were produced by some medical companies, but at the end, most of the pharmaceutical medicines are imported to Turkey.

Nowadays, after the COVID experience, COVID period, I think two things that gave us an opportunity to create a health literacy among the politicians.

They suddenly learned, they were obliged to learn, to invest on the medical devices. So, Turkey produced a lot of ventilators and other types of emergency medical equipment. Still keep investing.

The government is so eager to invest in pharmaceutical manufacturing, but I would say it is in early phases.

Zainab Shinkafi-Bagudu: Okay. Perhaps that would help to increase access. So, my last question is about the barriers that you have talked about and how we can overcome them in your opinion, in your context.

You have mentioned social barriers like culture. Does it affect pediatric outcomes in any way? Are there any particular cultures?

And of course, the role of advocacy. You have been a scientist for most of your life, but you have also dabbled in high-level advocacy, which I relate to a lot. I mentioned in the beginning, you’ve addressed the United Nations.

You’ve been the president of so many global and national organizations. So, those kinds of leadership positions means that you have been opportune to be an advocate and continue to advocate, particularly to the political class for better outcomes in cancer control. So, that I assume is one of the answers that you’re going to give, but let us hear from you the particular barriers that you face, socio-cultural, economic barriers in childhood cancer, and how advocacy plays the role in helping us.

Tezer Kutluk: Yeah. I already said the barrier on the human resources, not only in pediatric oncology, but also we had a problem on medical oncology. If we go back early 2000, for example, in 2003-2005, you will not believe that we had only a few hundred medical oncologists for a population of 85 million.

And the government didn’t see the problem, but people urged, it came to the door, then they were obliged to invest more in the education of medical oncologists. Now, we have around maybe 1,000 medical oncologists, but if it goes to pediatric oncology, I don’t know how to improve the situation.

Zainab Shinkafi-Bagudu: Why do you think the residents don’t want to be pediatric oncologists? What do you think is the problem?

Tezer Kutluk: I mean, there is a recent article published in the U.S. for the U.S. environment. Pediatric oncologists earn less money than medical oncologists, than radiation oncologists. Even the pediatricians, yes.

It’s not only the money issue, because it’s more painful, very difficult, comparing with the other sub-specialties. People are emotional, this is the other part. Plus, one thing also happened.

In 2010, Higher Education Council decided to merge pediatric oncology and hematology as a specialty. In the U.S., in some parts of the world, pediatric hematology, oncology is a single entity. But in some parts of the world, in some countries, there are separate branches.

In Turkey, it was separate. So, in one day, Higher Education Council combined hematology and oncology. The young generation, when they finish pediatrics, they decide to be a pediatric hematologist-oncologist.

Then, they are faced with another decision at the end of the hematology-oncology. Do they go to hematology side, benign side, or do they go to malignant diseases side? So, the people lost their motivation.

And then, at the end, pediatric oncology became, hematology-oncology became a less desirable sub-specialty. This is a real problem. But it is not only this.

Also, difficult specialties like thoracic surgery, neurosurgery, we government implemented the malpractice law. I am not against malpractice law. This is, of course, but you should have a good balance.

So, people, the young generation, once upon a time, gynecology and obstetrics was the number one choices for the young doctors. Now, gynecology and obstetrics, thoracic surgery, neurosurgery, pediatric oncology are less desirable options from the young generation. This is another barrier.

But I would say, I think in Turkey, the problem is the quality of the medical school is very good. The training is very high standard. We are having problem with the research.

I mean, the main single reason is the budgeting, financial issues. We don’t have any budget for research. People will say, we have this budget, this budget, but I don’t believe.

Almost zero budget, no budget for research. I mean, research, we are doing research, we are publishing our articles as a hobby. We overload, overload, all the doctors are overloaded.

So, they don’t have time to write an article. I do write my articles on weekend evening. So, this is a problem.

We don’t have spare time, extra time for research and academic side. This is not only pediatrics, it’s the clinical overload. Government is investing a lot on increased capacity in the last 10, 15 years.

Government established new city hospital projects, opened major hospitals through public-private partnerships, find the financing, opened new hospital. So, they are trying to increase the access to care, but still we are having problems. One last thing, although the care in Turkey and access to care is in good shape, and it’s getting better, it is still a problem.

The patient centricity is a problem. Patient does not have a name on decision-making about the future of the health. So, I mean, this is all over the world, in middle-income countries.

Somehow, high-income countries are investing a lot on the patient involvement or family involvement on planning, decision-making, getting their feedback, getting them in the system. Still, I think in low- and middle-income countries, we should find new innovative ways to get more involvement of the patients and the families.

Zainab Shinkafi-Bagudu: Thank you. Lots of very interesting points there, and insight into the work that you do, and even into yourself. We meet, but I now realize the heavy burden and workload that you have, and why sometimes it’s difficult for you to attend all the meetings.

But you have done very well in your global career. We appreciate you. We honor you and celebrate you at all times as a pediatrician, and also with a country that we have close relationships with in my country.

I like the way that you put it. Turkey is a country that is open to commercial as well as scientific relationships, and that really resonates with me. We have many medical students that go to your country to get a medical career.

They come back speaking the language so fluently, and through these collaborations, we can continue to advance not just pediatric, but cancer care for all patients. I thank you very much for your time today, Prof. I hope to see you soon. Are you going to be at the World Cancer Congress or not?

Tezer Kutluk: Yes, I will be there.

Zainab Shinkafi-Bagudu: Yes, you will. Good.

Tezer Kutluk: It’s always nice to talk to Your Excellency.

 Zainab Shinkafi-Bagudu: Thank you so much. The last thing we’re going to ask you to do before you go is to say, just with passion, I find this part the most difficult for the scientists. I just want you to say, United against cancer.

Tezer Kutluk: Okay. United against cancer.

Zainab Shinkafi-Bagudu: Thank you. That was good. The hand popped up.

Thank you so much, and have a wonderful day. You’re going back to the clinic now?

Tezer Kutluk:Yes.

Zainab Shinkafi-Bagudu: I hope we didn’t take too much. Thank you for your time, Tezer. Look forward to seeing you in September.

Tezer Kutluk: Thank you so much.

Zainab Shinkafi-Bagudu: Bye, Prof. Bye-bye. Thank you so much.

To see the first part of Advancing Pediatric Oncology: Insights from Dr. Tezer Kutluk and Dr. Zainab Shinkafi-Bagudu click here.