So, the purpose of this brief conversation is just to share with you some of the resources that we believe may be useful for cancer care in Africa that the NCCN has developed. And we have been very fortunate to interact with many colleagues from Sub-Saharan Africa, including the Ugandan Cancer Institute, which I'll show you in a little bit. So, let me just tell you a little bit, if you don't already know, about the NCCN. Next slide, please. Katie? Hello? Oh. Can you see my screen? Oh, yeah. Sorry. All right. My bad. So, NCCN is an alliance of now 30 leading cancer institutes devoted to patient care, research, and education. And so, you can see that shares a lot of similarities to the IGCS, although, of course, IGCS is in a much more focused area of gynecologic and maybe breast cancer. The two most recent institutions to join NCCN as of March was UCLA and UT Southwestern in Dallas. Our mission is to improve and facilitate quality, effective, efficient, and accessible cancer care so patients can lead better lives. And our vision is to define advanced, high-quality, high-value patient-centered care globally. And we can only achieve that in collaboration and partnership with other organizations and with experts like you all who perform the frontline cancer care at international sites. Next slide. So, the NCCN has a library of 76 guidelines featuring more than 198 algorithms that apply to 97% of cancer cases in the United States and arguably globally. The difference between guidelines and algorithms is that, for example, if you look at non-Hodgkin's lymphoma, that's one guideline, but it has six or seven algorithms because it includes brickets, aggressive B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, marginal zone. So, those are all subset guidelines, if you will, but there's 76 guidelines in total, including in GYN. And in GYN, the cancers, there's a cervix and uterine, vulva, and gestational trophoblastic neoplasia guidelines and ovarian cancer guidelines, as well as, and I know some of you may do breast cancer, there's also obviously a breast cancer guideline, and of increasing importance and relevance, breast and cancer, ovarian cancer, risk reduction, and prevention guidelines. Next slide. So, we are very pleased with the fact that NCCN guidelines are used worldwide. Last year, in 2019, there were 11.3 million guidelines downloaded throughout the world. About a third of those are downloaded outside the United States. Next slide. We have known for a long time that adherence to guidelines improves outcomes for patients, and I'm not just saying that these are NCCN guidelines. You know, we know ESMO, we know ASCO. We know that many organizations do provide good guidelines. The one unique characteristic of the NCCN guidelines is that they are updated in real time, because as soon as a new drug or new device or new technique is available, they get updated rapidly. For example, and I know this is not specific to GYN cancers, but non-small cell lung cancer gets updated each year between five to eight times because of approval of drugs. And in ovarian cancer, for example, even if it is not in the yearly renewal cycle, when drugs like the PARP inhibitors get approved or there is a trial presented, that gets updated in interim fashion very rapidly. I will share these slides, and in fact, Susan will share these slides with you, so I'm not going to go over them all in detail, but you can see the various aspects of improved outcomes. Next slide, please. And these are more recent guidelines-based research. I want to bring up a very recently published article that was just published in GYN Oncology a few months ago that showed that guidelines concordant treatment associated with improved survival in patients with non-endometrioid endometrial cancer. So in your discussions today with serous endometrial cancer, you would see that there are specific issues that may be useful for you. Next slide. And you can see that the NCCN guidelines are downloaded globally in over 180 countries. I want to point out a very interesting thing that we learned. If you look at Sub-Saharan Africa, it seems to have a relatively low download. This is a map of downloads by absolute numbers, but we found out in collaboration with people from Sub-Saharan Africa that based on the number of oncologists, if you were to correct this and normalize it for the number of oncologists, the number of downloads in Sub-Saharan Africa is actually just as high as in, say, the United States or China, again, when you normalize it for the number of oncologists. So we do realize that there is good penetrance and reference to the guidelines. Next slide. As I mentioned to you, we have been very fortunate to work with a group of Sub-Saharan African oncologists. The NCCN is committed to making its guidelines available globally. So there are translations, adaptations, frameworks. I won't go over those in detail, but the harmonized guidelines in Sub-Saharan Africa we feel has been one of the most gratifying aspects of collaboration. In two and a half years, or about three years, we now have about 46 guidelines that have been harmonized with our Sub-Saharan colleagues, and that covers about 80% to 85% of all cancers in the Sub-Saharan region. And beyond just cancers, specific site-specific cancers, we've also managed to harmonize supportive care. For example, survivorship, emesis control, pain and distress, and those things that may be helpful for use irrespective of cancer type. Next slide. I'm going to skip through the framework. That's a process that we used before we went to the harmonization to kind of teach ourselves how to develop tools that may make the guidelines relevant in resource-constrained areas. Because as originally done, the NCCN guidelines were done for U.S.-based comprehensive cancer centers, and we realized that in many places, you can even argue in many places in the United States in rural settings, there's not all those resources available. So next slide. In the harmonized guidelines, which is available for all to download, you will see that we have modified the NCCN guidelines to sort of a color-based scheme. The parent guidelines, the context remains in the background. What is left in black text is generally available standard of care. And it's not what NCCN decides to be the generally available standard of care. It's what people in Uganda and Kenya and Zambia tell us is the generally available standard of care. The harmonized guidelines are all made with collaboration and actually leadership from the Sub-Saharan specialists. What we gray out are things that may be costly, challenging, and while they may be important in the future, it serves as an aspirational roadmap. In blue text, we add things that may be regional options that are considered when availability precludes general standard of care. A very classic example of that is if there is no radiotherapy available, we recognize that for some patients with advanced cervical cancer, new adjuvant chemotherapy followed by surgery may be an option. It may not necessarily be the best option, if you will, but it is certainly a reasonable option if radiotherapy is not available. And then there's a small group that we recognize are options that will essentially never be available in the near future. Next slide. So for example, here's cervical cancer, which was one of the first guidelines developed or harmonized because of the incidence of the disease. And you can see that at the time that we did this, surgical staging, routine surgical staging was grayed out because that was felt not to be regularly available. And you can see that added in blue text, even though locally advanced cervical cancer, everybody agreed that chemo radiation was the standard of care. If radiotherapy was not available, various options that are still supported by evidence were made available. With the notion that as availability and resource and training increases, we will move to remove the blue and gray text and turn everything to black. In fact, that was the mantra at our last meeting, make the gray black, as advocated by folks from Africa. Next slide. So this has represented a multidimensional collaboration with, as I mentioned, the African Cancer Coalition, the American Cancer Society, the Clinton Health Access Initiative, and the IBM Foundation. And these guidelines for Sub-Saharan Africa have now been endorsed by the Ministries of Health or National Cancer Institutes in Ethiopia, Malawi, Nigeria, Tanzania, specific to UOL, Uganda, and Zambia, representing almost half of the population in Sub-Saharan Africa, understandably excluding South Africa itself. Next slide. The use of the harmonized guidelines for clinical decision support, for education, people have used it for policy and for advocacy, for improvement in funding and support, identification of gaps for research, and hopefully in the future, in collaboration with organizations like IGCS, using them to measure outcomes. There's also a use of the guidelines to be able to predict chemotherapy use, and this has been partnered with the Clinton Health Access Initiative for inventory management and for bulk ordering of chemotherapy, either in a hospital or in a region, or sometimes across countries. Next slide. So as I mentioned, we now have 46 published guidelines, and this is all thanks to the leaders from Sub-Saharan Africa, and you can see the list of cancers that have been harmonized. Next slide. This process has led to a formalization of this relationship, now called Allied Against Cancer. There is a website that you all can all go to, evaluate the work, download information, and those are the partners. Next slide. From the Uganda Cancer Institute, you can see that there have been very important people involved in the whole harmonization process. So the one I know the most is Henry Dodongo, but Nixon, Niozema, and Fred Okuku have all contributed in various ways to the harmonization process. Next slide. I do want to mention that if you go to the Allied Against Cancer website, you are able to download something called the Cancer Guidelines Navigator. This was developed by IBM, and it has the guidelines where you can input patient-related factors and come up with recommendations so that you don't have to peruse the entire guidelines. This is a process that continues to develop, but within this Guidelines Cancer Navigator, we have placed and developed protocols or processes for cervical, breast, Kaposi sarcoma, B-cell lymphoma, and we're almost done with prostate cancer. Next slide. For those of you, and I know in many places, we're all dealing with COVID-19 issues, and the NCCN has a COVID-19 resources webpage that may be helpful to provide general information and shared best practices. Next slide. So these are the lists of the NCCN member institutions. I'm going to stop here and thank you for your time and attention. We want to be a resource to you all, so if there's any questions, you know, please contact myself or Katie Winkler-Preschner. Again, we will make these slides available for you as a resource, but more importantly is for you to go to the websites if you need to download the information and help it in your practice, in your education, and ultimately in advocacy and resource development. Thank you.

National Comprehensive Cancer Network

cancer care

Africa

guidelines

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