Ami Bhatt is mobilizing Stanford experts to fight the growing threat of cancer in the developing world.
By Ruthann Richter
As a child growing up in the United States, Ami Bhatt would frequently take trips with her parents back to their native country of India, where she saw a world altogether different from her comfortable life in San Jose, where she was born. It was a lesson in global disparity that she would not forget.
“It was impossible not to see the inequity,” she said recently. “It seemed like we needed to do better.”
Now the director of global oncology at Stanford, Bhatt, MD, PhD, is determined to do just that for patients in the developing world, who are more likely to suffer and die from cancer than those in developed countries. The majority of cancer cases — 57 percent — occur in low- and middle-income countries, and 65 percent of global cancer deaths occur in these parts of the world, according to the American Cancer Society.
“If you ask people, ‘What do you think is a bigger problem in the developing world, malaria or cancer?’ they will say malaria,” said Bhatt, an assistant professor of medicine and of genetics. “But cancer kills more people than HIV, malaria and TB combined worldwide and in the developing world.”
More cancer deaths in developing nations
Of the estimated 14 million new cancer cases reported worldwide in 2012, nearly 8 million were among patients in developing countries, according to the latest figures from the American Cancer Society. And more than 5 million of the 8.2 million reported cancer deaths that year were among patients in these nations.
Bhatt, who came to the School of Medicine in late 2014, has spent the last year and a half mobilizing dozens of faculty and trainees at the university to collaborate on projects to combat cancer in the developing world, where the disease is on the rise. With longer life expectancies, people are surviving into middle age and beyond — long enough to become prone to conditions such as heart disease and cancer. In Rwanda, for instance, life expectancy in the early 1990s was just 30 years, as many died of uncontrolled HIV. Now, with the wide availability of new life-prolonging antiretroviral drugs, life expectancy in the East African nation is 63, said Shruti Sheth, MD, a Stanford breast cancer specialist collaborating with Bhatt on a project to improve care in Rwanda.
Cancer-causing infections, such as hepatitis B and C, human papilloma virus and H. pylori, also are much more prevalent in the developing world. These pathogens can lead to liver, cervical and stomach cancers, respectively, with the highest rates occurring in developing countries, according to a recently published report.
Like most people, Bhatt was unaware of this trend until she started a hematology/oncology fellowship at Harvard in 2009 and began to look more closely at the numbers, which jumped off the page.
Not just a First World problem
“I had fallen victim to the same myth about global cancer — thinking it was only a First World problem,” Bhatt said. “I started to look at the data and realized just how misguided that was.”
She became passionate about the issue, finding a like-minded colleague in Franklin Huang, MD, PhD, another fellow in her program. “I think we really connected because we felt this strong sense of need for equity in cancer care,” said Huang, now an instructor in medicine at Harvard. “We were surrounded by the most advanced treatments in the world, yet both of us knew there was a great distance between that and what less-fortunate people in the world suffer. We connected on day one, as we both believed deeply that that was wrong.”
The two decided to form a nonprofit, called Global Oncology Inc., or GO, to build a community of people, both inside and outside academia, to tackle the issue and become advocates in the field. Bhatt’s travels to developing countries, such as Botswana and India, brought home the stark disparities in care and reinforced her determination to act.
“When you go to these places, it’s heartbreaking,” she said. “You see women who come in with a mass of breast cancer that is out of control, causing their bodies to be misshapen.”
While in Boston, she and her colleagues hosted the lone oncologist from Malawi, who serves a population of some 16 million. “There are probably more oncologists in the San Francisco Bay Area than in the entire region of sub-Saharan Africa,” she said.
When they asked him how they could help, they learned that many patients drop out of treatment because they don’t understand the therapeutic process and what to expect from chemotherapy. Through GO, Bhatt and Huang worked with a design firm and colleagues in sub-Saharan Africa to develop patient-friendly materials with appealing visuals and simple messages about chemotherapy and its potential side effects, as well as a log that patients can use to chart their complications.
The materials have been expanded for use in Rwanda, Botswana and Haiti, where they are distributed in cancer wards. “The feedback is that patients really appreciate them and share them with family members. It’s something real that patients can touch and take home with them,” Huang said.
The pair also worked with the National Cancer Institute — which has made fighting cancer worldwide a priority — to develop a map of cancer researchers and program managers, a first-of-its-kind resource to help spur collaboration among international experts in the field. The map includes more than 1,500 projects on six continents, with a search mechanism so individuals can readily connect with colleagues and share their collective knowledge.
“This is an excellent initiative, and it really brings people together,” said Ann Hsing, PhD, MPH, a professor of medicine, who is co-leader of the Stanford Cancer Institute’s Population Sciences Program. “If you want to work in this field, there is no easy way for people to find each other. This network will greatly facilitate that.”
There have been other successes as well. In 2013, while teaching classes on cancer and palliative care in Botswana, Bhatt discovered that patients in the southern African country had lost free access to Gleevec, an expensive, life-prolonging drug used to treat certain kinds of leukemia. Patients were being put on hydroxyurea, which might extend life for three to five years, compared with 20 to 30 years with Gleevec, she said. She and her colleagues persisted for months, lobbying the Ministry of Health, the drug manufacturer and other groups to restore access to the drug — an example of her relentless drive to gain more equitable treatment for patients.
“I’m obsessed. I can’t stop,” she said. “This is so important, and there aren’t enough people doing it.”
In 2014, Bhatt was recruited to Stanford on the strength of her research, which focuses on how changes in the microbiome are associated with cancer. Because of her international work, Michele Barry, MD, professor of medicine and director of the Stanford Center for Innovation in Global Health, tapped her to lead the university’s global cancer effort.
Since her arrival, Bhatt has been scouring the campus, rallying people who have an interest in the field and an expertise and willingness to work on projects.
A national oncology program for Rwanda
Last summer, she introduced Sheth, a clinical assistant professor of medicine, to a Rwandan physician visiting Stanford for a global health training course. The Rwandan doctor, Francois Uwinkindi, MD, had previously led the country’s HIV/AIDS effort, but had recently been charged by his government to develop a national oncology program from scratch. Bhatt and Sheth met with him to see what they could do.
He said that because of huge service gaps, “they had to prioritize all cases of cancer and put those people on the plane to Uganda or India,” recalled Sheth, who was incredulous. “We just send our patients across the street. … We felt we must do something about this.”
She said his initial goals were to create a cancer registry to get a realistic view of how many people are suffering from the disease, and to build the country’s first radiation therapy center. The center is a huge undertaking; it means there has to be a stable electrical and water supply, as well as trained personnel to run the machinery, among other things, Sheth noted. She and Bhatt arranged meetings for Uwinkindi at Varian Medical Systems Inc. in Palo Alto, a pioneer in radiation therapy. They hope to travel to Rwanda later this year to get an up-front view of the challenges on the ground.
“It is achievable. Rwanda is absolutely poised to do this,” said Sheth. “It’s the only country in the region that is far enough ahead to consider these objectives. I stay up at night thinking, ‘This is a big deal. It could happen.’ It could be overcome but requires serious efforts.
“This is where a partnership with an academic institution is helpful,” she added. “With a dynamic person like Ami, she can mobilize a lot of people and be really instrumental in overcoming these challenges.”
An international tumor board
In another effort, Bhatt has gathered together a team of clinicians, including a radiologist, a radiation oncologist, a pathologist and residents, to serve on Stanford’s first international tumor board. Tumor boards are teams of clinicians from diverse subspecialties who meet regularly to discuss difficult cancer cases and decide on the best course of action.
The group would essentially serve as a consulting body for cases in developing countries, using an online platform developed by GO to upload imaging studies and connect with clinicians from distant locales — a system that Bhatt said “throws a lifeline” to nonspecialists in the developing world.
“The idea would be to discuss cases via the Internet, review radiology and pathology images and other tests and come to a consensus on the best treatment options, trying to adapt them to the realities,” said Eduardo Zambrano, MD, professor of pediatrics and of pathology, who has agreed to be part of the team.
An expert on bone, soft tissue and pediatric solid tumors, Zambrano serves on the musculoskeletal tumor board at Stanford, participating in reviews of both adult and pediatric cases. But he also has volunteered his expertise for years reading tumors slides and providing cancer diagnoses for very poor pediatric patients in Latin America.
He said the fledgling international tumor board would likely focus its initial efforts in Guatemala; one of the participating clinicians, pediatric oncologist Sandra Luna-Fineman, MD, a professor of pediatrics, is a native of the country and has been in contact with colleagues there.
Seeking help from population scientists
Bhatt also has been connecting with Stanford Cancer Institute faculty in population sciences who are trying to assess the extent of cancer in various parts of the world. Among the 56 countries in Africa, for instance, only a handful have high-quality cancer registries, large databases with patient histories, diagnoses, treatments and outcomes, said Hsing.
Providing reliable data on cancer and supporting research and prevention in the developing world are among the global populationwide initiatives of the Stanford Cancer Institute.
Bhatt said Stanford is in a unique position to lead this international effort.
“There are few universities that have the wealth of technical and engineering expertise and the multidisciplinary culture to contribute to solving this problem,” she said. “That’s why I think this is the year of global oncology at Stanford. I think if we sprinkle a little water on it, it will grow.
“There are so many places where we can make improvements,” she added. “We just need to start.”