When Dr. Corey Casper joined the Hutchinson Center nine years ago, its commitment to HIV/AIDS research puzzled him.
“It was an enigma to me why a cancer center would have a premier HIV/AIDS program,” Casper said.
It didn’t take him long to figure it out. The Center’s researchers have always studied and fought infectious diseases. Controlling infections in immune-compromised leukemia patients was critical in the pioneering use of bone marrow transplantation. So it was only natural that Center scientists would expand their research into other infectious diseases.
Today, as a leader in both cancer and infectious disease, the Center is uniquely qualified to address the global burden of infection-related cancers. But it’s not something it chooses to do on its own. That’s where Uganda comes in—an African nation whose people seek to tame one of the highest rates of cancer in the world.
Earlier this year, the Center and the Uganda Cancer Institute signed a five-year commitment to work together to better prevent, detect and treat infection-related cancers in Uganda, a partnership that’s likely to have a major impact beyond the country’s borders.
“It puts us at the intersection of cancer and infectious disease just as momentum to explore their connection is growing,” said Casper, co-director of the Center’s new Uganda Program on Cancer and Infectious Disease. “No one is better suited to work on this than us.”
We now know that infectious diseases contribute to about 20 percent to 25 percent of the world’s cancers—a statistic that would have been unthinkable only a few years ago, before research established how chronic infections from certain viruses, parasites and bacteria led to cancer.
A key discovery involved the human papillomavirus, a common infection. Researchers finally ascertained in the 1980s that the virus is the main cause of cervical cancer, which remains the second most common cancer in the world, with about 500,000 new cases and 250,000 deaths each year—virtually all linked to HPV. Tens of thousands of lives could be saved each year if the HPV vaccine—which is 98 percent effective in preventing cervical cancer—is made widely available, especially in developing nations.
Cervical cancer is a major killer but it’s far from alone. The World Health Organization estimates that the proportion of infection-related cancers continues to grow, with 1.5 million people around the globe dying each year from them.
By working closely with Ugandan researchers and oncologists, Center researchers hope to expand their knowledge of infection-related cancers, improving cancer care in Uganda and at home. It is a critical area of study. Infections have been identified as contributing factors in lymphoma, sarcoma, liver cancer, prostate cancer, bladder cancer and stomach cancer.
In Uganda, infection-related cancers are taking a growing toll on the population. The country’s 30 million people already suffer from one of the highest rates of cancer in the world. And the disease is ravaging two vital groups: children under the age of 12 and middle-aged adults—the primary wage earners.
“In Uganda, cancer is overshadowed by communicable diseases (such as HIV/AIDS and tuberculosis) and hence not accorded high priority,” said Dr. Jackson Orem, head of the Uganda Cancer Institute and Casper’s co-director of the new cancer partnership. “But that doesn’t mean that cancer is rare. Instead, it is growing due to many factors including the aging population, infections and probably environmental changes.”
Two infection-related cancers—Kaposi sarcoma and Burkitt lymphoma—are affecting Uganda’s population, and yet, the entire country has only one cancer treatment facility of modest means and three oncologists who are overwhelmed with more than 10,000 patients a year. In contrast, there are more than 13,000 oncologists practicing in the United States.
The majority of Ugandan cancer patients suffer from chronic viral, parasitic or bacterial infections, and a cancer diagnosis is practically a death sentence. And yet, the majority of cancer cases could be cured with proper medical care. This is one reason why infection-related cancers represent one of the most immediate opportunities for the prevention and treatment of cancer, not just in Uganda but also in many other countries around the globe.
Infection-related cancers offer an opportunity for prevention, early detection and cures that are unique in the field of cancer research. Thanks to ongoing studies at the Hutchinson Center and other institutions, medicine now has the ability to make a major dent in infection-related cancers. They can be detected early and cured—not in 10 or 20 years into the future, but today. That’s because hope for curing these diseases is based on already successful research.
Drs. Jackson Orem and Larry Corey tour the UCI facilities.
Center researchers believe that by studying infection-related cancers, we may also be able to define biomarkers that predict those at greatest risk for developing cancer in the future and target these people for cancer prevention strategies.
The Center’s Vaccine and Infectious Disease Institute (home to the Uganda project) is one of the nation’s largest, and a leader in efforts to develop an HIV vaccine. Its reach is global, with international programs in Africa, Asia, Europe, Australia and South America. By going to Uganda, the Center is seeking to develop a comprehensive program to combat infection-related cancers around the world.
A Center presence in Uganda also makes sense because the country has a long history of cancer research and has been home to many landmark cancer discoveries.
“Uganda has a long history of education and literacy,” Casper said.
Uganda is home to Makerere University, one of Africa’s oldest and most prestigious universities, and Mulago Hospital, which supports the university’s medical school and hosts the Uganda Cancer Institute. Another valuable asset: Uganda has maintained a registry of cancer patients—certified by the World Health Organization—since 1954. “That’s really important if you want to do any sort of population-based study,” Casper said.
A milestone in cancer research occurred in Uganda in 1958 when Dr. Dennis Burkitt, an Irish surgeon, described a childhood tumor that would later be named after him. Uganda made history again a decade later when its cancer institute pioneered the use of combination chemotherapy to treat Burkitt lymphoma—a method that is now standard treatment for many cancers.
That legacy of research continues today. Over the years, the Uganda Cancer Institute has published more than 200 studies and engaged in robust collaborations with international partners such as the U.S. National Cancer Institute, which helped found UCI in 1967.
“There’s a lot of political support for collaboration in Uganda,” said Erica Sessle, managing director for the Center’s Uganda project. “There are so many great people working both in Uganda and here at the Hutchinson Center.”
The potential to make meaningful progress in Uganda has already been demonstrated. Working with international partners, the country has cut the prevalence of HIV in the population from 41 percent in the 1980s to 6 percent today.
However, HIV has compounded the cancer problem in many African countries, including Uganda. Some cancer rates have increased more than 20,000-fold in many African regions since the start of the HIV pandemic. And yet, cancer has failed to draw a response equal to its devastating effects. While significant international resources have been allocated to combat HIV, malaria and tuberculosis, the same has not happened with cancer—and the devastation it leaves behind has been largely unappreciated. That’s why Center researchers said their interest in Uganda is more than fleeting.
“We’re not in this to collect data and then leave,” Casper said. “We’re in it for the long haul.”
The Center-Uganda partnership’s goal is to make inroads against infection-related cancers and apply what is learned in Uganda to the United States and the rest of the world.
Researchers hope to answer a number of key questions: How are cancer-causing infections transmitted and acquired? What factors govern the progression from chronic infection to cancer? Can the progression to cancer be predicted? Which therapies can be employed to prevent infection-related cancers?
The Center also has been working closely with the Uganda Cancer Institute since 2004, training the next generation of American and Ugandan researchers and doctors to deal with infection-related cancers.
A significant component of the Center-Uganda partnership is a training program to address the country’s dearth of oncologists. “It’s pretty overwhelming what they face,” Casper said. “We looked at that and said we have to do something about it.”
So far, the Center has tripled the number of oncologists in Uganda—from one to three. “Eventually, we hope to expand the program to include other medical professionals such as nurses and pharmacologists,” Casper said.
The Center-Uganda partnership opens the door to studies that would be difficult to pursue in the United States, where some infection-related cancers such as Kaposi sarcoma and Burkitt lymphoma are far less common. That’s why the needs and opportunities in Uganda have drawn interest from investigators throughout the Hutchinson Center, including Dr. Alan Kristal, who specializes in the connection between diet and cancer.
In Uganda, far fewer people with Kaposi sarcoma respond to treatment than would be expected. Many are also underweight. Kristal is leading a trial to learn whether providing nutritional supplements will improve treatment success. His trial illustrates the two-way nature of the Center’s mission in Uganda.
“The biggest building block in a situation like this is trust,” Casper said. “We want to do research and the Ugandans want to know that our research will benefit their country.”
In Uganda, according to Hutchinson Center estimates, about 85 of every 100 cases of Burkitt lymphoma can be cured for less than $600 a patient; three-quarters of Kaposi sarcoma cases can be treated for a little more than $700 per patient.
Located in the capital city of Kampala, the Uganda Cancer Institute is a long trek from the rural villages where many of its patients live. And although treatment may cost only a few hundred dollars, that’s a fortune in Uganda, where about half of the population lives on less than $1.25 per day. Also, families provide all non-medical care for hospital patients, including food and bedding, putting cancer care out of reach for most Ugandans.
One of the goals of the Center-Uganda partnership is to raise $3 million for a new building to house modern research and patient care facilities and education programs and services.
“What we’re hoping to do is create a center of excellence in infection-related cancer,” Sessle said.
Such a facility would expand access to care for the Ugandan people. At the same time, it would increase opportunities for Hutchinson Center faculty to do more research.
“My hope,” Casper said, “is that over the next five years we establish a first-class facility in Uganda, train a significant number of Ugandan oncologists and that people who are interested in international oncology will come to the Center for the chance to work in Uganda.”