Authorship of Publications Supported by NCI-Funded Grants Involving Low- and Middle-Income Countries

Importance

Scientific publication is an important tool for knowledge dissemination and career advancement, but authors affiliated with institutions in low- and middle-income countries (LMICs) are historically underrepresented on publications.

Objective

To assess the country income level distribution of author affiliations for publications resulting from National Cancer Institute (NCI)-supported extramural grants between 2015 and 2019, with international collaborating institutions exclusively in 1 or more LMICs.

Design and Setting

This cross-sectional study assessed authorship on publications resulting from NCI-funded grants between October 1, 2015, and September 30, 2019. Grants with collaborators in LMICs were identified in the National Institutes of Health (NIH) Query/View/Report and linked to publications using Dimensions for NIH, published between 2011 and 2020. Statistical analysis was performed from May 2021 to July 2022.

Main Outcomes and Measures

Author institutional affiliation was used to classify author country and related income level as defined by the World Bank. Relative citation ratio and Altmetric data from Dimensions for NIH were used to compare citation impact measures using the Wilcoxon rank sum test.

Results

In this cross-sectional study, 159 grants were awarded to US institutions with collaborators in LMICs, and 5 grants were awarded directly to foreign institutions. These 164 grants resulted in 2428 publications, of which 1242 (51%) did not include any authors affiliated with an institution in an LMIC. In addition, 1884 (78%) and 2009 (83%) publications had a first or last author, respectively, affiliated with a high-income country (HIC). Publications with HIC-affiliated last authors also demonstrated greater citation impact compared with publications with LMIC-affiliated last authors as measured by relative citation ratios and Altmetric Attention Scores; publications with HIC-affiliated first authors also had higher Altmetric Attention Scores.

Conclusions and Relevance

This cross-sectional study suggests that LMIC-affiliated authors were underrepresented on publications resulting from NCI-funded grants involving LMICs. It is critical to promote equitable scientific participation by LMIC institutions in cancer research, including through current and planned programs led by the NCI.

Global oncology research and training at US National Cancer Institute-designated cancer centres: results of the 2021 Global Oncology Survey

Global oncology research and training are crucial to address the growing global burden of cancer, which largely and increasingly occurs in low-income and middle-income countries. To better understand global oncology activities at the 71 National Cancer Institute (NCI)-designated cancer centres, the US NCI Centre for Global Health regularly surveys cancer centre directors, global oncology leads, and principal investigators in 36 US states and the District of Columbia. The survey results complement internal and publicly available data about global oncology research funded directly by the US National Institutes of Health to provide a comprehensive catalogue of global oncology research, training, and activities led by NCI-designated cancer centres. 91% (61 of 67) of responding cancer centres reported global oncology activities not directly funded by the National Institutes of Health. The survey results indicate that global oncology is an important priority at cancer centres and provide a valuable resource for these centres, researchers, collaborators, trainees, and the NCI and other funders.

Abstract 4186: Underrepresentation of low- and middle-income country affiliated authors in NCI-supported cancer research

Introduction: We conducted a bibliometric analysis to assess authorship of recent publications involving collaborations in low- and middle-income countries (LMICs) supported by the National Cancer Institute (NCI) of the National Institutes of Health (NIH).

Methods: We identified active NCI grants awarded directly to LMIC institutions or to US institutions with a collaborator site or sites exclusively in LMICs between 2015-2019 in NIH Query View Report (QVR). Grants were linked to resulting publications using Dimensions for NIH. Because grants may have been active in 2015 while beginning in earlier years, we analyzed any linked publications from 2011 to 2020. Publications with missing author information were excluded. Author institutional affiliation was used to classify author country income level as defined by the World Bank. Authors with multiple institutional affiliations from a high-income country (HIC) and LMIC were classified as such. Relative citation ratio (RCR) and Altmetric data from Dimensions were used to compare citation impact measures using the Wilcoxon rank sum test.

Results: NCI funded 159 grants to US institutions exclusively with LMIC collaborators and five awards directly to institutions in LMICs from 2015 to 2019, resulting in 2,428 publications between 2011 and 2020, of which 49% had at least one author affiliated with an LMIC institution. Of all publications, 78% and 83% had a first and last author with high-income country (HIC) affiliation, respectively. Publications with HIC-affiliated last authors had significantly higher median RCR and Altmetric attention scores than publications with LMIC-affiliated last authors (p=0.0134 and p=0.0004, respectively). Publications with HIC-affiliated first authors had significantly higher Altmetric scores than publications with LMIC-affiliated first authors (p=0.001).

Conclusion: LMIC-affiliated authors are represented on only approximately half of publications resulting from NCI grants awarded directly to LMIC institutions or to US institutions with LMIC collaborators, and rarely in the first or last author position. LMIC-affiliated authors also receive less bibliometric attention when represented. Increased scientific capacity and more equitable collaboration should be critical priorities for the cancer research community working in LMICs moving forward.

Citation Format: Linsey Eldridge, Elise Garton, Kalina Duncan, Satish Gopal. Underrepresentation of low- and middle-income country affiliated authors in NCI-supported cancer research. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4186.

The US President's Cancer Panel: A Model For Gathering Country-Level Input to Inform Cancer Control Policy and Program Initiatives

PURPOSE

The President's Cancer Panel (Panel) is a federal advisory committee charged with monitoring the US National Cancer Program and reporting directly to the US President. Since its creation a half century ago, the Panel has gathered input from individuals and organizations across the US cancer community and beyond and recommended actions to accelerate progress against cancer. The Panel is unique in its structure and function, and merits examination for its potential applicability in other settings worldwide.

METHODS

We present an overview of the general President's Cancer Panel model and describe the noteworthy and unique characteristics of the Panel that help achieve its charge. We also detail the specific processes, outputs, and achievements of the Panel appointed by President Barack Obama, which served between 2012 and 2018.

RESULTS

From 2012 to 2018, the Panel focused on three topics that addressed timely issues in cancer prevention and control: (1) HPV vaccination for cancer prevention, (2) connected health and cancer, and (3) value and affordability of cancer drug treatment. The Panel held 11 meetings with 165 participants who provided diverse perspectives on these issues. Four reports were delivered to the president, which were cited about 270 times in the literature. Over 20 collaborator activities, including commitments of funding, can be linked to the recommendations published in these reports.

CONCLUSION

The US President's Cancer Panel highlights the importance of independent advisory bodies within a national cancer control program and of national leadership support for the cancer community. The structure and function of the Panel could be applicable in other settings worldwide.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Mapping global oncology priorities: A survey of the directors of the NCI-designated cancer centers

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Background: By 2040, an estimated 69% of all cancer deaths globally will occur in LMICs. Recognizing this, ASCO formed the Academic Global Oncology Task Force in 2017 to help formalize the global oncology (GO) field. Their recommendations included: better engagement with the National Cancer Institute (NCI) Center for Global Health (CGH), increased funding, and development of forums to highlight global cancer research and control activities. To further clarify how GO programs are defined and to better understand the perspectives and needs of cancer research leaders, CGH conducted a survey of the 71 Directors at the NCI-Designated Cancer Centers (NDCC). Methods: A 19-question survey was designed using Microsoft Forms and sent to the NDCC Directors via email. Responses were collected from July to September 2021. Two coders reviewed the qualitative responses to categorize the data into thematic areas. Analyses were conducted in Microsoft Excel. Results: Seventy of 71 (99%) NDCC Directors responded to the survey. 41 NDCCs (59%) reported dedicated GO programs or plans to create such a program within 5 years. Additionally, 16 Directors reported GO activities without a dedicated program, while 13 reported no GO activities. The Directors described GO as having high/extremely high (39%) or moderate (50%) importance relative to other priorities, across all types of NDCCs (basic, clinical, or comprehensive). Eight NDCCs (11%) described GO as a low priority or non-priority. 31 NDCCs (44%) reported dedicated funding for GO activities. Directors estimated interest in GO to be higher among junior faculty and trainees than senior and mid-career faculty. Future goals for established or developing GO programs included: recruitment of leadership, formalizing a strategic vision, establishing partnerships, and increasing the number of activities with international collaborations. Barriers noted were limited funding, limited capacity and expertise, and prioritizing the needs in domestic NDCC catchment areas. Conclusions: Despite variation across NDCCs, GO interest is strong as expressed by Center Directors. Strategic planning, increased funding, and improved collaboration within and between NDCCs were reported as necessary to strengthen GO at NDCCs. Continued leadership from ASCO, the NCI, and other international organizations can help facilitate dialogue and increase the prioritization of GO activities at NDCCs.

Exploring country priorities and contextual considerations for implementing national cancer control plans (NCCP) among participants of International Cancer Control Partnership (ICCP) ECHO

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Background: Promoting NCCP implementation by low- and middle-income countries (LMICs) is key to addressing inequities in cancer outcomes and the global burden of cancer. We explored contextual factors that may influence implementation of NCCP priorities in LMICs. Methods: Seven countries participated in the 2021 International Cancer Control Partnership ECHO (R) geared toward creating a community of practice to inform NCCP implementation. Using qualitative methods, we conducted focus group discussions (FGDs) with country teams who were asked to identify NCCP priorities and provide contextual considerations around implementing these in the 12-months program. FGDs were audio-recorded, transcribed, double-coded, and underwent thematic analysis. Results: Thirty-three participants from 6 Sub-Saharan African countries and 1 country in Asia took part in 7 FGDs, including 14 physicians, 9 non-governmental organizations, 6 Ministry of Health/NCCP and 4 cancer registry representatives. All seven country teams (100%) prioritized cancer early detection, especially for cervical (71%) and breast (57%) cancer, including by educating primary care clinicians (57%) and general population (43%) about cancer signs and symptoms. Related contextual factors included late-stage diagnosis of cancer (43%) and low knowledge about cancer among primary care clinicians and the general population (29% each), respectively. Finding resources for implementation of NCCP priorities was important given lack of funding (57% each). Harmonizing programs and building partnerships for implementation (57%) was prioritized given perceived fragmentation of efforts and benefit of leveraging limited resources (29% each). Improving access to treatment (43%) was a priority given a lack of oncology specialists (29%) and unaffordable treatment (14%). Improving access to palliative care (43%), including by writing guidelines (29%), was prioritized due to late-stage diagnosis and insufficient access to palliative care (14% each). Improving cancer registry data was essential for NCCP program planning (43% each), while cancer research (43%) was key to answering specific questions related to cancer registry data (14%) and program impact (29%). Additional contextual considerations for making progress on these priorities dicussed by country teams included leveraging existing programs (100%) and learning from other countries and ICCP technical experts (57% each). Conclusions: There were similarities in country NCCP priorities and contextual factors affecting implementation. These results allow for future exploration of how LMIC country teams implement NCCPs and examine the value of communities of practice promoted by ICCP and facilitated by ECHO, towards improving cancer outcomes.

Analysis of Low Estrogen Receptor (ER+) Breast Carcinomas in a Large Community Breast Cancer Center in Northern California

Introduction/Objective

Estrogen Receptor (ER) expression in breast cancers is a crucial factor for endocrine therapy in patients with tumors expressing ER in ≥1% of tumor cells. The 2019 guidelines published by ASCO/CAP states that breast cancers that have a 1% to 10% of cells staining Estrogen Receptor (ER) positive should be reported as ER Low Positive cases. This study aims to address this subset of low-positive ER tumors and compare the clinical features to other known breast cancer subtypes.

Methods/Case Report

We conducted a retrospective review of a prospectively maintained breast cancer registry from 2013 to 2021 at Mills-Peninsula Medical Center, a Sutter Health Affiliate. The study reviewed patient charts with respect to the pathology report, operative report, chemotherapy regimen, and clinical outcomes. Statistical analyses were conducted using R Project for Statistical Coding, with The Student’s T-test used to compare continuous variables. Two-sided P values less than 0.05 indicate statistical significance.

Results (if a Case Study enter NA)

Our study identified 1316 cases of invasive breast carcinomas, of which 29 (2.16%) demonstrated ER Low-Positive expression. We aimed to evaluate the clinical and pathological features, such as histological grade, ER, PR, HER-2, Ki-67%, and patient age for these tumors. We found that ER Low-Positive tumors demonstrated higher mean histological grade morphology (2.5 out of 3, p<0.001) that was similar to that of Triple Negative Breast Cancers (TNBC) (3 of 3, p<0.001) than to High ER-Positive (1.6 of 3, p<0.001) cancers. Further observations, through examining proliferation rates by utilizing the Ki-67 index, indicate comparative trends between the ER Low-Positive cohort and the TNBC cohort.

Conclusion

The results suggest that the ER Low-Positive carcinomas, despite reported as ER-positive cases, present with similar clinicopathological features to those of ER-negative tumors. Through this study and future research, we would like to emphasize a stricter set of guidelines that can be adopted to reduce variability for reporting biomarkers. This standardization will allow oncologists to provide more appropriate treatment options and improve the quality of patient care.

Trends in International Cancer Research Investment 2006-2018

The International Cancer Research Partnership (ICRP) is an active network of cancer research funding organizations, sharing information about funded research projects in a common database. Data are publicly available to enable the cancer research community to find potential collaborators and avoid duplication. This study presents an aggregated analysis of projects funded by 120 partner organizations and institutes in 2006-2018, to highlight trends in cancer research funding. Overall, the partners’ funding for cancer research increased from $5.562 billion (bn) US dollars (USD) in 2006 to $8.511bn USD in 2018, an above-inflation increase in funding. Analysis by the main research focus of projects using Common Scientific Outline categories showed that Treatment was the largest investment category in 2018, followed by Early Detection, Diagnosis, and Prognosis; Cancer Biology; Etiology; Control, Survivorship, and Outcomes; and Prevention. Over the 13 years covered by this analysis, research funding into Treatment and Early Detection, Diagnosis, and Prognosis had increased in terms of absolute investment and as a proportion of the portfolio. Research funding in Cancer Biology and Etiology declined as a percentage of the portfolio, and funding for Prevention and Control, Survivorship and Outcomes remained static. In terms of cancer site–specific research, funding for breast cancer and colorectal cancer had increased in absolute terms but declined as a percentage of the portfolio. By contrast, investment for brain cancer, lung cancer, leukemia, melanoma, and pancreatic cancer increased both in absolute terms and as a percentage of the portfolio.

The 9th Symposium on Global Cancer Research: Looking Back and Charting a Path Forward in Global Cancer Control

The NCI Center for Global Health convened the 9th Annual Symposium on Global Cancer Research as a virtual 2-day meeting alongside the Consortium of Universities for Global Health Annual Conference, March 10–11, 2021. The virtual format allowed for diverse and inclusive participation by over 400 attendees from 70 countries, 25+ speakers from 12 countries, and sharing of research conducted in 68 countries. The highly interactive 2-day program explored the science and complex considerations around resilience and equity in global cancer research and control. The Symposium convened individuals working in global oncology to discuss trends in global cancer research and control and map out collaborative efforts to move the field forward. The accepted scientific abstracts are published in this special supplement of AACR Cancer Epidemiology, Biomarkers, and Prevention.

Analysis of the National Cancer Institute’s Investment in Site-Specific Cancer Research Funding Involving Collaborators in Latin America and Its Correspondence to Regional Cancer Burden

PURPOSE

Economic and social-behavioral changes over the last two decades in Latin America and the Caribbean (LAC) are associated with increases in the regional cancer burden. We aim to describe the National Cancer Institute–funded extramural research portfolio with collaborators in the LAC between fiscal years 2014 and 2018 and compare project numbers by site with subregional cancer burden.

METHODS

This analysis included National Cancer Institute–funded extramural projects with LAC collaborators from fiscal years 2014 to 2018 from the National Institutes of Health IMPAC II database. Projects were stratified by Pan American Health Organization’s Latin American subregions, tumor sites, and regional site-specific rates of cancer incidence and mortality using Globocan 2018 estimates. To better understand subregional variations in cancer incidence and mortality, this analysis focused on the top 5 sites of incidence and mortality in LAC after breast and prostate cancer.

RESULTS

Between fiscal years 2014 and 2018, 108 projects with LAC collaborators were funded. Project collaborators came from 22 countries in the region, and projects covered 20 tumor sites. The Southern Cone had the most projects funded, followed by the Central American Isthmus and Mexico, Andes, Latin Caribbean, and non-Latin Caribbean—this was roughly proportional to subregional populations. Variation exists at the subregional level for the top 5 cancers when comparing incidence and mortality with subregional project counts. Disparities between projects and incidence by tumor site were the largest for colorectal, lung, and uterine cancers. Disparities between projects and mortality by tumor site were the largest for lung and uterine cancers. Disparities between projects and both components of cancer burden by subregion were the largest for the Latin Caribbean and non-Latin Caribbean. The number of funded projects for Kaposi sarcoma and non-Hodgkin lymphoma largely outpaced both incidence and mortality in every subregion.

CONCLUSION

This analysis suggests that projects’ alignment with cancer burden is variable by subregion, provides an understanding of cancer research funding by site, and highlights areas of interest for additional investigation, training, and collaboration in LAC.

Promoting Evidence-Based Practices for Breast Cancer Care Through Web-Based Collaborative Learning

PURPOSE

The objective of the Project ECHO (Extension for Community Healthcare Outcomes) for Knowledge Summaries for Comprehensive Breast Cancer Control (KSBC) was to strengthen the capacity to plan and implement evidence-based, resource-appropriate breast cancer control programs using virtual case-based learning within a global network of experts and peers.

METHODS

The KSBC ECHO was a collaboration between the US National Cancer Institute Center for Global Health, Women’s Empowerment Cancer Advocacy Network, and Breast Health Global Initiative in alignment with the Breast Cancer Initiative 2.5 campaign to reduce disparities in breast cancer outcomes. Using the ECHO model, we developed a 6-month Web-based program to support the development of locally relevant, resource-appropriate cancer control programs through mentorship and use of KSBCs. The course was advertised via existing networks, conferences, and social media. Breast cancer control project teams from around the world applied and were accepted to participate in the KSBC ECHO. Fourteen biweekly ECHO sessions were held via Zoom and included case presentations, didactic presentations, and discussion. Projects spanned the care continuum and sessions addressed preplanning, assessing need/barriers, setting objectives/priorities, and implementing/evaluating. Baseline and end point surveys were used to evaluate the ECHO program. Participants identified a mentor, completed worksheets, and presented on the project status.

RESULTS

Fifteen project teams from 11 countries—64 participants: advocates, clinicians, policymakers, and researchers—were enrolled. Twenty-eight participants (57%) completed the baseline and end point surveys. Analysis of the data using a paired t-test indicates that the knowledge increase was statistically significant: The average knowledge gain was 0.76 ± 0.89 (95% CI, 0.44 to 1.08; P < .0001). Additional feedback on the Web-based collaborative learning model will be presented.

CONCLUSION

The ECHO model encouraged interaction between policymakers, clinicians, advocates, and technical experts while using evidence-based tools to develop locally relevant, resource-appropriate implementation strategies and policy recommendations.

Subsequent Cancer Prevention and Control Activities Among Low- and Middle-Income Country Participants in the US National Cancer Institute's Summer Curriculum in Cancer Prevention

PURPOSE

A dramatic shift in the burden of cancer from high-income countries to low- and middle-income countries (LMICs) is predicted to occur over the next few decades. An effective response requires a range of approaches to capacity building in cancer prevention and control in LMICs, including training of cancer prevention and control professionals. Toward this end, the US National Cancer Institute includes LMIC-based participants in its Summer Curriculum in Cancer Prevention, which is an annual, short-term in-person training program.

METHODS

In 2015 and 2016, the US National Cancer Institute fielded a survey to all Summer Curriculum alumni who were based in LMICs when they participated in the program, between 1998 and 2015. Its aims were to learn about subsequent engagement in cancer prevention and control in LMICs and attribution of activities/accomplishments to participation in the Summer Curriculum in Cancer Prevention.

RESULTS

Respondents (N = 138) worked in academia/research (n = 61), health care (n = 41), and health policy/Ministries of Health (n = 36) in all six world regions. Most respondents (90.6%) worked in the same LMIC as when they participated in the Summer Curriculum in Cancer Prevention. When asked about activities/accomplishments completed as a result of participation, 92.8% reported at least one cancer prevention and control practice activity/accomplishment, 81.2% reported at least one cancer research activity/accomplishment, and 44.2% reported authoring one or more peer-reviewed publications. Reported ways that the Summer Curriculum in Cancer Prevention contributed to these activities/accomplishments were emphasizing a public health approach; focusing on research priorities, methods, and scientific writing; and highlighting the importance of research and publications. Finally, 79.7% of respondents reported using Summer Curriculum in Cancer Prevention materials to train others.

CONCLUSION

These findings have implications for the design of future training initiatives for LMIC-based cancer prevention and control professionals.

Areca Nut and Betel Quid Control Interventions: Halting the Epidemic

Background: Areca nut (AN) and betel quid (BQ) are classified as Group 1 carcinogens. There are approximately 600 million AN/BQ users globally; the majority of users live in the Asia-Pacific region which, correspondingly, has the highest rates of oral cancer. Despite significant disease burden associated with AN/BQ use, there have been no systematic reviews of interventions to reduce product use. Objectives: To analyze interventions that prevent use of AN/BQ, present a basis for a future systematic review on the topic, and provide decision makers with examples of strategies that have demonstrated reduced AN/BQ use. Methods: To identify publications, we searched the literature using terms for AN/BQ and related synonyms in three databases: PubMed, Embase, and Scopus. Interventions that prevent AN/BQ use, that are published in English and that provide original data analysis, were included in this review. Interventions focused primarily on disease outcomes e.g. oral cancers (secondary prevention) were excluded. Results: Our search revealed 21 interventions targeting AN/BQ use between 1990 and 2018. Strategies include product bans, media campaigns, education, cessation, and taxation at individual and population levels, with varying evidence of impact. While these studies yielded some novel and promising findings, particularly regarding the impact of product bans, mass media campaigns, and cessation interventions, research on interventions specific to AN/BQ use remains limited. Conclusions: We have assessed published interventions that reduce AN/BQ use and identified future research priorities. These findings can be used to develop evidence-based interventions and help guide policymakers in implementing evidence-based policy to regulate these products.

Characteristics of Current Betel Quid/Chewing Tobacco Users, Smokers and Dual Users in Indonesia: An Analysis of GATS 2011 Data

Background: Indonesia has the third largest population of smokers in the world, however, little is known about the use of chewing tobacco/betel quid in Indonesia. This paper describes the characteristics of chewing tobacco/betel quid users in Indonesia, to understand the user population and inform future research. Methods: The 2011 Indonesia GATS included 8,176 adults ages 15 and older. These data are weighted to be nationally representative. Weighted descriptive statistics and multivariate logistic regression were run using SAS 9.4. Results: Estimated national prevalence for exclusive chewing tobacco/betel quid use was 0.9%, for exclusive smoked tobacco use was 33.9% and for dual use was 0.8%. Multivariate logistic regression analyses showed that exclusive chewing tobacco/betel quid users were significantly more likely to be female, and to be older adults (45-64); while smokers are more likely to be male and younger (25-44). Conclusions/Importance: These results provide information on the different characteristics of users by product type, and show that users' demographics vary by their product of choice. This study helps to inform researchers and practitioners of the burden of chewing tobacco/betel quid use in Indonesia. These data, especially specific data on chewing tobacco/betel quid use patterns, are limited in this context, and this knowledge can help to identify populations who need quit tobacco interventions.

Landscape of Global Oncology Research and Training at National Cancer Institute-Designated Cancer Centers: Results of the 2018 to 2019 Global Oncology Survey

PURPOSE

The National Cancer Institute (NCI)-Designated Cancer Centers (NDCCs) are active in global oncology research and training, leading collaborations to support global cancer control. To better understand global oncology activities led by NDCCs, the NCI Center for Global Health collaborated with ASCO to conduct the 2018/2019 NCI/ASCO Global Oncology Survey of NDCCs.

METHODS

Seventy NDCCs received a two-part survey that focused on global oncology programs at NDCCs and non-National Institutes of Health (NIH)-funded global oncology projects with an international collaborator led by the NDCCs. Sixty-seven NDCCs responded to the survey. Data were coded and analyzed by NCI-Center for Global Health staff.

RESULTS

Thirty-three NDCCs (47%) reported having a global oncology program, and 61 (87%) reported a collective total of 613 non-NIH-funded global oncology projects. Of the NDCCs with global oncology programs, 17 reported that trainees completed rotations outside the United States and the same number enrolled trainees from low- and middle-income countries (LMIC). Primary focus areas of non-NIH-funded projects were research (469 [76.5%]) and capacity building or training (197 [32.1%]). Projects included collaborators from 110 countries; 68 of these were LMIC.

CONCLUSION

This survey shows that there is a substantial amount of global oncology research and training conducted by NDCCs and that much of this is happening in LMIC. Trends in these data reflect those in recent literature: The field of global oncology is growing, advancing scientific knowledge, contributing to building research and training capacity in LMIC, and becoming a recognized career path. Results of the 2018 Global Oncology Survey can be used to foster opportunities for NDCCs to work collaboratively on activities and to share their findings with relevant stakeholders in their LMIC collaborator countries.

Global Oncology Research and Training Collaborations Led by the National Cancer Institute (NCI)–Designated Cancer Centers: Results From the 2018 NCI/ASCO Global Oncology Survey of NCI-Designated Cancer Centers

PURPOSE

The National Cancer Institute (NCI)–Designated Cancer Centers (NDCCs) are active in global oncology research and training, leading collaborations that contribute to the evidence to support global cancer control. To better understand global oncology activities led by NDCCs, the National Cancer Institute Center for Global Health (NCI-CGH) collaborated with ASCO to conduct the 2018 NCI/ASCO Global Oncology Survey of NDCCs.

METHODS

The 70 NDCCs received a two-part survey that focused on global oncology programs at NDCCs and non–National Institutes of Health (NIH)–funded global oncology projects with an international collaborator led by the NDCCs. Sixty-five NDCCs responded to the survey, and 57 reported non–NIH-funded global oncology projects. Data were cleaned, coded, and analyzed by NCI-CGH staff.

RESULTS

Thirty NDCCs (43%) report having a global oncology program, and 538 non–NIH-funded global oncology projects were reported. Of the NDCCs with global oncology programs, 17 report that trainees complete rotations outside the United States, and the same number enroll trainees from low- and middle-income countries (LMICs). In addition, 147 (28%) of the non–NIH-funded projects focused on capacity building or training, the second highest category after research. Of the 30 top project collaborator countries, 17 were LMICs. Compared with the NCI-funded international grant portfolio, non–NIH-funded global oncology projects were more likely to focus on prevention (12% NCI-funded v 20% non–NIH-funded); early detection, diagnosis, and prognosis (23% v 30%); and cancer control, survivorship, and outcomes research (13% v 22%).

CONCLUSION

This survey shows that there is a substantial amount of global oncology research and training supported by NDCCs, and much of this is happening in LMICs. Results of the 2018 Global Oncology Survey can be used to foster opportunities for NDCCs to work collaboratively on activities and to share their findings with relevant stakeholders in their LMIC collaborator countries.

Challenges and opportunities in the creation and implementation of cancer-control plans in Africa

Cancer on the African continent is quickly becoming an overt public health crisis due to an aging population and changes in lifestyle. The World Health Organization (WHO) states that a national cancer-control programme should aim to reduce cancer incidence and mortality and improve quality of life of cancer patients, through a national cancer-control plan (NCCP) that is systematic, equitable and evidence-based. Despite this, only 11 countries in Africa have a current NCCP. Participants in a US National Cancer Institute-supported, multi-year, technical assistance programme for cancer-control planning noted three main opportunities to improve how plans are created and implemented: 1) mobilisation of resources and partners for plan implementation; 2) accurate surveillance data to promote better resourcing of NCCPs; and, 3) sustainable and innovative partnership models to strengthen capacity to implement NCCPs. Most countries in the region face similar challenges in the development and implementation of an NCCP, including inadequate human, technical, and financial resources. Collaborative partnerships increase access to evidence-based cancer-control planning tools, mentoring and technical assistance, and have the potential to bridge the capacity gap and catalyse better implementation of NCCPs. Challenges can be overcome by better leveraging these opportunities to address the gaps that inhibit cancer control in Africa.

Advancing Cancer Research in Africa Through Early-Career Awards: The BIG Cat Initiative

PURPOSE

The burden of cancer in Africa is growing rapidly, and increased cancer research on the continent is a critical component of an effective response. In 2010, the US National Cancer Institute, in partnership with the African Organization for Research and Training in Cancer, launched the Beginning Investigator Grant for Catalytic Research (BIG Cat) initiative to support cancer research projects conducted by early-career African investigators.

METHODS

To date, BIG Cat has provided 18 awards of up to $50,000 to support 2-year cancer research projects. In 2017, the National Cancer Institute evaluated BIG Cat's early outcomes for cancer research and impacts on career development and local cancer research capacity. Data collection consisted of a review of project documentation and a survey fielded to the 12 investigators who had completed their BIG Cat awards.

RESULTS

BIG Cat-supported research projects have generated locally relevant findings that address a range of cancer sites and multiple areas of scientific interest. The 11 survey respondents produced 43 scholarly products (e.g., publications, presentations) about findings from their BIG Cat research. They reported increases in cancer research funding applications and awards after receipt of the BIG Cat award compared with before the award. They also reported increased resources for cancer research, participation in teaching and mentoring on cancer research, and supervision of cancer research staff. Investigators identified scientific mentoring as a key facilitator of the success of their BIG Cat projects and limited time and funding as key challenges.

CONCLUSION

Findings provide early evidence that BIG Cat advanced locally relevant cancer research and facilitated career advancement and development of local cancer research capacity. Findings have implications for the design of future related efforts.

Evaluation of the Project Echo Tele-Mentoring Model for Knowledge Sharing and Technical Assistance in Cancer Control Planning and Implementation

Background: There is increasing demand for dissemination and implementation of evidence-based guidelines in cancer control. In 2017, the National Cancer Institute's Center for Global Health (NCI-CGH) partnered with University of New Mexico and The University of Texas MD Anderson Cancer Center to provide the Project ECHO (Extension for Community Healthcare Outcomes) model of tele-mentoring as an extension of existing programs that convene relevant stakeholders for knowledge sharing and technical assistance in national cancer control planning. In early 2018, NCI-CGH launched Project ECHO programs in the Caribbean, Asia-Pacific, and sub-Saharan Africa regions, and began plans for implementation in south Asia. As a new approach for the center in program development, NCI-CGH included evaluation measures from the inception of the program to adequately measure its efficacy. Aim: Evaluation of NCI-CGH Project ECHO programs will guide future program development, and assess achievement of the program's goals: (1) to increase individual participant knowledge in specific areas; (2) to improve application of the knowledge learned; and (3) to increase collaboration within and among countries. Methods: Using Project ECHO Evaluation 101, a guide developed by the New York Academy of Medicine, NCI-CGH developed a comprehensive logic model including a concise list of program outcomes prior to the launch of ECHO programs. NCI-CGH used the logic model to develop and pilot-test a Web-based baseline and post-ECHO survey, to be completed by participants in each program, that measures participants' knowledge of cancer control planning principles and strategies. NCI-CGH conducted the baseline survey for all three ECHO programs. The post-ECHO survey will be distributed at the conclusion of each program. Each program is expected to run for approximately six months to one year. Results: Response rates for baseline surveys were: 32% in the Caribbean, 43% in Asia-Pacific, and 78% in sub-Saharan Africa. Respondents (by region) reported high levels of knowledge of the following evidence-based principles and guidelines: the Caribbean - HPV vaccination, Asia-Pacific - cervical cancer early diagnosis, sub-Saharan Africa - raising awareness. Low levels of knowledge were reported for: psychosocial support for cancer patients, family members, and caregivers in the Caribbean; survivorship care for cancer patients in Asia-Pacific; and alcohol consumption control in sub-Saharan Africa. This presentation will highlight baseline and post-ECHO survey analysis findings and the impact of these data on future program development. Conclusion: Inclusion of evaluation measures in the design phase of NCI-CGH Project ECHO tele-mentoring programs enhanced planning efforts by providing a blueprint for developing program curricula, creating an embedded system for gathering data from participants, and informing the pathway to future improvements.

Mapping Stakeholders to Enhance Coordination of Cancer Prevention and Control: The Kenyan Experience

Background: Coordination of stakeholders in cancer prevention and control ensures prudent use of available resources toward a common goal while limiting overlaps and redundancies. The National Cancer Institute of Kenya (NCI-K) is a statutory body with an overall mandate to coordinate and centralize all activities related to cancer prevention and control in Kenya. To identify baseline status of cancer control stakeholder activity to guide implementation of the National Cancer Control Strategy, NCI-K collaborated with US National Cancer Institute (NCI-US) to map stakeholders involved in cancer control in Kenya. Aim: The survey set out to determine the geographical distribution, scope of cancer prevention and control activities, and sources of financing for identified stakeholders involved in cancer prevention and control in Kenya. Methods: Between October 2017 and March 2018, we conducted an online survey among stakeholders involved in cancer prevention, research and control in Kenya adapted from similar stakeholder mapping activities coordinated by NCI-US in other settings. Using attendance lists to past multisectoral forums organized by NCI-K, Kenyan Ministry of Health, and NCI-US, a Google link to a standard pretested questionnaire was circulated. Descriptive analysis was conducted using Microsoft Excel. Results: A total of 52 responses were received with 38 respondents reporting Kenya as their institution country. Twenty (38%) had ongoing activities in all the counties in Kenya. Nairobi County had the highest reported number of active institutions (19) followed by Kisumu (16) and Uasin Gishu (10). The three program focus areas most reported were training 28 (54%), clinic-based screening 27 (52%) and advocacy/information and educational 26 (50%), while the least reported was financing 12 (23%). For organizations involved in cancer screening, 22 (81%) focused on breast cancer while 18 (67%) prioritized cervical cancer. Among the programs that identified cancer prevention as one of their focus areas, a large majority (91%) were involved in health education, while only 1 organization focused on environmental control activities. The most reported source of funding for the cancer programs was grant funding 17 (33%). Conclusion: This stakeholder mapping activity has identified a strong stakeholder presence in most parts of the country while also highlighting gaps in the focus of cancer prevention and control programs. This baseline information on stakeholder activity will help shape future collaborations in cancer prevention and control and will guide NCI-K in developing appropriate policies and ensuring effective coordination.

A Snapshot of Global Oncology Programming at US Cancer Centers: Results of the 2018 US NCI/ASCO NCI-Designated Cancer Center Global Oncology Survey

Background: The US National Cancer Institute (NCI) Center for Global Health (CGH) serves as a clearinghouse of information on global oncology activities within the NCI and across the 70 NCI-designated Cancer Centers. Global oncology, as defined by the American Society of Clinical Oncology (ASCO), “addresses disparities and differences in cancer prevention, care, research, education and the disease's social and human impact around the world”. While CGH routinely reports on NCI-funded global oncology projects conducted at the cancer centers, there is limited reporting of non-NCI funded global oncology activities of the cancer centers. To address this gap, CGH has surveyed the cancer centers about their global oncology programs and projects informally in 2012 and 2014. The 2018 survey, in partnership with ASCO, represents the first systematically conducted survey, with new questions about cancer center global oncology programs, faculty, and trainees. Aim: The aim of the 2018 survey is to develop a summary report of cancer center global oncology programs for use by cancer centers as a knowledge sharing and collaborative tool; by the NCI to inform program development; and, by ASCO to better understand the current state of global oncology training at US institutions. Methods: CGH developed a 2-part online survey with questions about global oncology projects led by cancer centers, and the level of support for global oncology training and faculty engagement at cancer centers. CGH piloted the survey to 7 of the 70 cancer centers (10%) from January to March 2018. Revisions based on the pilot were made, and CGH fielded the survey to the rest of the 63 cancer centers (90%) from March to July 2018. CGH supplemented the survey data with an Internet search of cancer centers' Web sites. The submitted data will be compiled, analyzed, and organized into a summary report for distribution to NCI, ASCO, and the cancer centers. Results: Data from the 7 pilot institutions show that while all 7 institutions (100%) have a global oncology program, there is great variance in the percentage of global oncology faculty who receive external or administrative research grant support for their work. Three institutions (43%) report that 50% or fewer global oncology faculty receive external research grant support, and 6 institutions (86%) report that 50% or fewer global oncology faculty receive cancer center administrative fund support for their work. Additional results and analysis will be available and presented as part of this presentation. Conclusion: In addition to serving as a knowledge sharing and collaboration tool for cancer centers, the global oncology survey allows NCI, ASCO, and global oncology partners to understand the current landscape of and sources of support for global oncology training, research, and programming at the cancer centers. This information will inform future discussions on how to strengthen global oncology programming and partnerships.

The Kenya cancer research and control stakeholder program: Evaluating a bilateral partnership to strengthen national cancer efforts

Background

In response to a growing cancer burden and need for improved coordination among stakeholders in Kenya, the US National Cancer Institute and the Kenya Ministry of Health collaboratively hosted a stakeholder meeting in 2014 which identified four priority areas of need (research capacity building, pathology and cancer registries, cancer awareness and education, and health system strengthening) and developed corresponding action plans.

Methods

Surveys were conducted with participants to collect input on the progress and impact of the 2014 stakeholder meeting.

Findings

Of 69 eligible participants, 45 responded from academia, healthcare institutions, civil society, government, and international agencies. Of the four technical focus areas, three have continued to conduct working group meetings and two have conducted in-person meetings to review and update their respective action plans. Accomplishments linked to or enhanced by t meeting include: Kenyan and international support for expansion of population-based cancer registries, increased availability of prioritized diagnostic tests in selected regional referral hospitals, a greater focus on development of a national cancer research agenda, strategic planning for a community education strategy for cancer awareness, and improved coordination of partners through in-country technical assistance.

Interpretation

The Stakeholder Program has successfully united individuals and organizations to improve cancer control planning in Kenya, and has enhanced existing efforts and programs across the country. This model of partners working in parallel on prioritized track activities has supported development of long term coordination of cancer research and control activities sustainable by the Kenyan government and Kenyan institutions.

Defining a global research and policy agenda for betel quid and areca nut

Betel quid and areca nut are known risk factors for many oral and oesophageal cancers, and their use is highly prevalent in the Asia-Pacific region. Additionally, betel quid and areca nut are associated with health effects on the cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. Unlike tobacco, for which the WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Multidisciplinary research is needed to address this neglected global public health emergency and to mobilise efforts to control betel quid and areca nut use. In addition, future research is needed to advance our understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance possible prevention and cessation programmes for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programmes to address the growing burden of cancers that are associated with use.

Creation of Minimum Requirements Guidelines for Cancer Centers in Kenya

Abstract 39

Background:

Cancer is a leading cause of mortality worldwide and accounts for nearly 8.5 million deaths—more than malaria, tuberculosis, and HIV combined. In Kenya, the majority of cancer care is provided at two national referral hospitals, but there is growing interest by various counties in managing patients with cancer locally. However, there are currently no national standards to describe the minimum requirements for a health facility that wishes to offer cancer management services. Beginning in 2015, the US National Cancer Institute’s Center for Global Health (CGH) has assisted the Kenyan Ministry of Health (MoH) and the Kenyan National Cancer Institute (NCl-K) in creating national guidelines for minimum requirements for facilities that wish to offer cancer services in Kenya. With this work, we report the MoH and NCI-K minimum requirements in infrastructure, equipment, and human resources needed for facilities that offer cancer services in Kenya.

Methods:

Technical experts who work with patients with cancer in Kenya were approached to create specific sections of the document. MoH, NCI-K, and CGH collated the various drafts, and CGH connected experts from the US National Cancer Institute community with stakeholders in Kenya to provide insight into specific fields. A final draft document was redistributed to all participants before a stakeholder meeting held in early 2017, during which the document was finalized.

Results:

Finalization of an MoH and NCI-K document that dictates the minimum requirements for health care facilities that wish to offer cancer services to their patients.

Conclusion:

After publication, the guidelines will be distributed to health facilities, and monitoring and evaluation will be completed by NCI-K to ensure that guidelines are being followed and updated as needed.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

Addressing NCDs through research and capacity building in LMICs: lessons learned from tobacco control

Confronting the global non-communicable diseases (NCDs) crisis requires a critical mass of scientists who are well versed in regional health problems and understand the cultural, social, economic, and political contexts that influence the effectiveness of interventions. Investments in global NCD research must be accompanied by contributions to local research capacity. The National Institutes of Health (NIH) and the Fogarty International Center have a long-standing commitment to supporting research capacity building and addressing the growing burden of NCDs in low- and middle-income countries. One program in particular, the NIH International Tobacco and Health Research and Capacity Building Program (TOBAC program), offers an important model for conducting research and building research capacity simultaneously. This article describes the lessons learned from this unique funding model and demonstrates how a relatively modest investment can make important contributions to scientific evidence and capacity building that could inform ongoing and future efforts to tackle the global burden of NCDs.

A Global Cancer Project Map Integrating Global Cancer Statistics to Guide International Efforts

Abstract 39

Background:

In response to the growing burden of cancer, Global Oncology, Inc., and the National Cancer Institute Center for Global Health launched a free, online, interactive map, the Global Cancer Project Map (GCPM) [ http://gcpm.globalonc.org ], to allow policy makers, researchers, and civil society around the world to search this central repository of international cancer control and research projects. The GCPM serves to catalyze collaboration in cancer research and clinical care, as well as inform research and care gaps.

Methods:

In addition to search options by project attributes, the GCPM provides map overlays of epidemiological measures using IARC’s GLOBOCAN cancer-specific estimates of incidence, prevalence, and mortality, cancer disability--adjusted life years, and UN Human Development Index country values. Currently, the map displays projects with international collaborators collated from the NCI, NCI-Designated Cancer Centers, UICC and ASCO.

Results:

The GCPM search options offer countless angles of looking at projects worldwide. Of the 1,479 currently-mapped projects, 44.8% have investigators or collaborators in less-developed countries (LDCs) (as defined by the UN). Of the 1218 with a project type classification, 104 relate to capacity building and/or training, with 69 of these projects (66.3%) occurring in LDCs. Utilizing the cancer type search options, the GCPM currently displays 54 cervical cancer projects with LDC collaborators, where the cervical cancer mortality age--standardized risk is more than 2.5 times higher for LDCs than more-developed countries.

Conclusions:

The GCPM is a real-time needs assessment tool to allow the cancer community to visualize international efforts in cancer control and link need to action. To better address the growing burden of cancer, the partnership is actively seeking collaboration and additional project submissions. Utilized with cancer statistic overlays, the GCPM can help develop regional priorities in cancer research and control. Funding: This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST:

Ali Chisti No relationship to disclose Nour Sharara No relationship to disclose Manaswi Gupta No relationship to disclose Jane Craycroft No relationship to disclose Ilyana Rosenberg Employment: Connance, Inc., Hayes Management Consulting Camille Morgan No relationship to disclose Kalina Duncan No relationship to disclose Rachel Abudu No relationship to disclose Billy Andre No relationship to disclose Shannon Silkenson No relationship to disclose Jennifer Silva No relationship to disclose Ami Bhatt No relationship to disclose Ted Trimble No relationship to disclose Franklin Huang Stock or Other Ownership: GlaxoSmithKline, Abbvie

Joining Forces to Overcome Cancer: The Kenya Cancer Research and Control Stakeholder Program

BACKGROUND

Cancer is the third leading cause of mortality in Kenya, accounting for 7% of annual deaths. The Kenyan Ministry of Health (MOH) is committed to reducing cancer mortality, as evidenced by policies such as the National Cancer Control Strategy (2011-2016). There are many Kenyan and international organizations devoted to this task; however, coordination is lacking among stakeholders, resulting in inefficient and overlapping expenditure of resources.

METHODS

The MOH and the NCI Center for Global Health collaboratively executed a two day workshop to improve coordination among government, NGO, and private organizations. Over 80 stakeholders participated from leading cancer research and control institutions in Kenya and the international sphere.

FINDINGS

Actionable recommendations include: establishment of a nationally representative population-based cancer registry; enhanced training for community health workers, nurses, researchers, pathologists, and oncology specialists; a reconfigured referral process, including leveraging of existing resources to improve access to cancer care; and coordinated community outreach and education. The MOH is in the process of forming a Technical Working Group (TWG) and has elected a Board of Directors for the newly established Kenyan National Cancer Institute (KNCI), with both entities committed to advancing the cancer control work of the MOH.

INTERPRETATION

This stakeholder meeting enhanced in-country networks, identified priority needs and developed actionable proposals for coordinated improvement of cancer research and control. Active, persistent follow-up by the TWG, KNCI, and other partners will be needed to turn proposals into reality and ensure that partners' investments are integrated into larger cancer control efforts prioritized by MOH.

(18)F-FDG-PET/CT imaging in an IL-6- and MYC-driven mouse model of human multiple myeloma affords objective evaluation of plasma cell tumor progression and therapeutic response to the proteasome inhibitor ixazomib

(18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and computed tomography (CT) are useful imaging modalities for evaluating tumor progression and treatment responses in genetically engineered mouse models of solid human cancers, but the potential of integrated FDG-PET/CT for assessing tumor development and new interventions in transgenic mouse models of human blood cancers such as multiple myeloma (MM) has not been demonstrated. Here we use BALB/c mice that contain the newly developed iMyc(ΔEμ) gene insertion and the widely expressed H2-L(d)-IL6 transgene to demonstrate that FDG-PET/CT affords an excellent research tool for assessing interleukin-6- and MYC-driven plasma cell tumor (PCT) development in a serial, reproducible and stage- and lesion-specific manner. We also show that FDG-PET/CT permits determination of objective drug responses in PCT-bearing mice treated with the investigational proteasome inhibitor ixazomib (MLN2238), the biologically active form of ixazomib citrate (MLN9708), that is currently in phase 3 clinical trials in MM. Overall survival of 5 of 6 ixazomib-treated mice doubled compared with mice left untreated. One outlier mouse presented with primary refractory disease. Our findings demonstrate the utility of FDG-PET/CT for preclinical MM research and suggest that this method will play an important role in the design and testing of new approaches to treat myeloma.

High altitude pulmonary oedema

High altitude pulmonary oedema (HAPE) is an important and preventable cause of death at high altitudes. However, little is known about the global incidence of HAPE, in part because most cases occur in remote environments where no records are kept. Furthermore, despite international efforts to achieve consensus, there is wide disparity in the diagnostic criteria in clinical and research use. We have reviewed the literature on the incidence and epidemiology of HAPE. There is broad agreement between studies that HAPE incidence at 2500m is around 0.01%, and increases to 1.9% at 3600m and 2.5-5% at 4300m. Risk factors for HAPE include rate of ascent, intensity of exercise and absolute altitude attained, although an individual pre-disposition to developing the condition is also well described and suggests an underlying genetic susceptibility. It is increasingly recognised that clinically-detectable HAPE is an extreme of a continuous spectrum of excess pulmonary fluid accumulation, which has been demonstrated in asymptomatic individuals. There is a continued need to ensure awareness of the diagnosis and treatment of HAPE among visitors to high altitude. It is likely that HAPE is preventable in all cases by progressive acclimatisation, and we advocate a pragmatic "golden rules" approach. Our understanding of the epidemiology and underlying genetic susceptibility to HAPE may be advanced if susceptible individuals register with the International HAPE Database: http://www.altitude.org/hape.php. HAPE has direct relevance to military training and operations and is likely to be the leading cause of death at high altitude.