Vision 2020: looking back and thinking forward on The Lancet Oncology Commissions
Authors: Mary K Gospodarowicz, David A Jaffray, Felicia M Knaul
Journal: The Lancet Oncology (2020)

The Lancet Oncology was launched 20 years ago with a mission to bridge the divide between science and clinical practice, and to address the enormous global burden of cancer. Since 2011, The Lancet Oncology Commissions (figure) have been at the core of fulfilling that mandate, representing an important global public good. Together with many relevant Commissions published in The Lancet, the Commissions have made invaluable contributions to understanding and meeting the global cancer challenge, and highlighting the importance of cancer within the health system and universal health coverage. In addition, the Commissions have been instrumental in creating the opportunity for informed dialogue by enabling cancer professionals to reach and engage with advocates. By bringing together a diverse group of actors, including oncologists, non-governmental organisations, and UN agencies, and other stakeholders, the Commissions provided a neutral ground for exchange and aligning of ideas to inform and recommend solutions to major cancer problems. A description of each Commission would not do them individual or collective justice; rather, one can only congratulate the editors and the hundreds of diligent and dedicated researchers who contributed to the wealth of information that make up each report, which is in itself a new body of knowledge. The first Commission, which addressed the delivery of affordable cancer care in high-income countries, set the tone for those that followed by engaging a wide spectrum of experts from around the world. The next three Commissions examined cancer control in Latin America and the Caribbean, China, India, and Russia, and the potential role of primary care in cancer control, addressing the issues of diversity of health systems and culture. In 2015, the Lancet Cancer Campaign and Commissions dealing with global access to cancer surgery and radiotherapy were launched. The radiotherapy Commission was modelled on the Global Task Force for Cancer Care and Control and engaged experts in global health, economics, and UN agencies, in addition to oncologists, physicists, and radiation therapists. It embraced new ways to look at the problem—ensuring global access to radiotherapy—by describing not only the cost of scaling up radiotherapy capacity but also the economic benefits of such investment. The Commission report inspired new focus on radiotherapy as an essential component of effective cancer control. The need for access to, and the benefits of, radiotherapy are no longer questioned. The Commission highlighted the need to initiate action given the long timelines required and the need for leadership to achieve its goals. The solution was to urgently engage young leaders who would continue research, advocacy, and action for years to come, such as the GlobalRT initiative, which advocates for radiotherapy to become a global health priority. These leaders have acted on the many innovations in technology, education, and financing highlighted by the Commission. Similarly, the issue of palliative care was recognised as a key, yet neglected, element of the continuum of cancer care and control. The cancer integration aspect of palliative care by The Lancet Oncology Commission was complemented by a Lancet Commission that showed why palliative care and pain relief are imperative to universal health coverage and how to achieve universal access as part of health system strengthening. Finally, in 2020, The Lancet Oncology Commission on childhood cancer, another neglected issue, proposed concrete actions and quantified the return on investment. The Lancet and The Lancet Oncology Cancer Campaign and Commissions have had a large impact in the global health arena. These journals have provided the evidence required to organise the 68th World Health Assembly resolution on access to surgery and the 70th World Health Assembly Cancer Resolution. Cancer treatment and palliation are included in the UN Joint Global Programme on Cervical Cancer Prevention and Control, and the childhood cancer Commission is informing the WHO Global Initiative for Childhood Cancer announced in 2018, in partnership with St Jude Children's Research Hospital (Memphis, TN, USA). A litmus test of the quality of a research paper is its relevance years after its publication. The suite of The Lancet Oncology Commissions passed this test as they have not become obsolete. Indeed, much of the data, analysis, and recommendations continue to be applicable and pertinent. Further, individually and as a set, they constitute an excellent tool for teaching and for global cancer control advocacy. Their success might well be because of the flexible format of the The Lancet Oncology Commissions—they do not have a common template—which allows researchers to explore new avenues of inquiry and expand horizons. Although The Lancet Oncology and the cancer community should be very happy with the Commissions' high-quality analysis and evidence, they might not be happy with their impact. Far too much remains to be done in the face of a growing global cancer challenge. There is ample evidence that the progress in cancer control is too slow and we are failing to flatten the curve of cancer incidence and mortality. Cancer control desperately needs a change in direction, from perseverating on its complexity to embracing innovations that "bury the complexity". The Lancet Oncology can enable this change through a vision inspired by what the future might hold, even if the foreseeable present does not. We now know that presenting evidence is not enough. Evidence must reach the audiences who can use it and transform it into action. Oncologists and researchers are only one group and The Lancet Oncology Commissions can, and must, go further. Outside these groups, and sometimes even within them, complex messages fall on deaf ears. The research might be elegant, but inaccessible to many. Who are the audiences of the future? We suggest that information must be more accessible to diverse audiences through innovation in communication (eg, through condensed messaging similar to that used by the Blinkist book-summarising service). There are opportunities to enable and use new machine-learning technologies to facilitate the dissection and integration of information from across the Commissions. Should the messaging be different for students and researchers than for leaders and advocates who might not be prepared to digest complex reports? The experts might want to read about the new findings in the Commissions, whereas non-experts might only want to read a brief summary of these findings. It should now be possible to tailor the text to specific audiences. There is also a need to collate the information published over time to help readers digest what thousands of papers inform us of every year. Is it time for a meta-Commission on cancer? Should that be a regular activity? Although improved messaging and knowledge transfer are important, there is also desperate need for innovation. Although health care is notoriously slow to adopt new technologies, the COVID-19 pandemic drove progress in digitalisation faster that anyone imagined possible. The digitalisation of health care introduced virtual care, virtual second opinions, and immediate access to expertise, thereby removing several barriers to care delivery. Telepathology, teleradiology, and remote quality assurance are also all examples of how digitalisation of health care can be used to scale up access to cancer care, and show the importance of harnessing this acceleration for cancer control. As The Lancet Oncology enters a new vicennial period, it is imperative that the Commissions set new targets on impact. The rapid pace of innovation in digital technology and the growth in digital competency activated by the COVID-19 pandemic creates the opportunity for the Commissions to adopt a more futuristic approach. The so-called thinking futures approach promoted by the Organisation for Economic Co-operation and Development is compelling. Can commissioners be asked to imagine what the world will look like in 20 years, do more than leap-frog, and write as though the world will be better than it is today? Cancer is complicated. But if we understand cancer, we will understand the entire health system. We can make cancer the engine for understanding and improving health systems to achieve universal health coverage and sustainable development goal 3. In the future, cancer control could be the key to unlock a more efficient, effective, and well integrated health system for all, spanning from primary to specialty care. Achieving this means sharing our systemic innovations with communities we do not often interact with (eg, health system designers, economists, and political scientists). Further, the history of cancer innovations in medicines and interventions shows us how prices can come down and access can increase, as seen with the human papillomavirus vaccine. The future of research in global cancer should be based on the economics of hope. A vision guided by a world where we are prepared for crisis and pandemics, but also account for a better tomorrow. We would argue that this future is more feasible than ever as the COVID-19 pandemic has been a great wake-up call for society at large. It provides the best evidence for the economic value of health, with governments pouring resources into economic stability that could have been managed more effectively and at a reduced cost by use of a systems thinking paradigm. It is time to take full advantage of this realisation and integrate the future cancer system that so many of the Commissions have called for. Thinking forward, we must accept that there can and will be disruptive changes, both within and outside health care, and we have the opportunity to weave a better cancer system into what emerges. DAJ reports patents from multiple licensees through University Health Network (Toronto, ON, Canada). FMK reports grants and personal fees from Merck KGaA and EMD Serono, and grants from Higia, Fundacion Axa, Pfizer, Roche, and Novartis, outside the submitted work. MKG declares no competing interestsFor the Commission on cancer control in China, India, and Russia see Commission Lancet Oncol 2015; 16: 1405–38For more on the Global Task Force for Cancer Care and Control see Knaul FM, Gralow JR, Atun R, Bhadelia A. Closing the cancer divide: an equity imperative. Cambridge, MA, USA: Harvard University Press, 2012For more on the GlobalRT initiative see Rodin D, Yap ML, Hanna TP. GlobalRT: building a new radiotherapy community. Lancet Oncol 2014; 15: 926 DAJ reports patents from multiple licensees through University Health Network (Toronto, ON, Canada). FMK reports grants and personal fees from Merck KGaA and EMD Serono, and grants from Higia, Fundacion Axa, Pfizer, Roche, and Novartis, outside the submitted work. MKG declares no competing interests For the Commission on cancer control in China, India, and Russia see Commission Lancet Oncol 2015; 16: 1405–38 For more on the Global Task Force for Cancer Care and Control see Knaul FM, Gralow JR, Atun R, Bhadelia A. Closing the cancer divide: an equity imperative. Cambridge, MA, USA: Harvard University Press, 2012 For more on the GlobalRT initiative see Rodin D, Yap ML, Hanna TP. GlobalRT: building a new radiotherapy community. Lancet Oncol 2014; 15: 926 The Lancet Oncology at 20—two decades of influencing the oncology landscapeThis month's issue of The Lancet Oncology marks our 20-year anniversary. Much has changed in the journal and in oncology alike over the past two decades. The journal has grown from its formative years as a review-only publication into a full research journal; from its early steps as The Lancet's first specialty title to one of the most prominent clinical oncology journals worldwide; and from an educational journal to a publication driving major advances in treatment and health systems. Full-Text PDF