Uganda Cancer Institute Executive Director Dr. Jackson Orem once told an African colleague about the partnership he had forged with Fred Hutchinson Cancer Research Center in Seattle. His friend replied, “It’s like you’re collaborating with someone on the moon!”
He wasn’t just talking about the 8,800 miles and 11 time zones that separated the institute in Kampala, Uganda, from the one in Seattle. At the time the alliance began, U.S.-style cancer research and treatment seemed out of this world.
Orem made a rare visit to the Fred Hutch campus last week to celebrate the partnership’s 10th anniversary and reflect on the distance traveled over the last decade.
“Through cooperation and collaboration, by building capacity through training and technology transfer, with engagement with our partners and our government, we are showing that we can have a sustainable cancer program,” he said. “Despite the fact that we are collaborating with people who are living on the moon, we have shown that we can do some work on Earth.”
Transplant and immunotherapy researcher Dr. Edus H. “Hootie” Warren, head of Global Oncology at Fred Hutch, was even more optimistic about the alliance’s next 10 years.
“We want to build the capability to do original, important science,” he said. “We’d like to put even more effort into the training of scientists who can do both translational and clinical research. We want to train the scientists who are going to lead African science in the coming decades.”
It was hard to imagine such optimism back in 2008, when the alliance was formally established, or in 2004, when the small research pilot project that preceded it began. Back then, Uganda had a single oncologist for about 30 million people.
Orem for a while was that single oncologist. But the man whom Warren described on Friday as one of the most inspirational people he had ever met persuaded medical graduates from Makerere University in Kampala to volunteer at the UCI with the promise that better times lie ahead.
Dr. Fred Okuku, who accompanied Orem to Seattle for the celebration, was one of Orem’s early recruits. Fred Hutch President and Director Emeritus Dr. Larry Corey, who helped launch the original pilot project in 2004, recalled first meeting Okuku. The young Ugandan physician was treating patients at a clinic that lacked even running water. His drive impressed Corey mightily.
“There must have been 60 people in line, and Fred was the doctor taking care of them,” Corey said. “It was amazing to me how, without running water, without practically anything, what a good doctor could do.”
Thanks to the partnership, Orem’s promise to his young recruits came true: Conditions have improved vastly since then. The UCI-Fred Hutch Cancer Centre that opened in Kampala in 2015 is the most visible sign of the alliance’s accomplishments. The three-story, 25,000-square-foot structure houses all of the alliance’s work — laboratories, training facilities, and separate outpatient clinics for children and adults.
It was the first comprehensive cancer center jointly built by U.S. and African cancer institutions in sub-Saharan Africa, and it is a beauty to behold, its three-color-blend brick exterior designed to match Fred Hutch’s Seattle campus. (Corey’s toast included a shout-out to Scott Rusch, Fred Hutch’s vice president for Facilities and Operations, who oversaw the construction; Rusch confessed that he still keeps a photo of those bricks as the backdrop image on his cell phone.)
But as crucial and impressive as the building is, everyone agrees that the heart of the alliance is the people. Today, 14 Ugandan clinician-scientists have completed yearlong training fellowships in Seattle and returned to the UCI to practice, do research and take up leadership positions.
Okuku was one of them, coming to Seattle in 2009-2010 to take graduate classes at the University of Washington schools of Medicine and Public Health and do clinical rotations at Seattle Cancer Care Alliance, Fred Hutch’s clinical care partner.
“It’s remarkable to see how far we’ve come,” he said during a round of toasts at the reception. “The scientists in this room have the will to work together and collaborate with us to see that we train more oncologists, more scientists. I believe that there are going to be great scientific breakthroughs in the near future.”
Indeed, two potentially groundbreaking clinical research trials are underway or soon to be. One, which opened in late April, could change the way breast cancer in sub-Saharan Africa is diagnosed and treated. It could lead also to a better understanding of why the disease tends to strike younger women and to be more aggressive in both sub-Saharan Africa and among African-Americans.
The study is being led by Fred Hutch oncologist-researcher Dr. Manoj Menon along with Orem. Dr. Nixon Niyonzima, a Ugandan physician who in 2016 received his doctorate in molecular and cellular biology from Fred Hutch and the University of Washington, will be involved in running the trial in Kampala.
Still in the planning stages with the goal of opening by early next year, a second clinical trial will study the use of rituximab, a monoclonal antibody treatment commonly used in the United States for patients with aggressive B-cell lymphomas. The medication will be given subcutaneously, or under the skin, which would be easier to deliver in low-resource settings than an intravenous infusion. That study will be led by Global Oncology Deputy Director Dr. Thomas Uldrick with Orem and UCI physician-researcher Dr. Henry Ddungu, who trained in Seattle in 2011.
With a treatment that is more intensive will come the need for better supportive care, including management of infections. That will be the focus of another Seattle trainee, Dr. Margaret “Maggie” Lubwama.
The rituximab study is designed to test the treatment in adults first and then in adolescents and children. Researchers hope it may improve survival for Burkitt lymphoma, a leading cancer killer of children in sub-Saharan Africa. Intensive case management and nutritional supplementation — practices originally provided by the alliance’s Burkitt Lymphoma Project and now taken over by the UCI — boosted survival rates some, but nowhere near as high as in patients treated in the United States. One difference: In Uganda, chemotherapy used to treat the cancer has not changed in 50 years.
“We’re hoping rituximab will be a game-changer,” Warren said.
Its 10-year investment in capacity-building — meaning the new building but especially the people trained — has helped the alliance reach this point, according to Dr. Warren Phipps, alliance medical director and director of faculty development in Kampala.
“Early on, you’re building critical mass,” he said. “It just takes time to do that. But once you hit that, things really take off. We’re at that inflection point now.”
That doesn’t mean the alliance has slowed its training efforts. In May, Fred Hutch Global Oncology, in partnership with the UW School of Medicine, the UCI, the government of Uganda, Makerere University, and Mulago Hospital in Kampala, announced the launch of the East Africa Adult Hematology-Oncology Fellowship Program. After a decade of bringing Ugandan physicians to Seattle for training, this new program will send Fred Hutch and UW Medicine oncologists to the UCI.
Another new program will focus on training oncology nurses. Dr. Kathleen Shannon Dorcy, director of clinical nursing research, education and practice for SCCA and a staff scientist at Fred Hutch, traveled to Kampala over the winter and spring with SCCA nurse Arlyce Coumar to help launch the new venture and award the first scholarships to nursing students.
At the reception, Dorcy made a point of saluting the UCI’s indomitable head nurse back in Kampala, Sister Allen Naamala Mayanja, for initiating the SCCA partnership.
“Sister Allen said, ‘We have done much for science. We have done much for medicine. Now we need to do something for nurses,’” Dorcy said, raising a glass. “This is for Sister Allen: Tell her we are so grateful for the opportunity.”
Undergirding the two new training fellowships is a peer-mentoring program started in 2010 by Phipps and Dr. Rhoda Morrow, who recently retired as head of the Faculty Affairs Office in the Hutch's Vaccine and Infectious Disease Division, or VIDD.
Mentoring plays a key role in biomedical research, ideally providing a sustained relationship that helps junior colleagues acquire the knowledge, skills, behaviors, and values needed to have a successful career and contribute to the field. But how do you form such a relationship when there are few experienced physician-researchers on-site to serve as mentors?
The solution that Phipps and Morrow came up with was for mentees to mentor each other, augmented by weekly Skype sessions with senior colleagues in Seattle. The Ugandan researchers meet regularly to discuss research in progress or go over the latest papers published in medical journals.
“What’s nice about it is that more and more responsibility for it is being handed over to senior trainees now,” said Phipps, an assistant VIDD member who first traveled to Kampala as a fellow himself and has lived there full time for more than 10 years. For example, Drs. Innocent Mutyaba, James Kafeero, and Niyonzima, all of whom trained in Seattle, now help lead the peer-mentoring effort. The program, as described earlier this year in the Journal of Global Oncology, is being held up as a model for other low-resource countries.
The excitement of seeing these young researchers “blossom into leaders” has kept Phipps in Kampala for as long as the formal alliance has been in existence.
“The idea of building the future leaders and mentors — that’s really happening,” he said. “We’re creating that next generation of researchers, and they’re already mentoring medical students. They’re the role models who are setting the tone for being well-rounded clinician-researchers.”
Niyonzima is one of them. Now clinical lab director and head of research and training at UCI, he was invited back as a distinguished alumnus to deliver the keynote speech at the hooding ceremony for this year’s graduates of the program in molecular and cellular biology. He arrived in Seattle early so that he could attend the alliance anniversary celebration.
At the toast, he issued an invitation. Call it a moonshot in reverse.
“We hope that maybe for the 20 years’ celebration, we will invite you to Uganda,” Niyonzima told his Seattle colleagues, “and you won’t be able to tell the difference between Seattle and Kampala.”
Mary Engel is a former staff writer at Fred Hutchinson Cancer Center. Previously, she covered medicine and health policy for the Los Angeles Times, where she was part of a team that won a Pulitzer Prize for Public Service. She was also a fellow at the Knight Science Journalism Program at MIT. Follow her on Twitter @Engel140.
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