Dr. Lawrence N. Shulman is the Deputy Director for Clinical Services of the Abramson Cancer Center and the Director of the Center for Global Cancer Medicine, both at the University of Pennsylvania; abroad, he sits on the Vice Chancellor’s Advisory Council for Rwanda’s University for Global Health Equity and helps to lead the development of the national oncology program in Botswana.
“Medicine had become not a changed profession but a perpetually changing one.”– Dr. Michael Crichton, Author of Five Patients: The Hospital Explained and Jurassic Park
Weeks before our March 2020 lockdown, Dr. Lawrence N. Shulman left a global oncology symposium packed with wide-eyed Penn medical students and flew to Butaro Cancer Center, which he helped build from ground-up on the rolling green hills of rural Northern Rwanda. He had one goal in mind: provide quality cancer care, even when resources are scarce.
Working tirelessly with colleagues in medicine, industry, academia, and government over the last two decades, Shulman has improved cancer care delivery in low and middle-income countries (LMICs), building cancer clinics and treatment regimens for countless patients who need lifesaving care. Devoted to the notion that access to cancer care should be agnostic to national citizenship and socioeconomic status, Shulman has become oncology’s diplomat, lighting the path for global oncology before the field even bore its name.
Dr. Shulman was a history buff before he found his footing in medicine. As an undergraduate at Syracuse University, he occupied the corners of Carnegie Library poring over ancient texts and modern literature. On one of these nights, he picked up Five Patients: The Hospital Explained, written by Dr. Michael Crichton, a fourth-year medical student at Harvard at the time. While chronicling the hospital experience of five patients, the book outlines medicine’s past and forecasts its future—one defined by the emerging role of technology in clinical decision-making, coupled with increasing medical costs that threatened healthcare accessibility. History entertained Shulman’s mind, but medicine offered an opportunity to shape a future that embraced the triumphs and challenges described in Crichton’s book to positively influence the lives of millions. That opportunity proved too tantalizing for Shulman to resist.
Shulman transitioned into medicine right at the dawn of astounding medical innovations in oncology and a political climate that fought for these advancements. As he finished his undergraduate studies in the late 1960s, the first combination chemotherapy regimen—nicknamed “MOPP” for the components included (mustargen, oncovin, procarbazine, and prednisone)—offered a miraculous cure for advanced Hodgkin’s lymphoma, which previously took every life it touched. Scientists had just discovered the Philadelphia chromosome, a powerful diagnostic biomarker for chronic myeloid leukemia (CML). Midway through Shulman’s first year of medical school, President Nixon signed the National Cancer Act of 1971, declaring a “War on Cancer” and announcing that “The time has come in America when the same kind of concentrated effort that split the atom and took man to the moon should be turned toward conquering this dread[ful] disease.” Excited by the potential for progress in cancer care, Shulman joined the army of scientists working on the cure, finding a mentor who studied leukemia in his second year at Harvard Medical School.
Over the years as an oncologist, Shulman witnessed an emergence of groundbreaking cancer treatments—checkpoint inhibitors for Hodgkin’s Lymphoma, tyrosine kinase inhibitors for CML, CAR-T cell therapies for B-cell lymphomas. These interventions successfully treated 80-90% of patients with their respective cancers in cities like Boston and Philadelphia. However, none of the regimens reached the hands of cancer patients in countries like Rwanda. Shulman realized the utilitarian potential of providing global access to the therapies available in the US, and the millions of deaths that they could prevent. He was determined to secure these biomedical promises for everyone.
Dr. Shulman started forming his lifelong commitment to global health equity as an oncology attending at Brigham and Women’s Hospital (BWH), facilitated by a serendipitous connection with two interns—Drs. Paul Farmer and Jim Kim. Years before, Farmer and Kim had joined forces with Ophelia Dahl to co-found Partners in Health (PIH), a non-profit organization dedicated to providing healthcare to the poorest areas around the world. Dr. Farmer’s early PIH missions took him to Haiti, but there he struggled to find a solution for his cancer patients. He turned to Shulman for advice.
Oncological therapies were still nascent and limited even in well-resourced settings like BWH; transporting complex regimens to Haiti posed a formidable challenge. Their solution: Farmer returned to Haiti with a suitcase heavier than usual, carrying units of chemotherapy and a phone that reached Shulman for detailed instructions on how to administer the medications, to treat patients in need.
In the late 2000’s, at the request of Drs. Farmer and Kim, Shulman began developing formal cancer programs in Rwanda and Haiti. After years of development, the Butaro Cancer Center of Excellence is fully operational in northern Rwanda, and the oncology center at Haiti’s Hospital University Mirebalais, the Centre Roselene Jean Bosquet (named after the first successfully treated patient with cervical cancer, who remains a vocal advocate for cancer care in Haiti), treats thousands of cancer patients each year.
Despite early successes in Haiti and the rewarding career ahead, the journey to continue providing cancer care in LMICs has been riddled with logistical and ethical challenges. “The two experiences were starkly different,” Shulman reflects on the construction of the cancer centers in both Rwanda and Haiti. “Different obstacles needed to be overcome, but we have had success in both locations treating countless patients regardless of their ability to pay. For many patients in both Rwanda and Haiti, poverty would prevent them from receiving care without this provision.” With this approach, the cancer programs at both Rwanda and Haiti see over 1,500 newly diagnosed patients each year, and have now reached more than 10,000 patients who previously would have had no access to life saving treatments.
Innumerable lives have been extended with increased access to chemotherapies, but still healthcare workers at both centers remain frustrated, faced daily with scenarios where they must turn down patients who could be easily treated with American resources. For some conditions, existing treatments simply are not locally available. In more complicated situations, bureaucratic obstacles bar healthcare delivery.
For instance, Shulman regularly sends Rwandan HER2+ breast cancer patients home with an end-of-life conversation instead of trastuzumab, a drug given to most HER2+ patients in America. Trastuzumab substantially improves the cure rates for HER2+ breast cancer patients, reducing mortality for early stage and locally advanced disease by nearly 50%, but is also associated with the rare complication of cardiomyopathy in 2-3% of patients who receive it. Trastuzumab is currently unaffordable for the programs in Rwanda and Haiti, and to date, companies have been unwilling to make trastuzumab available to these cancer programs as part of structured trials because cardiac monitoring is not consistently available in these countries. As such, breast cancer patients in many LMICs, including Rwanda and Haiti, do not receive trastuzumab, resulting in avoidable loss of life.
Our Hippocratic Oath swears us to Primum non nocere (“First, do no harm,” Latin translation), but we often misinterpret this dictum to mean avoid all harm. This is an impossible promise we make on the first day of medical school. Should we avoid prescribing ACE inhibitors for a hypertensive patient because of the small risk of hyperkalemia? Or refrain from a diagnostic endoscopy due to the minute chance of getting a nosocomial infection? In both cases, the benefit of taking the medicine, or getting the surgery, outweigh the potential harms.
To avoid a medical catch-22, we ought to “calculate the risks and benefits of cancer care delivery in countries around the world differently,” Shulman explains, weighed down by the decisions he has had to make in Rwanda and Haiti. “In America, we have cardiologists, and intensive disease specialists, and other resources to maximize the good outcome. But in many countries, we don’t have this infrastructure.” Shulman continues his fight to convince governments and pharmaceutical companies to administer trastuzumab—and a host of other treatments—to cancer patients in LMICs, even in the absence of complex medical infrastructure, where it is clear that curing nearly 50% more patients with this type of breast cancer would more than outweigh the 2-3% risk of cardiac toxicity.
Shulman prematurely returned to America last March due to COVID travel restrictions, but since then he has written editorials (links below) on his interpretation of primum non nocere in the context of global healthcare. He has also applied these lessons to increase access to healthcare within our own country, in resource-poor places like rural Alabama. Shoes still fresh with Rwandan soil, he continues to work tirelessly to expand access to cancer care.
Angela Chen and Likhitha Kolla are MS2 student leaders of Penn Med Global Oncology (GO), for which Dr. Shulman serves as an advisor. For more information on the ethics of global oncology, please read these articles:
Applying Lessons Learned From Low-Resource Settings to Prioritize Cancer Care in a Pandemic
