You are interested in research on results of medical treatment and international health. You are studying the surgical outcomes in middle and low income countries. You have done very interesting research about colorectal cancer in Ukraine. What have you learned from studying cancer treatment outcomes in international settings? What advice you would give to patients about receiving better medical and surgical treatment of cancer? Thank you so much for asking me that question. This is another topic that is very dear to my heart. I did study colorectal cancer outcomes. I researched what happens with colorectal cancer patients in Ukraine. The sad part of the story is that 30 to 40 percent of patients with colorectal cancer in Ukraine die within a year of their diagnosis. That's really unacceptable. In the United States we don't even look at one-year survival in colon cancer and rectal cancer. We look at five-year survival. Five-year survival in colorectal cancer in the US is about 70%. It obviously depends on cancer stage but that is data for all stages combined. 30 to 40% mortality from colorectal cancer in Ukraine within one year! It is just mind-blowing. We looked in more detail why death rate from cancer in Ukraine is so high. We looked at how cancer stage is determined in patients in Ukraine. In Ukraine the majority patients do not get proper cancer stage determination. It means they do not get CT scans of the chest, abdomen, and pelvis to look for the metastatic disease. Then patients with cancer have surgery. But pathologist’s reports do not include information about a number of lymph nodes that were removed during surgery. That is very very important to do in cancer surgery. Because in order to properly treat colorectal cancer, you have to know if the patient had positive or negative lymph nodes. In order to properly determine cancer stage, we need to see 12 lymph nodes. Then pathologist is able to tell us if some of lymph nodes are positive for cancer or not. But you have to obtain at least 12 lymph nodes during colorectal cancer surgical operation. Then you are able to tell if one of the lymph nodes is positive for cancer. Patients with lymph nodes positive for cancer will require chemotherapy. Sometimes the lymph nodes are negative for cancer. Then you can observe the patient without doing chemotherapy. There are some nuances in treatment of colon cancer and rectal cancer after surgery. Some patients might still require chemotherapy. But that is a topic that is open for discussion. But all patients with positive lymph nodes for cancer, need to have chemotherapy. If a patient can tolerate it. You may look only at three lymph nodes after the surgery. They could be all negative for colon cancer. But it doesn't tell you much. Because maybe you just miss the positive lymph nodes. That is a very important thing to do when you deal with colorectal cancer. It is crucial to remove at least 12 lymph nodes during surgical operation. So that a pathologist can examine them under the microscope for signs of metastatic cancer. It is very important thing to do postoperatively. You look at the cancer specimen removed during surgery. There are several methods to improve the outcomes of colorectal cancer treatment in Ukraine. Physicians have to start a national colorectal cancer screening program. You can screen for colorectal cancer in many different ways. One method is optical colonoscopy every 10 years. You can do fecal occult blood testing. There are many methods of doing it. But we looked at doing colonoscopy screening every 10 years. If you do screen patients with colonoscopy every 10 years, then you can not only save lives but actually save cost in Ukraine. You have to start colonoscopy screening at age of 50 and do it every 10 years. Country will save money and will improve the cancer treatment outcomes. We did the cost-effectiveness analysis on screening colonoscopy program. Screening will detect disease earlier, so you can only sometimes treat it just with surgical operation. Patients might not need expensive chemotherapy. Screening can actually prevent colorectal cancer. If you detect a colon polyp, this is precancerous condition. Surgeon will remove a polyp in the colon. Then the patient will not develop colorectal cancer. Another method is to improve determination of cancer stage. Every patient should have MRI and CT imaging up immediately after diagnosis of colorectal cancer. Every patient with colorectal cancer has to have a proper lymph node evaluation. Unfortunately, it's quite difficult to get patients to do colonoscopies. Now there is virtual colonoscopies possible. This is also called CT colonography. But nevertheless worldwide about 1,5 million of colorectal cancer cases happen every year. They are all potentially preventable. Prevention of colon cancer is the best. But it is also difficult for some reason for patients to do colonoscopies, even every 10 years. That's right. It is very difficult to get patients to do colonoscopy. Increasing awareness of colorectal cancer prevention. It is also important to build a program nationwide that encourages patients to be screened for colorectal cancer. Even starting with a program that actually allows people the opportunity to get screened for colon cancer. That would be the first step. Awareness and building awareness and prevention is the best and the most cost-effective method to reduce colorectal cancer in many countries. Exactly! There are patients who are already diagnosed with colon cancer or rectal cancer. Where do you see the most challenges for them? Is it in the training of surgeons and medical oncologists? Is it the question of availability to pay for cancer treatments? There are situations when you have well trained surgeons and oncologists, and the medical system exists. But something is broken in the infrastructure or coordination of treatment or in the decision-making process. Where do you see most of the problems? Well, part of the problems is cost. Definitely, Ukraine's medical system is struggling right now. Training in Ukraine is good, the surgeons are well-trained. But they have to have better access to standards of care available worldwide. For example, we have in the US, we have NCCN guidelines that we adhere to. Other countries have their own guidelines. But it is important to have clinical guidelines that the surgeon and medical oncologist can follow. It is important to cooperate closely with a pathologist. Pathologist can perform a better cancer staging of the lymph nodes, as I discussed before. It is important to build a better infrastructure in the system around clinical care of the patients with colorectal cancer. Have you looked at any other countries? Maybe some other countries of the former USSR? We have the data from Poland and we will publish that. Poland is doing actually much better than Ukraine. The cancer staging is much much better, so they definitely got something correctly. Ukraine should follow that example probably.