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Title page
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Variations in gynecologic oncology training in low (LIC) and middle income (MIC)
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countries (LMICs): common efforts and challenges
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Corresponding author:
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Carolyn Johnston
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All authors:
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Carolyn Johnston
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Division of Gynecologic Oncology Dept Ob/Gyn
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1500 E. Medical Center Dr SPC 5276
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Ann Arbor, MI 48109
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1-734-936-6886 phone
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734-764-7261 fax
L4606 UH-South
[email protected]
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Joseph S. Ng.
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Dept of Obstetrics & Gynecology, National University Hospital. 1E Kent Ridge Road,
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Level 12 Singapore 119228
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+6567795555. [email protected]
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Dr Ranjit Manchanda MD, MRCOG, PhD
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Clinical Senior Lecturer & Consultant Gynaecological Oncologist
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Barts Cancer Institute - a Cancer Research UK Centre of Excellence | Queen Mary
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University of London Room 4, Basement, Old Anatomy Building | Charterhouse Square
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| London EC1M 6BQ Department of Gynaecological Oncology | Bartshealth NHS Trust,
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Royal London Hospital 10th Floor, South Block | Whitechapel Road | London E1 1BB |
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Fax: 0203 594 2792 [email protected]
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Audrey Tieko Tsunoda, MD, PhD
Address: Rua Frei Orlando, 169
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Curitiba/PR Brazil
Zip:82530-040
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[email protected]
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Phone/Fax: +55 41 3099-5800
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Cell: +55 41 9187-7387
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Linus Chuang MD MPH
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Professor of Gynecologic Oncology
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Divisional and Fellowship Director of Minimally Invasive Surgery Department of
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Obstetrics, Gynecology and Reproductive Science Icahn School of Medicine at Mount
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Sinai New York, NY USA
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1-212-241-1111
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1-888-959-6811
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[email protected]
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Key words: LMICs; Gynecologic: Oncology; Training
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Abstract
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Gynecologic cancer, cervical cancer in particular, is disproportionately represented in the
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developing world where mortality is also high. Screening programs, increased availability
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of chemotherapy, and an awareness of HIV-related cancers have in part accelerated a
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need for physicians who can treat these cancers, yet the infrastructure for such training
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is often lacking. In this paper, we address the variations in gynecology oncology training
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in LMICs as well as the ubiquitous challenges, in an effort to guide future agendas.
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Introduction
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It is well established that outcomes of gynecologic cancer patients are better when treated
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by appropriately trained subspecialist gynecologic oncologists.[1–3] The infrastructure,
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environment, facilities and opportunities for training in gynecologic oncology vary widely
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across different countries. These training programs are better developed and well
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established in higher income countries, predominantly in the Western world. Are and his
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colleagues[4] also reported significant variations in the surgical oncology training
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requirements associated with geographic region and economic status. Furthermore the
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lack of adequately trained surgical oncologists was found to be another significant barrier
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to cancer care [5]. Investment in health infrastructure and training is also a function of a
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country’s income. The world-bank separates countries into four income categories on the
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basis of gross national income (GNI) per capita, in U.S. dollars: low income (LIC:
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≤$1,025), lower-middle income (LMIC: $1,026-$4,035), upper-middle income (UMIC:
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$4,036-$12,475), and high income (HIC: ≥$12,476).[6]
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expected to increase by 75% over the next 20 years.[7] Most of this increase will occur in
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LIC and MIC. For the purposes of this paper, MIC includes both upper and lower MIC.
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Gynecologic malignancies including cervical, uterine and ovarian cancers are second to
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breast cancer in incidence and represent 16.3% and 19.2% of all cancers in women from
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all economies and less developed countries, respectively.[8] Also 87% of cervical cancer
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deaths occur in less developed countries.[8] Growing and expanding a properly trained
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workforce in these countries is crucial for fulfilling the future needs and improving
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outcomes of women with gynecologic cancer. In this article we examine the current state
Global cancer incidence is
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of training in gynecologic oncology in LMICs and make recommendations for a way
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forward.
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Training in Africa
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The gynecologic oncology training programs in Africa are mostly new since 2012, 2 to 3
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years in duration, and have a range of training emphasis from comprehensive, similar to
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those in the United States, Canada and parts of the EU, to a primary concentration on
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cervical cancer care. Three common themes are an association with a teaching university
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and medical school, lack of internal funding and a reliance on outside mentorship.
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South Africa
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The certificate subspecialty program began in 2008 and is a comprehensive program with
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requirements for an exit exam, research project and a case log book. Presently, the
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program uniquely does not require external mentors; in fact other trainees can rotate
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there.
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Zambia
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The Gynecologic Oncology Consultation Service, based at the University Teaching
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Hospital in Lusaka, was established in January 2010. The Divisions of Gynecologic
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Oncology at the University of North Carolina at Chapel Hill and University of California,
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Irvine support the service via faculty exchange visits. [9,10] They also have a strong
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research component led by Zambians who trained under a NIH sponsored grant and
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returned to run the program.[9] There is an extremely well developed comprehensive
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cervical cancer screening and care training program, most attributable to the efforts of Dr.
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Groesbeck Parham, the Founding co-Director.
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Uganda
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A gynecologic oncology fellowship 2-year training program under the joint auspices of
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Uganda Cancer Institute/Mulago/Makerere University (also the certifying bodies) is
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anticipated to start in 2017. Outside mentorship is provided by Dr.s Paula Lee (Duke
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University School of Medicine) and Stephanie Ueda (UCSF).
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Kenya
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A Masters of Gynecological Oncology 2-year comprehensive program approved by the
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Kenyan Medical and Dental Board, was initiated at Moi University Medical School in 2012.
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Outside mentoring is provided by visiting oncologists associated with AMPATH [11],
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including Dr. Barry Rosen. This program also includes rotations in communication and
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palliative care and has a unique strong emphasis on research. Two physicians are in
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training and 5 have completed the program.
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Ghana
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Gynecologic oncology fellowship training is a certificate program of the Ghana College of
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Physicians and Surgeons (GCPS) and is available to those who have completed an
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Obstetrics and Gynecology residency and who are members of the GCPS. It is a
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comprehensive model with rotations through radiation and medical oncology, pathology,
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epidemiology, urology and general surgery. The University of Michigan provides the
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outside mentorship, the monthly telemedicine-facilitated tumor board and on-site surgical
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training. The sole remaining program in Kumasi at Komfo Anokye Teaching Hospital has
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3 fellows in training and began in 2013. The other center lost its fellow due to frustration
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over his perceived lack of training support, despite being a strong teaching institution for
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obstetrics and gynecology.
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Ethiopia
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There are 3 fellowship programs, 2 in Addis Ababa and 1 in Gondar. The first program at
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Black Lion Hospital/Addis Ababa University School of Medicine (BLH) started in 2012,
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provides comprehensive gynecologic oncology training, is unique in its 3-year duration
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and is directed by Dr. Dawit Desalegn, one of 4 gynecologic oncologists who completed
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the program, passed their final exams in 2015, and received their certifications. The other
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2 fellowships started in 2015 and are accredited by their medical schools and universities,
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St Paul’s Millennium and Gondar, respectively. BLH thus has 3 practicing gynecologic
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oncologists and the other 2 programs rely on outside mentorship/training and visiting
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faculty from the Universities of Michigan, Minnesota, and Jena. They all require
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documentation of surgical expertise and an oral exam to receive certification of
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completion.
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Training in Asia
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The Association of Southeast Asian Nations (ASEAN) was formed in 1967 and current
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member states are: Brunei Darussalam, Cambodia, Indonesia, Laos, Malaysia,
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Myanmar, Philippines, Singapore, Thailand and Vietnam. ASEAN is the 3rd largest global
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economy and the fastest growing economy in Asia after China. [12] Southeast Asia also
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has one of the highest cancer mortality rates in the world. [7] There are 24 gynecologic
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oncology training centers in Indonesia, Malaysia, Singapore, and Thailand, all offering
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somewhat differing levels of training in gynecologic oncology to meet local and national
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women’s cancer needs, with programs running from 2 to 6 years and focusing on surgery
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for cervical cancer to proficiency in the full spectrum of gynecologic oncological care
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including urological and colorectal surgery and managing chemotherapy. Close physical
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proximity of LMICs to first-world healthcare environments in Southeast Asia, means that
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trainees from Southeast Asian LMICs can quite easily train with mentors at facilities in
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more developed healthcare environments. Most of the first generation of gynecologic
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oncologists in Southeast Asia trained predominantly in Australia and the United Kingdom
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with some being trained in France, Germany and the Netherlands following traditional
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colonial associations in the region. A good example of an emerging economy that is
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interested in building rudimentary healthcare infrastructure is Vietnam. Early efforts to
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develop local expertise in the management of women’s cancers thus far have involved
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ad hoc efforts to connect with NGOs and individual institutions in the US and Singapore
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for assistance with training. There are also countries in Southeast Asia that are only
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starting to build primary level healthcare infrastructure like Timor-Leste, that at present
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do not have the capacity to address diseases like women’s cancer.[13] Southeast Asia
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therefore presents opportunities, available training resources and certainly clinical need
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for developing expertise in women’s cancer care.
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Indonesia
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Gynecologic oncology training is endorsed by the Indonesian College of Obstetricians
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and Gynecologists (SPOG). The training program is 4 semesters and available at 3
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training centers in Bandung, Jakarta, and Surabaya. Completion of a training program
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similar to residency in obstetrics and gynecology is a requirement for all applicants. The
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training curriculum encompasses elements of exposure to chemotherapy, radiation
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oncology, classical surgical oncology and research. The College certifies sub-specialists.
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Malaysia
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Malaysia has one program that is centrally organized by the Ministry of Health (MOH).
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The national curriculum is taught at 8 centers which are primarily hospitals run and
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managed by the MOH. The program is 3 years with an option to spend one of the 3 years
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overseas. There is exposure to chemotherapy, radiation oncology and trainees are
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expected to publish one paper. There is a qualification process which involves an oral
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examination and a review of the case logs for candidates applying for sub-specialist
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recognition by the MOH, a process known as gazettement.
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Thailand
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There are 10 centers in Thailand which conduct gynecologic oncology training under the
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auspices of the Royal Thai College of Obstetricians and Gynecologists (RTCOG). It is a
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2-year program during which trainees get primarily surgical training with some exposure
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to medical and radiation oncology. Thailand has a healthcare infrastructure where access
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to urological and colorectal or general surgical expertise is not often an issue and as such
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bowel and bladder surgery are not core to the training curriculum. There is a certifying
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examination conducted by the RTCOG which also involves a case log review.
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Laos
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Laos is in the process of developing a national program and is sending trainees to
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Thailand to acquire the necessary exposure and expertise to help build the infrastructure
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in Laos.
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Training in Europe
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Although the European Society of Gynecological Oncology (ESGO) has made a number
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of strides towards harmonization of training by setting minimum standards and introducing
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and promoting a common training curriculum/program as well as system of accreditation,
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training opportunities and standards still vary significantly across European countries.
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Gynecologic oncology still remains unrecognized as an independent sub-specialty in
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many European countries. Most European programs vary between 2-3 years with a
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median length of 2.5 years.[14] Developing complex surgical skills for independent
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practice is well recognized as one of the more challenging aspects of subspecialty
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training. Additionally, trainees need to develop non-surgical proficiencies in medical and
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radiation oncology, palliative care, cancer genetics and research. Furthermore, clinical
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practice and training programs need to keep up to date by timely incorporation of new
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technological and scientific advances. Accredited programs are well structured and have
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a detailed curriculum, competency based logbook and structured assessments. A more
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detailed description of the training programs across European countries is given
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elsewhere.[15] Unfortunately low and upper middle income countries (MICs) in Europe
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lack ESGO accredited well-structured training programs. Training in these countries is
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loosely or moderately structured.[14] We have previously shown that training satisfaction
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and quality is significantly higher in accredited European programs (p<0.0005) with 17 of
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22 aspects of the training curriculum scoring higher in accredited centers. [16]
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Additionally, data show that the overall educational climate including supervision,
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coaching/assessment, feedback, teamwork, inter-consultant relationships, formal
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education, role of the tutor, patient handover, and overall consultant’s attitude towards
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training is significantly better (p=0.001) in accredited centers.[17] Given complete lack of
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accredited structured training in European MICs, the clinical learning climates, quality and
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satisfaction with training in these countries is significantly poorer than HIC. The need for
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better feedback mechanisms as well as workshops in laparoscopic surgery, anatomy and
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imaging have been highlighted as areas of greater need. [17,18] Trainees in HIC
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countries attach significantly greater importance to additional training in cancer genetics
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and radiotherapy than do MIC trainees.[18] There is a pressing and urgent need for
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harmonization and increase in accredited gynecologic oncology training centers in MICs
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in Europe. Local national societies and political stakeholders or structures have a crucial
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role to play in achieving this end. The recent establishment of the European Network of
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Gynecological Oncologists as a network of trainees led to an increased awareness of the
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need to improve training and to engage with trainees as well as to the creation of
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numerous initiatives to improve the quality of training. This includes workshops,
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masterclass, establishment of web based resources (e-academy) and involvement of
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trainees in the accreditation process. This endeavor can serve as a potential model for
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trainee engagement and development in other parts of the world.
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Training in Central America
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Gynecologic oncology training varies from the absence of formal training in Nicaragua
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and Guatemala to established gynecologic oncology fellowship programs in El Salvador,
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Costa Rica, and Panama.[19] Many of the gynecologic oncology training programs in
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Central America are included as part of the surgical oncology programs. One example is
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the surgical oncology residency program at Hospital San Felipe in Honduras, the only
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public cancer center that provides care for women and men in a nation of nearly 9 million
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people.[20][21] Trainees obtain their gynecologic cancer surgery training in a surgical
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oncology residency that is offered for graduates from medical schools or after completion
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of a residency in obstetrics and gynecology or general surgery. In addition to being trained
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in managing patients with gynecologic malignancies, residents are trained to manage
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breast, liver, colorectal and prostate cancers. During the 4 year training program in
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surgical oncology, residents typically rotate to gynecologic oncology services 4 months
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each year as cervical, ovarian and endometrial cancers represent the most common
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cancers in women in Honduras. To make up for the lack of education resources including
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Spanish textbooks and journals, residents learn to read English language medical
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textbooks. Residents are given tests monthly based on their assigned reading materials.
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Daily conferences are conducted in the morning to review pertinent cases or topics. There
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are no multidisciplinary tumor conferences conducted on a regular basis. In Hospital San
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Felipe, there is no brachytherapy to treat patients with cervical cancer.[22] Since more
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than 100 patients are treated with 2 Cobalt radiation machines every day, residents learn
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to manage patients based on the local guidelines and not from more current oncology
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textbooks. Training in gynecologic oncology in Honduras is challenging due to the lack of
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resources that fellows have for learning and treating patients. The Central America
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Gynecologic Oncology Education Program (CONEP)[23] and Health Volunteers
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Overseas supported by Society of Gynecologic Oncology (SGO) and American Society
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of Clinical Oncology[22] provide the outside mentorship, the telemedicine-facilitated
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tumor board and on-site surgical training in Central American countries. Major support in
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infrastructure and education of these trainees will help to improve gynecologic oncology
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training and care for their patients.
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Training in South America
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There are great variations in training of gynecologic oncology in South America. In Brazil,
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surgical gynecologic oncology is currently part of two specialties: surgical oncology (SO)
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and obstetrics and gynecology (ObGyn). There is no certification for professionals
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dedicated to gynecologic oncology. Adjuvant therapies are managed by medical
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oncologists and radiation oncologists. Around 34% of all cancer patients are currently
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treated in referral cancer centers. [24] Gynecologic oncology training is included as part
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of SO residency programs. These programs are regulated and accredited by National
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Education Organization. The prerequisite for entering a SO fellowship is 2 years of
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general surgery training. Didactic lectures, surgical training, cancer prevention, palliation
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and multidisciplinary managements are emphasized. Research is encouraged but not
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mandatory. During the 3 years of SO training, residents spend 3-16 months rotating on
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the gynecology oncology service. Some centers offer an additional training in minimally
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invasive surgery or radical surgery on management of peritoneal surface diseases. [25]
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Gynecology oncology training which typically lasts between 1 and 3 months, is also
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available in the three year Obstetrics and Gynecology residency programs. Interested
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residents have the option of pursuing GO training in one of the 15 centers upon
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completion of the OB/GYN residency program. This specialty training is offered for a fee
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of $1,200-5,000, and the length of training varies from one weekend/month for 12 months
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to as much as 60 hours/week for 2 years. Only 2 of these programs provide a minimum
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core curriculum and regular evaluations of their trainees. [25][26]
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Developing gynecologic oncology training in LMICs: successful examples and
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challenges
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To develop gynecologic oncology training in LMICs requires that several layers be
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present, including those from the country in question and, at a bare minimum, a willing
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foreign gynecologic oncologist/s to assist. From the LMIC perspective, this would include
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a teaching hospital with willingness to free fellows in training from some of their service
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responsibilities, hospital infrastructure (pathology, operating rooms, other surgical
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services, critical care, basic laboratory tests, available chemotherapy and radiation
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therapy, an opportunity for research, internet access), a certifying body, a structured and
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committed program, patients to treat, fellows that have completed a gynecologic
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residency, and a designated program head.
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One cannot expect the process to be easy, without hurdles and immutable.
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Flexibility, creativity and persistence are key personality traits to success. The standard
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expectation is that gynecologic oncologists do it all, at least when trained in the USA. This
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may be unrealistic in LMICs, where lower volume of general surgical and urologic
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procedures warrants collaboration with their respective surgical colleagues. With time and
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volume, more of these procedures will likely be performed by gynecologic oncologists.
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Additionally, a reliance on hand-sewn bowel anastamoses helps to keep the bowel
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surgery in the hands of the experienced general surgeon who can be called in to assist.
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Experience with facilitation of the development of gynecologic oncology
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fellowships in Ghana and in Ethiopia has revealed obvious and not so apparent
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requirements and hurdles. Based on the realization that it is imperative that the training
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be done in-country with outside assistance in order to retain trainees, specific curriculums
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were developed which utilized existing resources at their respective medical schools,
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itemized learning expectations and milestones, specified examination requirements, and
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identified outside mentors and institutions where observerships could occur. These
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formats differed for the two countries due to availability of integral rotations such as
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radiation and medical oncology, urology, pathology and general surgery, but the unifying
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factor was a consistent presence of a gynecologic oncologist to operate, make clinical
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rounds, evaluate patients in clinics and teach at the respective hospitals. Difficulties with
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this model are the need for the fellows to continue their daily hospital work and call
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responsibilities while participating in the fellowship, insufficient frequency and availability
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of mentoring visits by external gynecologic oncologists, lack of funding for Ghanaian
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fellows to receive the required 6 month rotation for continuous hands-on gynecologic
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oncology surgical experience at a foreign institution under the tutelage of experienced
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gynecologic oncologists and for outside mentors to travel, inexperienced and
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understaffed pathology departments, and inadequate radiation facilities. These
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challenges are in fact generalizable to many LMIC subspecialty training situations. The
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goal is for the institutions with fellowships to be independently training other fellows in 3-
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5 years. However to be able to achieve this goal, they will still need ongoing external
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assistance for some time. Three years ago we established a monthly gynecologic
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oncology tumor board by telecommunication with the training program in Kumasi, Ghana
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to alleviate some obstacles. The highlights of this have been the achievements made in
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real time management of cases and simultaneous teaching process benefiting fellows
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and residents in obstetrics and gynecology, oncology, and pathology as well as the
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patients. The associated challenges include the sustainability of the project, adequate
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real time pathology slide presentation and getting other teaching programs on board.
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High priority topics for LMICs
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Curriculum
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The process of curriculum development for LMICs should take into account the prime
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directive of context-sensitivity. Zetka’s analysis of the history of the rise of gynecologic
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oncology as a subspecialty in the United States is instructive.[27] While well-intentioned
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and well-informed, professional bodies engaged in developing training programs in
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gynecologic oncology in LMICs must also be politically savvy and culturally sensitive.
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With regard to cultural sensitivity, one gynecologic oncologist’s experience in Mongolia is
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most enlightening.[28]
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The key to developing a curriculum in gynecologic oncology for LMICs that is
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useful and effective, lies in crafting a program that is modular, adaptable and yet robust
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enough to produce the desired end result to meet the needs of each LMIC. It is also
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important that such a training program be able to nurture an identity of professionalism
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and instill a sense of ownership of the special knowledge and skills, ultimately producing
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healthcare professionals that identify themselves as gynecologic oncologists, and who
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are able to carry the subspecialty forward in their home countries. [29]
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This at a minimum would include a comprehensive didactic component that
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outlines a list of basic competencies that can be used by mentors and trainers to monitor
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a trainee’s assimilation and retention of a clinically relevant fund of knowledge, an
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externally well supported surgical skills component with a curriculum built to
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accommodate trainees who come into the program with wide variations in basic surgical
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skills and clinical experience. That said, it is probably best to assume the lowest common
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denominator of skills, ie only laparotomy experience. The skills curriculum must also take
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into consideration the variety of pathways through which trainees arrive at gynecologic
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oncology training in LMICs; for example, as an extension of general surgery and surgical
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oncology training or following a residency in obstetrics and gynecology.
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Training support
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The training process required to become an accredited consultant gynecologic oncologist
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is grueling, challenging, and arduous and necessitates development of a broad
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multifaceted skill set. Both trainers and the training institution work environment or
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learning climate have a critically important role to play in maximizing training outcomes
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and experience.[17,30] Some institutions facilitate this process better than others and are
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able to impart higher quality training. Training needs may clash or be at odds with clinical
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service commitments and increased work pressure/workload can make learning more
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difficult. Trainees should be trained in institutes with accredited well-structured training
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programs having a minimal defined and monitored set of standards, caseload,
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infrastructural and organizational processes.[16] This leads to well supported trainees
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with better supervision, training, formalized structured education, assessment, feedback
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and higher training satisfaction.[16,17] More favorable educational climates reduce
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pressures, stresses and conflict, leading to better quality learning. Data indicate that
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trainees need to be supported better in terms of timely and effective feedback.[17] Proper
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training in giving feedback (e.g. training the trainers courses) has been shown to improve
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teaching performance which would likely be a benefit in situations of limited exposure to
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outside mentors to LMICs. [31,32] Trainees also need support and opportunity to develop
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more complex surgical skills like advanced debulking, laparoscopic, urological and
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colorectal surgery.[16,18] Skill and competency development can be enhanced,
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knowledge gaps filled and learning facilitated by dedicated workshops, dry/wet lab,
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cadaveric, simulator training, watching surgical videos and working as an embedded
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member of the colorectal and urological teams. Most training programs suggest a
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research component but this requires funding and protected time, both of which are often
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a challenge to find. However, it is important to maintain the right balance between these
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aspects as excessive research time can lead to an extension in the duration of training
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and time is often at a premium in LMICs.[33] Recruitment and retention to our
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subspecialty can be challenging. An unsupportive institutional training climate, inferior
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work life balance, poor pay coupled with longer working hours are known reasons why
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obstetrics and gynecology trainees don’t pursue a career in gynecologic oncology.[34]
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Program organizers will need to take cognizance and consider steps to address these
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issues to develop a more balanced and happier workforce.
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Establishment of national gynecologic oncology society/board: an example from Brazil
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Professional medical educational societies may play a fundamental role in the process of
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a professional identity formation.[35]
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recognition of a need of expertise in a field.[36] Many countries including Brazil have no
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professional gynecologic oncology society. In 2015, a group of surgical oncologists from
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Brazilian Society of Surgical Oncology and gynecologists with the support of the President
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of SGO Dr. Robert Coleman started a steering committee to establish a gynecologic
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oncology society in Brazil. The first objective was to assess the needs of this specialty
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which was achieved through an electronic survey of more than 256 gynecologists,
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radiation, medical and surgical oncologists. (Tsunoda personal communication). The
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members of a working group for the Brazilian Society of Obstetrics and Gynecology are
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working to define gynecologic oncology as a subspecialty within the Brazilian Medical
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Association. A major achievement of mutual understanding and collaboration among
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heterogeneous professionals focused in the same field has been overcome and it will
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help nurture excellence in gynecologic oncology in Brazil. The success of establishing a
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professional society is vital in promoting education, training and care for women in
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gynecologic cancer in LMIC and such a process could be emulated elsewhere.
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Conclusion
Creation of a medical society starts with the
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Training in gynecologic oncology is lacking in many regions around the world. Even in the
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established training programs, there are significant variations between them with regard
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to the disciplines that are taught. While surgical training in pelvic surgery including radical
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hysterectomy is universal, intestinal and urologic surgery are not usually included as part
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of the formal training in Asia. In European countries, chemotherapy is often managed by
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medical rather than gynecologic oncologists. It is important to remain cognizant of these
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variations in the planning of gynecologic oncology training programs in LMIC. Selection
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of sites for training are equally important.
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The lessons learned in facilitating training programs in Ghana and Ethiopia are that
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fellowship sites should be located at stable, established teaching institutions with a strong
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commitment to fellow education, as well as have available basic oncology and pathology
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resources, frequent regular visits by outside gynecologic oncology mentors, access to
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telemedicine real time tumor boards, and outside pathologists who are willing to help
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teach the subtleties of gynecologic cancer pathology. Also if the trainees are to become
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certified oncologists, then the facilities and treatment resources must also exist for them
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to perform, thus the countries and medical schools are going to need to update and
433
increase the number of their radiation oncology machines and pathology resources, in
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particular. This will likely require the support of the Ministries of Health.
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Finally, the primary challenge and the key to success for any program aiming to
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provide gynecologic oncology training assistance to LMIC is being flexible and responsive
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enough to adapt to the broad spectrum of needs in each country and to deliver expertise
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in a context-specific, culturally-sensitive and politically-expedient manner.
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Conflict of interest statement: None of the authors has a conflict of interest.
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