As the Global Burden of Cancer Rises, Can Fellowship Training Adapt?

Mary Chamberlin, MD

As a medical oncologist who has long been interested in global health, I felt it was a privilege to be able to attend my first African Organization for Research & Training in Cancer (AORTIC) Conference last November in Kigali, Rwanda, and I look forward to many more. As I reflect on the excitement of the release of the National Comprehensive Cancer Network Harmonization Guidelines and the recent announcement by Pfizer and Cipla to increase access to 16 essential cancer treatments,1 I was a little amused but also rather shocked during rounds last week at Dartmouth Medical Center in Lebanon, New Hampshire. A patient with newly diagnosed rapidly progressive, poorly differentiated, metastatic lung cancer was being examined by 1 of our second-year hematology-oncology fellows. As I will explain, it was a reminder of how quickly we all have to adapt our teaching and training programs to keep up with the changing pace of care around the world.

The fellow and I were discussing a previously healthy 66-year-old white American male. Pathology showed poorly differentiated carcinoma, not otherwise characterized, and immunohistochemistry results were equivocal as to the primary site, but radiographically it appeared to be a lung primary. Molecular tests had been ordered several days prior, and results were pending. The patient had responded well to palliative radiation to an orbital metastasis but his pulmonary status was worsening because of a steadily growing left lung mass. When I asked the fellow what his treatment plan was, he said, “There’s nothing that can be done until we get the molecular pathology results back. Chemotherapy won’t work and will only make things worse.”

Understandably, he is “growing up” as an oncologist in a very different era from even a few years ago. He honestly had never seen a patient with advanced lung cancer receive carboplatin and paclitaxel. We then discussed the data behind platinum doublets in advanced cancer and the proven modest but significant improvement in quality of life compared with best supportive care, as well as the potential risks and benefits of radiation to the lung. We made a plan to proceed with radiation and, if no molecular targets were identified, or if the patient worsened further before results were available, to include chemotherapy.

For me, as his fellowship director, it was yet another eye-opener to the pace of change in high-income countries, while the majority of patients with cancer globally are lucky to have access to any chemotherapy, much less molecular profiling and targeted therapies. In just a few short years, we run the risk of producing oncologists who may not have sufficient experience with the very drugs that are just now barely becoming available to many parts of the world. Furthermore, as we work to expand opportunities for doctors caring for patients with cancer in low-income countries to come to the United States, we have to make sure the experience is appropriate to the setting to which they are going to return.

Hematology-oncology fellowship programs in the United States can adapt in several ways. One way is to create a Global Oncology track that would provide more exposure to a broader range of subspecialties, such as radiation oncology, gynecologic oncology, and pediatric hematologyoncology, and spend significantly less time in the hematology bone marrow or stem cell transplant ward, for example, which currently occupies almost 50% of their training. A Global Oncology track could be in parallel to traditional fellowships and could have a separate applicant pool to allow for international and domestic fellows interested in careers in global health to apply and train together with multiple options for continuity clinics in low-resource settings. To make international sites a feasible setting for Accreditation Council for Graduate Medical Education (ACGME) board certification, we need to increase the number of US faculty from ACGME-approved programs to be onsite as well. By attracting fellowship-trained oncologists to supervise fellows in low-resource settings, they would also be available to directly teach the local staff and doctors. These adaptations will require funding and organization, so it is with great anticipation that I await the results of the ASCO Global Oncology Task Force recommendations due to be released at the end of this year. Here at Dartmouth, we have had great success with a pilot program of a Global Oncology elective in Rwanda over the past 2 years,2 and we look forward to continuing our work as we strategize and brainstorm together on how to create more opportunities and larger programs to address the global cancer crisis.

There are also myriad opportunities for oncologists to get involved at the very beginning of cancer care in many parts of the world, and this will hopefully attract many fellows into this field. As an academic oncologist, I find it fascinating to try to articulate the “art of oncology” to a nononcologist and to winnow down over 15 years of experience into where the most benefit lies. What works the best and for what cost? As a new member of AORTIC, I applaud the efforts of the African Cancer Coalition as they organize and build on the momentum of the November meeting, expanding the guidelines to include additional disease types and raising money for the ChemoSafe Project as chemotherapy access begins to rapidly improve in countries such as Ethiopia, Kenya, Uganda, Tanzania, and Rwanda. The objectives of this program are commendable and include the following:

1. Training of nurses and pharmacists in safe handling and administration of chemotherapy
2. Strengthening of facilities that deliver cancer treatment to reduce risk of exposure to hazardous drugs
3. Improving access to personal protective equipment
4. Pathology strengthening Since the Harmonization Guidelines are intended for use by oncologists, and oncologists are still a very rare commodity in East Africa, and based on my own observations as a consultant in Rwanda over the past 2 years, I propose 2 additional objectives for the ChemoSafe project:
5. Training of physicians in assessing response and tolerance to chemotherapy to ensure safe and ethical use
6. Training all providers in the art of difficult conversations These are challenging topics in any setting, yet they are critical to maximize the benefit of limited resources and, more importantly, to avoid harm.

Once we agree on these additional objectives, the question then becomes how to teach these important skills.

There are many ways to evaluate benefit to treatment, and requires constant assessment, history, and physical examination as well as radiographic measurements. Patients for whom we have been caring during many lines of therapy, with long histories of metastatic disease, often will tell us when they have had enough. Patients who have been waiting months for treatment and have sacrificed the time and resources from many members of their family to get to a place where they can be treated may have a very different perspective on what they are willing to tolerate, leaving it to us as physicians to determine whether a treatment will help or harm. If someone presents with a large breast mass that is unresectable and the goal is to make it resectable and there is doxorubicin, cyclophosphamide, and paclitaxel available, it is appropriate to treat but also to watch closely for evidence of response. If the disease is not responding or is getting worse after 2 cycles, it is difficult to explain to someone that it is not helpful to continue and that it may harm them, but sometimes that is the most ethical choice. As chemotherapy becomes more accessible, there is an understandable sense of obligation to treat from all parties, yet it may not always be the right thing to do.

Expanding cancer care to places in the world where options are limited and resources are scarce will require education and research to assist us in predictive and prognostic methods that will undoubtedly be different from those in high-resource settings. We need to give our colleagues in low-resource countries the tools to assess who will benefit from treatment and teach them how to have difficult conversations with patients and families, to give them the words and support they need to say when there is nothing else that should be done, even if there may be more that could be done.

As senior oncologists, we need to train more of our fellows for careers in global health, or at least prepare them to be advisers. As the global burden of cancer accumulates, it is today’s fellows who will be called on to help. Cytotoxic chemotherapy is not perfect, but it will continue to have a role in treating many cancers and managing symptoms of advanced cancer for many decades to come.

References

1. McNeil DG Jr. As cancer tears through Africa, drug makers draw up a battle plan. New York Times. October 7, 2017. nytimes.com/2017/10/07/health/africa-cancerdrugs. html. Accessed March 28, 2018.
2. Lansigan F, Costa CA, Mpanumusingo E, Kigonya C, Butonzi J, Sebahungu F. A novel global health fellowship elective in oncology in Rwanda: a multi-faceted model in education. J Clin Oncol. 2017;35(suppl 15; abstr e18086). doi: 10.1200/ JCO.2017.35.15_suppl.e18086.