UICC World Cancer Congress 2006

As cancer becomes a higher fraction of the disease burden of developing countries and cancer control programs are adopted by an increasing number of countries, the present lack of resources in developing countries will become even more of a problem. It will be particularly difficult to augment existing human resources, and the hazard of losing trained persons to the high income countries is not likely to be lessened. Training in-country or in other developing countries is likely to at least reduce this problem, particularly if associated with ongoing cancer control projects conducted with international partners. Such projects, which may include clinical trials in cancer prevention or primary treatment or palliative care, can provide a focus for training as well as an enhanced professional experience. Because of the cost of travel and the limited time available, maximizing the use of “telemedicine” linkages for specific training, or consultation should considerably enhance training, education and service provision programs. Such links will also allow an increase in the frequency of interactions, and enhanced quality through greater understanding, on the part of faculty members of the difficulties faced, and the identification of problems that can sometimes be readily solved (e.g., poor fixation of pathological materials, unnecessary use of imaging studies etc.). The simultaneous inclusion of multiple international participants permits the possibility of repeated exchanges of ideas and sharing of experiences among many centers - a possibility that would be immensely cumbersome in the absence of IT linkages. Thus, IT approaches, while subject to some obstacles, such as the availability of necessary equipment locally, good high speed access to the internet (or to sufficient ISDN telephone lines), include many of the advantages of international meetings, in-country and external training, and international meetings. They also permit a more coordinated approach to be adopted, and allow wider and more varied interactions and collaborations. The development of international networks linked by IT will do much to improve cancer control at a global level.

Introduction

In May of 2005, the World Health Assembly passed a resolution recommending that all governments establish cancer control programs, assign priorities and conduct appropriate activities. This has the effect of putting cancer firmly on the map with respect to global disease control. This is highly desirable, considering that cancer already results in more deaths than AIDS, TB and malaria combined, and the situation will get worse as populations age and those in developing countries continue to expand - to say nothing of the increased exposure to risk factors associated with improved socioeconomic circumstances. Developing countries, whose share of the global cancer burden is already above 50% will bear the brunt of the impending cancer catastrophe, yet they already face severe limitations of a broad range of resources - human, financial and material - and the gap between needs and available resources, already large, will continuously increase unless confronted. The most difficult problem to address is the lack of human resources, although this is closely linked to the material and financial deficits. Education and training associated with the prevention or management of cancer is already hampered by the lack of well trained health professionals, and an additional compounding problem is that a high proportion of the brightest graduates from institutions in developing countries emigrate to countries that can offer better professional and personal rewards.

Standard Solutions

Many professional organizations encourage oncologists and other health professionals from developing countries to attend their meetings, and sometimes provide travel assistance. An increasing number of the upper echelons of the health professionals from developing countries, do attend, and doubtless benefit from such meetings. A particular value is the opportunity to exchange ideas, compare experiences and benefit from the solutions found by others for mutual problems. For the vast majority of health professionals from developing countries, however, there is no opportunity to attend such meetings and it is likely that, at best, they have a small impact on the problem of human resources.

A second standard response to the human resource problem in developing countries is to arrange for training in high income countries. It is assumed that this must be useful, since this permits the highest level of training. Many individuals from developing countries do, in fact, benefit greatly from such training - but frequently become part of the professional work force in the country in which they trained, or in another high income country, rather than return to boost the human resources in their homeland. Some trainees do return permanently to their own countries, and often make a major difference, although many find that much of what they learned abroad is inapplicable to their own countries and they must, in effect, start afresh, although, hopefully, with more insight into potential solutions than would otherwise have been the case.

In-Country Training

INCTR, an non-profit organization dedicated to helping to build capacity for cancer treatment and research in developing countries, espouses twin goals of developing high quality continuing education programs to improve, to the extent possible, the knowledge, skills and discipline of current health professionals, while introducing programs designed to expand the work force (ideally, coupled to specific projects within the area of cancer control) through in-country training programs of health assistants and nurses. These efforts are closely tied to focused cancer control programs such that education, training and service provision, and in some cases research, are closely integrated and interdependent. As centers in which such activities are taking place reach high enough levels of proficiency, they provide training and education to other health professionals in the country or region, at least in the context of particular cancer control projects. In this way, access to care will gradually be increased. The success of this program will, to a degree, depend upon its ability to function as a coordinated network embracing concerted action in the context of a global a community. An important element of this is an external “faculty,” to compensate for the limited resources available in-country. Optimal in-country training programs include a series of activities, including participation of the educator (depending upon his or her speciality) in daily activities, such as ward rounds, review of histopathological slides or laboratory techniques, discussions in multidisciplinary meetings, problem solving sessions, seminars and, where projects are ongoing, review of results, and quality of performance. Clinical trials (relating to prevention or primary treatment) also provide an opportunity for participatory training, for surveillance of quality (of diagnosis, management and data collection) and necessary remedial action, while also resulting in immediate benefits to patients as well as contributing to the development of a foundation of evidence on which to base future endeavors. Multi-institutional studies also improve communication and access, if indirectly, to expertise and have the potential to enhance professional opportunities.

In addition to continuing education it is also critically important to address the issues of health professionals undergoing primary training - for a good cancer control program is also dependent upon primary care health providers for early diagnosis and may often be called upon to participate in prevention programs and palliative care.

The Role of Information Technology

Personal approaches to in-country training require a great deal of time and money as well as a sufficient number of persons willing to participate. Considerable savings in both time and money can be accomplished by maximizing the use of programs conducted via videoconferencing, particularly, but not necessarily, after good relations have been established by face-to-face contacts. These can include a variety of approaches, including all of those used in actual visits of experts, but now conducted at a distance and with the opportunity to have multiple shorter, more frequent meetings that impinge less into busy schedules. Disciplines in which images play an important role (pathology, radiology, radiotherapy planning) may be particularly amenable to videoconferencing sessions including one or a number of participants or institutions. Such sessions can emphasize either consultation or education, but in either case, when professionals providing services participate, will have a potentially immediately beneficial impact upon service delivery. Such sessions will also help to identify problems which, on many occasions, may be readily solved. IT networks have the added advantage that several institutions can participate at once (whether in the same or a different country), further reducing costs with respect to travel and time. Such multicenter sessions may emulate the advantages of international meetings, allowing international exchanges of ideas and experiences. Even surgical procedures can now be directed or conducted from thousands of miles away. INCTR has access to a high quality telemedicine system, TeleSynergy®, provided by the National Cancer Institute, Bethesda, which has been used to date for virtual meetings with the King Hussein Cancer Center in Jordan, and multiple institutions in India collaborating in a clinical trial for the treatment of acute lymphoblastic leukemia.

Telemedicine programs can be carried out pari passu with other information technology based programs. For example, internet based clinical trials management systems are likely to enhance the speed, efficiency and quality of the conduct of clinical trials, at least, in countries with good internet access. INCTR, in collaboration with Capital Technology Information Services, have developed such a system that is in presently in use for management of a clinical trial in India. The concept of an international network, however, is greatly enhanced by a constantly accessible highly interactive web portal, allowing up or downloading of documents and information if users have appropriate privileges in password protected sites. Interactive discussions and even surveys are also possible. Such a portal site has also been provided to INCTR by CTIS and includes a broad variety of materials that can be used for teaching purposes as well as a number of working sites where participants from anywhere in the world can comment or modify documents. Particular elements can be developed into “communities of practice.” Interactive training sessions are also possible through the use of commercially available “meeting” tools and free or inexpensive internet “telephone” conferences combined with video. Although these tools are in their early phases of use, it is hoped that enhanced use of information technology will greatly improve communications and coordinated activities throughout the network, as well as providing enhanced educational opportunities. Savings on time and money may allow expanded efforts in other areas.

The greatest obstacle to the use of IT networks is the equipment required and the cost and effectiveness (as well as effective maintenance) of a high speed internet linkage (or of sufficient ISDN telephone lines). However, the cost of computers is now small compared to many other expenditures, and almost all countries have high speed access, if not widely available. It is likely that this deficit will be quickly resolved, at least at an institutional level, although the potentially high cost of high quality video equipment will remain, particularly when high quality image transmission is a requirement, although simpler, less versatile systems are already inexpensive. The increased commercial use of large image (PAC) files, which are routinely transferred between high income and low or middle income countries for a variety of medical purposes, and the ever increasing number of software solutions for the examination of, for example, histopathology specimens suggests that cost is likely to fall as quality rises. It is noteworthy that web-based systems for radiology greatly reduce the time lost in finding and arranging films. It seems probable that the next generation high speed “semantic web” will increase by an order of magnitude the capabilities of IT. Close collaboration between IT experts and companies on the one hand, and institutions and organizations on the other, will be essential if the potential is to be fully realized.

References

1. McAleer JJ, O'Loan D, Hollywood DP. Broadcast quality teleconferencing for oncology. Oncologist. 2001;6:459-62.