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.