The Challenges in Oncology Education

Continuing medical education (CME) is an important topic in current medical practice including the oncology field. The discussion about how to implement CME in oncologists’ training is not a novelty and has been taking place during the last few decades (Emiliani 1998). Building structured pathways in under- and postgraduate medical training allows proper quality of offered programs or educational events and assures equal chances in knowledge and skills gaining. However, harmonization in oncologists’ training meets obstacles that result from significant differences in specialization trainings (e.g., length of training, duration of initial training in internal medicine) and distribution of patients between different specialists that may vary from country to country. Taking into consideration Europe, we may see the local discrepancies. In most countries, medical oncology is recognized as a separate specialty (e.g., Spain, Romania, or Switzerland); in others, it is a subspecialty (e.g., Turkey) and is mixed with hematology (e.g., Germany) or radiotherapy (e.g., Sweden). There are still some countries where there is no official training in this specialty (Pavlidis et al. 2016). The situation for the training in radiation oncology is even more complicated. For example, Poland offers specialization in clinical oncology and radiotherapy. Clinical oncologists are de facto trained five and a half years to work as medical oncologists with 2 years of initial internal medicine involvement, and radiotherapists are trained to provide radiation therapy while they are commonly responsible for systemic treatment during radiochemotherapy. Thus, there is also a matter of local nomenclature.

The challenges in oncology education both locally and globally, especially in the postgraduate area, can be divided into (I) general issues common for all medical fields such as the following:

  • Limited guidelines provided by international societies in the area of medical education.

  • Lack of training/residency program harmonization.

  • Differences between countries in the access to local and international training activities (e.g., due to financial issues).

  • Differences between countries in the access (as a trainee) to top reference cancer care centers.

  • Differences between countries in legal regulations or access to electronic and blended learning (e- and b-learning) activities.

  • Challenges with obtaining a networking experience.

  • Challenges with direct transfer of know-how from higher to lower developed countries.

  • Lack of qualified medical staff in many parts of the world (trainers/faculty members).

  • Lack of medical education training activities provided for trainers/faculty members.

Challenges can also be divided into (II) area specific for oncology such as the following:

  • Differences between countries in the reimbursement process or access to new oncology drugs (thus, difficulties in obtaining practical experience).

  • Lack of harmonization in patient pathways/area of expertise of different experts (e.g., systemic treatment of skin malignancies can be a subject of interest of dermatologists or medical oncologists depending on country).

  • Major differences in training pathways for clinical oncologists, medical oncologists, and radiotherapists between countries.

The European Society for Medical Oncology (ESMO)/American Society of Clinical Oncology (ASCO) global curriculum in oncology provides detailed international guidelines for oncology training (Hansen et al. 2004; Dittrich et al. 2016). Following this strategy can result in harmonization of postgraduate oncology education all over the world. Unfortunately, any attempt of introducing these guidelines in different countries might meet obstacles resulting from financial or cultural discrepancies, particularly when transferring the guidelines to low- and middle-income countries (LMICs) but not limited to these settings.

Some examples of these challenges can be shifting the training from theoretical to practical, introducing research activities, overcoming the resistance from the faculty resulting from their work overload and lack of being paid for educational supervision, the trainees’ resistance that can be connected to their fear of new assessment methods introduced, and possible retaliation by superiors when being too frank in the assessment of a training program.

Using an e-learning or b-learning (blended learning) approach in medical education is not a novelty anymore. This approach has its well-known advantages but also numerous challenges, for example, choosing proper evaluation methods (O’Doherty et al. 2018; de Leeuw et al. 2019). A great example in oncology is an international blended learning program introduced by the University of Ulm more than a decade ago. More and more good quality offers are being introduced into the market with an example of an e-learning program regarding the use of evidence-based approach in improving World Health Organization (WHO) Classification of Tumours books. With introducing e-programs (as MOOCs, Massive Open Online Courses; or SPOCs, Small Private Online Courses discussed later), there is always a hope of facilitating the participation of oncologists from LMICs and a question about advertising such activity among them. Such educational activities can support building proper personal networking also among oncologists from LMICs allowing them easy access to international know-how but also enabling sharing their practical knowledge in running oncology centers and building educational structures with more limited financial support. Knowing their experience can help the others to define potential complications and to build a strategy for overcoming these obstacles. Scientific societies may offer smaller didactic bites, but uptake by professionals has been slow and with only very little adherence. This raises the question again on how to successfully implement the curricula described.

While focusing on harmonization of global oncology training or introducing new technologies into cancer education, one cannot forget that in many regions of the world, the lack of qualified personnel and facilities and general poverty require to do a step back and make more basic efforts to build an oncology training program from scratch. Setting up medical training in LMICs is an especially demanding task, and the results cannot be expected quickly. During the past 15 years, we have observed a general decay in global stability paired with considerable human capital flight from regions of war, hunger, and any other instability. Wealthier countries profit from this exodus of highly skilled manpower, but the regions left behind experience an increasing drought of well-qualified personnel and henceforth a widening gap in healthcare provision.

2020 being a year of SARS-CoV-2 brought additional problems in patients’ care and medical education in oncology. Cancer patients were exposed to a delay in diagnostic and treatment procedures, but also oncologists, being involved in restructuring of treatment forces, lost numerous opportunities of in-person training programs or continuing planned specialization trainings. However, one cannot say this year was “lost for oncology education development.” Switching numerous top activities from in-class to e-meetings allowed the contribution and active participation of a greater number of participants. What is more, paradoxically, initially it was helpful in reducing the discrepancy between countries in the access to good quality activities in oncology but also accelerated the decision of introducing e-activities into obligatory oncology training in numerous countries. 2021 being a year of vaccination has already shown a great discrepancy in the access to SARS-CoV-2 vaccines between high- and low-income countries. It is likely to contribute to a further deepening of medical education inequality.

Improving Education in Oncology: Real-Life Examples

Uta Schmidt-Straßburger, a scientific director of the Advanced Oncology Study Programme at the University of Ulm, presents a summary of a 10-year experience in continuous development and improvement of b-learning program created for oncologists and their colleagues. By implementing ESMO/ASCO recommendations for a global curriculum in oncology and organizing the material into seven modules, the program assured standardization and comprehensiveness. Adding soft skills workshops, for example, in negotiation or presentation, and assuring personal coaching and international environment created a unique opportunity for participants to build a very strong and supportive network. Probably the biggest potential in the studies lies in the strong interpersonal interactions among participants, staff, and associated researchers and tutors that have already resulted in numerous projects and led to further development of former students even after the graduation from the program. Such a network plays a role not only in exchanging opinions, experience, and views but also is a solid ground for building didactic, scientific, translational, and clinical projects.

Similar to the master classes in clinical oncology organized by the European School of Oncology (ESO) together with ESMO, the personal interactions between participants, organizers, and faculty create long-lasting positive associations with a lifelong learning experience in oncology and encourage participants to join networks of continuing medical education like e-ESO and to convene at ESMO annual meetings.

A good example on how to build the local curriculum for oncologists basing on the ESMO/ASCO recommendations can be provided by Zeinab Elsayed and Mohamed Reda Kelany—oncologists working in Egypt. The transfer of know-how cannot be direct in such situations as the socioeconomic and cultural background since, for example, former specialist training requirements, accreditation and organization of oncology centers, and the financing system are completely different. Some of the obstacles are common for a majority of countries, whereas others are cultural and financially dependent. Factors such as the risk of burnout or difficulties in motivating the busy faculty staff to devote the time to residents’ training are more general, and oncologists all over the world face these problems. On the other hand, limited facilities, shorter duration of a specialty training, and lack of research options are more specific for LMICs (Murali and Banerjee 2018; Burki 2018; Jalan et al. 2020).

Ahmed Magdy Rabea shares some practical solutions that were introduced in one of the oncology centers in Luxor. He managed to transfer and propagate well-known solutions such as regular educational lectures, clinical pharmacists’ meetings, and daily clinical rounds for residents and fellows. Supporting international training of the residents can bring future benefits to the parent unit, but one needs to be aware that it means loss on manpower at the beginning of such investment.

Building from scratch a national network for sarcoma treatment in Egypt seems extremely challenging. Mohamed Reda Kelany presents strengths, weaknesses, opportunities, and threats of the proposed sarcoma network. It is highlighted that even such project created from scratch needs patient advocate groups and the stakeholders representing different discipline involvements so as to make the effort lasting and sustainable.

The number of obstacles to face with and a massive effort while building an oncology educational program from the beginning is presented by Layth Mula-Hussain, a lecturer in radiation oncology from Iraq. The first board-certified residency program in radiation oncology was launched between 2013 and 2017 in Iraq (Mula-Hussain et al. 2019). Sharing this experience is extremely valuable as the problem was defined not only in the lacking procedures but also lack of staff or facilities. It is not an exaggeration to say that the presented example addressed almost all the challenges of postgraduate medical education, both general and specific for oncology, those present all over the world, and characteristic for LMICs. Four years after the program’s establishment, its authors can pass the updated knowledge and know-how to other colleagues. Ten physicians completed the training in radiation oncology between 2017 and 2020 allowing the care for the population of over ten million people. When trying to find the main factors responsible for this success, two facts cannot be neglected: the preparation period was long including technical and logistical planning and the faculty setup to create the syllabus consisted of local and external specialists. That would not be possible without the preexisting network organization.

How to set up a new program is also a topic for Blanca Iciar Indave Ruiz, a research assistant currently working at the International Agency for Research on Cancer and World Health Organization (WHO) Classification of Tumours Group. However, this time the goal is to build an online training program named Evi-Pat and propagate high-quality and well-functioning scientific activities, that is, further work on the WHO Classification of Tumours by an evidence-based approach in order to improve adopting these methods. The main educational obstacles in this situation are more specific for e- and b-learning. Apart from obvious ones, choosing the proper virtual learning environment (VLE) or evaluation methodology, new challenges appeared, for example, how to advertise internationally, how to define and reach proper course recipients, and how to obtain additional funding to build such a program. To deal with potential issues, a collaboration between partners was established: the Master Online Advanced Oncology program at the University of Ulm, the Cochrane Netherlands, the Universidade Estadual de Campinas in Brazil, and the WHO Classification of Tumours. This is a new initiative, where in order to keep the reliability of tumor classification, addressing critical questions and finding research gaps seem crucial.

The presented list of real-life examples is not limited to transferring knowledge from high- to low-income countries or supporting to build other successful online programs. A great model of how the activities of current and former students and staff can serve also in high-income country is presented by Judy Vicente de Paulo, a medical oncologist from Portugal and a president of the Young Oncologists Committee of the Portuguese Society of Oncology in a section: Continuing education for the young oncology workforce in Portugal. These initiatives are frequent in developed countries where oncologists in training take over partial responsibility for their training and its improvement with a support from ESMO or national societies. The Nucleus of Interns and Young Specialists of the Portuguese Society of Oncology was founded in 2015. The chapter summarizes the challenges that young oncologists face during the residency program in Portugal and the solutions implemented to meet these challenges including soft skills workshops or additional training to cover hot topics in oncology like oncological emergencies. Currently, a similar initiative has been born in Poland.


This section summarized the exemplary projects run by participants and supervisors engaged in the Master Online Advanced Oncology program at the University of Ulm—researchers and physicians representing various fields of oncology, living in different parts of the world, facing challenges typical for countries with high, middle, and low income, and representing all steps of career pathway from residents in training to chairs of departments. It is worth noticing that while debating on these projects, all challenges in oncology education pointed out at the beginning of this chapter were covered.