Keywords

Revising the Current Curriculum in Clinical Oncology

In Egypt, oncology training programs are either clinical oncology, radiation oncology, or medical oncology (https://www.rcr.ac.uk/clinical-oncology/revalidation. Accessed 2 Feb 2021). Within these programs, candidates are awarded a Master of Science (MSc) degree after three years of training and a Medical Doctorate (MD) after another three training years. For both degrees, the candidate must pass written, clinical, and oral exams together with preparation of an academic medical thesis. The Ministry of Health (MOH) is offering a separate fellowship for radiation oncology and another one for medical oncology in a five-year training. The Children’s Cancer Hospital Egypt (57357) has already established a one-year fellowship program in pediatric radiation oncology in collaboration with the Dana-Farber Cancer Institute and Massachusetts General Hospital, Boston, Massachusetts (Bishr and Zaghloul 2018). We have a national standards system for all postgraduate studies (Academic Reference Standards), but we do not have a national board for oncology training.

At the Ain Shams (AS) Clinical Oncology Programs, we have the European Society of Medical Oncology (ESMO), the American Society of Clinical Oncology (ASCO), and the European Society for Therapeutic Radiology and Oncology (ESTRO) recommendations as benchmarks.

This system is different from the UK system in which clinical oncology trainees must complete two years of core medical training and five years of clinical oncology training (https://www.rcr.ac.uk/clinical-oncology/revalidation. Accessed 2 Feb 2021). Our system is also different from that in the USA in which radiation oncology training is a five-year process, while path and training of adult hematology/medical oncology fellows can vary significantly. To enter a fellowship program, candidates must have completed residency training in internal medicine either as categorical or in a combined residency training, such as medicine pediatrics (Knoll 2015).

Challenges

As an LMIC, Egypt has several barriers to providing high-quality professional education (Frenk et al. 2010). In the next section, we are going to highlight the most prominent challenges that we face at AS clinical oncology department as an example of oncology departments in university hospitals in Egypt.

Clinical Oncology Curriculum

Clinical oncologists are uncommon in developed countries (apart from the UK) but are the main providers of the service in many LMICs (Popescu et al. 2013). In the past two decades, knowledge has increased rapidly in both radiation oncology and medical oncology specialties, and this makes achieving the necessary competencies in both fields simultaneously very challenging (Sarin 2015). Another problem is that clinical oncologists find it easier to practice the use of systemic therapy than in radiation oncology thereby decreasing in the number of highly qualified radiation oncologists.

Duration of Clinical Oncology Program

Compared to the UK and US programs, the duration of our program is shorter which leads to deficits in training in important parts like research, leadership, communication, and managerial skills. This is also reflected on shortening of other parts in the curriculum as molecular biology and palliative care and spending most of the training time on treating patients with solid tumors.

Limited Resources

Establishing competency-based radiation oncology programs in LMICs is hindered by a lack of resources such as state-of-the-art radiotherapy machines, highly qualified radiation oncologists, and supporting staff (Khader et al. 2020). At the AS clinical oncology department, we have two linear accelerators (one of them is volumetric modulated arc therapy), a CT simulator and an eclipse planning system (with five stations). There is no brachytherapy machine as of this date (due to be launched in April 2021). This infrastructure makes training approximately 15 candidates at different educational stages at a time challenging. We have around 20–25 monthly cases treated by intensity-modulated radiotherapy (IMRT), while the majority of patients receive three-dimensional conformal radiotherapy.

Systemic therapy at the department is sponsored by the Egyptian Ministry of Health (MOH). As other university hospitals and as a country with limited resources, many drugs—especially targeted and immunotherapy—are not covered. These drugs are available in the private sector and some of the health insurance-run hospitals. The safe use of these drugs and management of their side effects constitute an essential part of the clinical oncology training. The present situation makes parts of the curriculum only theoretical with regard to clinical application and thereby incomplete.

Supervision of Trainees

Lack of a structured workplace-based assessment (WPBA) is a very serious problem of the program. This is due to a combination of factors such as limited time of supervisors, lack of faculty training, and resistance of trainees.

Busy Hospital Environment

Egypt has the third largest population in Africa (> 100,000,000) and that makes public and university hospitals very crowded and busy with high volumes of patients and a limited number of supporting staff. At the AS clinical oncology department, we have around 200–250 visiting patients every day. As the system is very hierarchical, trainees are burdened with most of the work, which makes training and feedback very difficult.

Burnout

Burnout and the inability to have a healthy work-life balance are the most serious challenges in our working environment. According to a recently published survey study at the AS clinical oncology department, 72% of participants (52 clinical oncologists) had burnout on the emotional exhaustion (EE) scale, 49% on the depersonalization (DP) scale, and 38% on the personal accomplishment (PA) scale (Ghali et al. 2019).

Lack of Research Opportunities

Limited budgets for research together with time constraints and lack of a reasonable number of international clinical trials at the department make trainees lack the opportunity to publish in high-impact specialized medical journals.

Assessment System

Our current assessment system is a pass-fail system (at 60%) and summative. It enforces focusing on knowledge rather than skills and lacks the very important part of “feedback.” Candidates have one final exam at the end of their training. Lack of frequent formative assessment is a serious problem with the current program as it makes the continuous professional development at this early career stage less transparent and less encouraging.

Chances

Residents

While the described challenges are eminent, the biggest resources are the physicians themselves, their ties to the country, and their eagerness to perform. This is particularly true for graduates from Ain Shams (AS) University, who are traditionally very competitive and have high aspirations with regard to their own performance, but also with regard to supporting infrastructure. The decision to care for oncology patients oftentimes comes from a biographical background and therefore is a very strong motivator to perform and to perform best. We already have many physicians—trained within this system—who transferred to the USA and Europe and are doing very well. We have also many other successful graduates who chose to continue in their country and contribute to the advance of AS University in the international ranking with their publications.

Educators

Ambitious students and residents may sometimes challenge established pathways. Even though this may be perceived as a threat by some individuals, the possibilities are that faculty is adopting new knowledge and new ways of conduct thereby strengthening their own positions by allowing innovation but also empowering residents and younger faculty. The constant challenge to update one’s own knowledge and skillset keeps a young spirit and an ambiance of mutual respect.

The Pathway to Reform

Needs Assessment

Many focus group discussions of the different stakeholder groups together with program evaluation tools revealed the shortcomings of the current program as mentioned above. We conducted these discussions between residents and educators encouraging an exchange.

A Separate Radiation Oncology and Medical Oncology Curriculum

As a result, the separation between the two specialties seems inevitable. The ESMO/ASCO Global Curriculum for Training in Medical Oncology is one of the benchmarks of AS clinical oncology program, but it cannot be applied in the current situation. Separating the two specialties will allow the proper implementation of this curriculum. The ESTRO Core Curriculum for Radiation Oncology/Radiotherapy will be one of the main benchmarks for our Radiation Oncology curriculum. Community and cultural issues must be taken into consideration. All stakeholders will be invited to participate. It is of utmost importance to keep the ties that were historically established in order to provide residents with the best training according to their interest as well as the patients with the best comprehensive care possible.

National and International Collaboration

Collaborating with both national and international bodies is very important. Sharing of resources and expertise will enhance high-quality radiation oncology education. The Ulm Master Degree in Advanced Oncology is a very good example of how international collaboration can help LMICs in faculty development. Implementing the ESMO/ASCO curriculum with the help of ASCO outreach for international programs will be the next step in adapting a blueprint for postgraduate education of medical professionals in Egypt.

Faculty Development

In a period of change, open communication is key to a successful implementation of the envisaged changes. Therefore, training staff on WPBA and mentorship is crucial. One option to achieve this objective would be to enroll in international mentorship programs available free of charge, for example, of the European School of Oncology or to send residents and faculty to respective mentorship programs of the ESMO or the ASCO.

Change the Current Assessment System

In order to change the current system of assessment and to make its outcome more transparent to all parties involved, a portfolio and WPBA must be implemented. Continuous formative assessment and remediation strategies must be endorsed, and the ACGME Milestones for Hematology and Oncology provide excellent guidance for this purpose (Collichio and Muchmore 2018). It is essential to assess resident’s performance regularly and to give feedback, also 360° feedback, without fearing repercussions from any party involved in the process.

In summary, all these processes are aimed at improving the current procedures and pathways by professionalizing continuing education of our oncology and radiotherapy residents and thereby providing a mutually beneficial atmosphere of respect, trust, and quality.

Establishing a Sarcoma Program in Egypt

Sarcomas are very rare tumors and very heterogeneous, and their treatment is particularly challenging since it demands a high level of cooperation between different medical and nonmedical subspecialties. Even the official site on cancer statistics, the Global Cancer Observatory (www.gco.iarc.fr), does not issue fact sheets for sarcomas other than Kaposi’s sarcoma, a disease associated with HIV infection (Bray et al. 2018).

Egypt had completely lacking incidence rates at the national level until the development of the National Cancer Registry Program of Egypt (NCRPE) in 2008. The NCRPE stratified Egypt into three geographical strata: lower, middle, and upper. A recent publication from NCRPE based upon the incidence rates of cancer in Egypt in 2008–2011 revealed that “the crude incidence rates for all cancer sites excluding non-melanoma skin cancer were 113.1/100,000. Soft tissue sarcoma crude incidence is 2.2/100,000 for the male population and 1.9/100,000 for the female population (Ibrahim et al. 2014).

Finishing the Advanced Oncology study program at Ulm University strengthened the desire to establish an Egyptian soft tissue sarcoma network. On one hand, we have the patients with their challenging diseases; on the other hand, the treating physicians might feel the need to double-check their treatment decisions with equally educated and experienced other professionals. Even though everybody is working hard and is an avid reader of the scientific literature, the differences in health-care provision and reimbursement might pose an additional challenge for the physicians, but most definitely also for the patients and their families.

Despite increasing evidence supporting a referral to specialized sarcoma units, most of our patients are not managed according to guidelines, particularly those in the early stage of their disease requiring surgery.

Here in Egypt, we have a lot of great minds and hard workers, but they work separately in different national-based oncology centers or privately based within a very wide range of different health-care facilities like separate islands lacking from bridges or power collaboration between them, which affects the outcome (less so-called effective outcome) and also significantly affects the research work and the international clinical trial involvement. So, despite these great single workers, we still remain in a dark zone internationally.

Focusing in one cancer subtype (sarcoma) is my dream to create a national sarcoma network aiming for a better clinical registry also for better pathological diagnosis using molecular pathology as well as improving the surgical and overall outcomes.

The goal is to reach the true multidisciplinary approach in managing individual malignancies and establishing formal training based on the ASCO/ESMO Task Force on the Global Core Curriculum in Medical Oncology with collaboration with various major specialties such as surgery, radiotherapy, and pathology (Hansen et al. 2008). This a step further, creating an adaptive national guideline in oncological management of soft tissue sarcoma and creating a well-developed nest with tissue banking to participate in international clinical trials globally (Table 1).

Table 1 Strengths, weaknesses, opportunities, and threats of the proposed Egyptian sarcoma network
Full size table

Only joint action and education on the different topics can overcome the current weaknesses and threats. The benefit for patients and society must be clearly communicated and involve patient advocate groups as well as different stakeholders for the scientific societies representing the disciplines involved in the management of patients with sarcomas.

Challenges that Need to be Met

I am a medical oncologist from Egypt and one of the first graduates of the Advanced Oncology study program. The curriculum seemed and still seems to help in my career as a faculty member in the National Cancer Institute of Egypt, where I am a lecturer and consultant of Medical Oncology and Hematology. The module particularly interesting to me was the one that covered molecular biology during the first semester. Also getting to know physicians from all over the world, staying connected to them to this day, the experience of diversity in the methodology of thinking and collaboration, meeting at international conferences, and keeping a strong relation, particularly with part of the faculty program, changed my professional perspective and finally its trajectory.

I have been using the knowledge and skillset I gained during the master’s program in teaching the young residents and fellows. Also, the knowledge I gained helped me a lot in understanding the new treatment modalities and the translational medicine behind it. Currently, I serve as the head of the medical oncology department in a nongovernmental organization hospital called Shefa El Orman Hospital in Luxor, South of Egypt, where we are treating patients for free and accepting fellows and residents whom I am responsible for with regard to their training.

What has been established so far? Weekly educational lectures and daily clinical rounds for residents and fellows bring bench to bedside teaching to these trainees. In addition, twice weekly clinical pharmacists’ educational meetings and monthly nursing staff educational meetings ensure proper education of nonmedical professionals involved in the care of oncology patients. Some of our trainees and residents are now residents in the UK, KSA, and UAE, perfecting their training in these countries.

Egypt is a developing country, and there are challenges that need to be addressed and will help in the improvement of the academic level of the hospital and the educational programs currently available. Collaboration with an international body in assisting and guiding the improvement of our current training program and obtaining the accreditation required for this program to be internationally known and applied would help. Also, other developing countries in the region might feel encouraged and empowered by sending their physicians, nurses, and pharmacists for clinical and academic training. This will definitely reduce the cost of traveling and accommodation and widen the locoregional network. Another option would be to collaborate with other internationally oriented academic programs to supply the clinical part of the program which will strengthen the academic program in other faculties and would allow more collaboration between this and other international centers through supplying their academic parts to students and fellows. Also, this can open a collaboration channel for physician exchange programs again helping transfer the Western experience and applying it in other developing countries, which will improve the medical and academic services supplied by other centers.

Considering the busy clinics and difficulties to maintain the clinical and academic parts, bringing more fellows and trainees would help in improving the medical services provided. The fellows from abroad will experience the clinical training required through hands-on experience, real-life data, and not only academic education. Afterward, they can transfer the knowledge that they have acquired to their own countries and faculties thereby starting their own educational programs. Hoping for a domino effect, this might lead to a huge collaborative educational body in the region and will allow for clinical trials and research to be applied.

The educational program provided at my current Shefa El Orman Hospital is similar in many points to the curriculum recommended by ESMO/ASCO. Using the ESMO/ASCO logbook, benchmarking (Hansen et al. 2008) was performed, and efforts to implement the Egyptian curriculum for future use and to accredit this program are underway. So far, the Egyptian board of medical oncology approved hosting of residents, and enlistment by the UICC (Union for International Cancer Control) has been completed. The whole medical team, the board of directors, and the pharmaceutical companies have supported educational events with very much enthusiasm.

If this model succeeds and receives the deserved recognition, our project’s blueprint can be used as a model for other faculties and centers allowing improvement of the oncology services available to our patients.