|Year : 2015 | Volume
| Issue : 4 | Page : 675-678
Global trends in specialist training, certification, and regulation of oncology practice and its implications for the developing world
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||15-Feb-2016|
Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sarin R. Global trends in specialist training, certification, and regulation of oncology practice and its implications for the developing world. J Can Res Ther 2015;11:675-8
|How to cite this URL:|
Sarin R. Global trends in specialist training, certification, and regulation of oncology practice and its implications for the developing world. J Can Res Ther [serial online] 2015 [cited 2019 Sep 16];11:675-8. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/675/176090
Of the various chronic diseases, cancer requires the maximum number of distinct therapies and specialists for its diagnostic workup, staging, treatment, and rehabilitation. These include specialists in pathology, molecular pathology, genetics, radiology, interventional radiology, nuclear medicine, cancer surgery, reconstructive surgery, radiotherapy (RT), chemotherapy (CT), biological therapy, pain and palliative care, and a few more. Distinct modalities of investigating, treating, and rehabilitating cancer patients, along with their specialists, evolved in Europe and North America during the 20 th century. Rest of the world adapted these modalities and specializations at varying pace, with local customization in the training, certification, and regulations for specialty practice. A marked contrast has emerged between the developed nations and the low- and middle-income countries (LMIC), with emerging economies such as India and China being in a state of flux. In addition to the major resource constraints, the structure of oncology training and services in developing countries is not well defined. 
Differences in the scope and strength of training and certification programs for various specialties over the years is influencing how these modalities are currently practiced around the world. Unmet needs and contentious issues within and between the three principal modalities of cancer therapy - surgery, radiotherapy, and chemotherapy are discussed here. The past and present of these cancer disciplines in India are fairly typical of what other developing countries are facing or likely to face in the near future. In India, formal training and M.D. courses in radiotherapy and oncology started half a century ago, but D.M. and M.Ch. in medical and surgical oncology started much later and gained momentum only in the last decade. A quarter of a century ago when almost 400 trained and M.D. certified radiation oncologists were practicing radiation and clinical oncology throughout the length and breadth of India, there were only a few dozen D.M. or M.Ch. qualified medical oncologists or surgical oncologist in the country. The 5-10-fold differences in the number of qualified radiation oncologist versus all the other qualified oncology specialists 25 years ago in India was representative of the developing world, with the situation being worse in many countries. There has been some course correction with a major thrust to increase the number of D.M./M.Ch. seats in medical and surgical oncology in the last few years. However, the rate at which qualified medical and surgical oncologists are being produced and opting for public funded institutions, restricting cancer surgery to surgical oncologists and chemotherapy to medical oncologists seems difficult in the near future.
| > Radiation oncology and clinical oncology|| |
0In developing countries, the first oncology discipline practiced as a distinct and exclusive discipline was radiotherapy oncology or clinical oncology. Half a century ago when the order of the day was general surgeons performing some cancer surgery and diagnostic radiologists doubling up as therapeutic radiologists, half a dozen clinical oncologists returned to India after comprehensive training and qualification (FRCR) from the Faculty of Clinical Oncology, Royal College of Radiologists, London. Very quickly, they succeeded in establishing exclusive clinical oncology practice and M.D. Radiotherapy programs in major academic centers in Chandigarh, Delhi, Kolkata, Mumbai, Vellore, and Trivandrum.  Over the last five decades, the radiation oncology or clinical oncology training programs in India have grown manifold, producing approximately 2500 postgraduate oncology specialists who now practice exclusive radiation oncology or clinical oncology. While their numbers are still inadequate for the growing cancer burden,  they remain the workhorse against cancer, providing radiotherapy and other nonsurgical cancer therapies and palliation across the length and breadth of the country. As the first major body of comprehensively trained oncologists in the country, in addition to their radiotherapy and chemotherapy practice, they also established pioneering programs in cancer epidemiology, public awareness and public health, rehabilitation, palliative care, and cancer genetics in India. Playing a key role in developing the Indian National Cancer Control Programme in 1970s and 80s, they brought out the need for cancer services including radiotherapy equipment, manpower and palliation palliation, without diluting the emphasis on prevention.
Paradoxically, at the time when in LMICs, the specialty is an increasingly popular career choice, and modern equipment is rapidly replacing the obsolete, it is facing contentious issues linked to the training and certification process. The most pressing issue is the inadequate training and credentialing for the practice of modern radiotherapy coupled with declining clinical skills. Many radiation oncologists have not trained or worked in departments with the requisite equipment and expertise. Another major bone of contention is the continued practice as a clinical oncologist, i.e., chemotherapy and targeted therapy along with radiotherapy versus exclusive radiation oncology practice. Most prefer to retain the option of continuing with their clinical oncology practice, as is still prevalent in the UK and most other LMICs. However, a growing body of radiation oncologists, especially those overburdened with modern radiation oncology practice are more than willing to give away chemotherapy practice if qualified medical oncologists are available in their centers. There is growing realization that in the longer run, being a broad specialist with 3 years M.D. degree may affect their career progression as compared to super specialist surgical or medical oncologist with 3 years M.Ch. or D.M. qualification after 3 years postgraduate M.D. or M.S. degree. These issues and the possible future directions were hotly debated at a special symposium on "Education in Radiation/Clinical Oncology" of the Association of Radiation Oncologists of India, 2015 annual conference in Lucknow. Expert radiation oncologists and clinical oncologists from India, UK, Malaysia, Canada, and the USA deliberated upon issues related to duration and curriculum for training and the pros and cons of clinical oncology training program versus exclusive radiation oncology program. Should the current 3 year M.D. programme be retained and reoriented? Or should we start a 3 year super specialist D.M. program after M.D. or a direct 5 years programme. Would this create a two tier system within the fraternity of radiation and clinical oncologists.
Though a qualified clinical oncologist, personally I am happy not to have the added responsibility of giving chemotherapy, especially since my hospital has a well-developed Medical Oncology Department. Does that mean that I wish away the scope of clinical oncology training for my students? Based on personal experience as a trainee of the comprehensive UK clinical oncology training in radiotherapy, chemotherapy, hormone therapy and radionuclide therapy for FRCR and as external examiner for the 5 years Masters in Clinical Oncology program of Malaysia, my preference for the developing world trainees is a longer and comprehensive clinical oncology training. Whether in future they practice radiation oncology or clinical oncology will depend upon the prevailing circumstances - both professional and regulatory. But patients will certainly benefit being managed by oncologists with comprehensive clinical oncology training.
| > Cancer chemotherapy and medical oncology|| |
All the LMICs have a great shortage of trained and certified medical oncologist. The entire country of Tanzania was served by a single medical oncologist and four radiation oncologists for an estimated 21,000 new cancer cases in 2008.  With poor affordability and access to cancer drugs, growth factors, and supportive care, the practice of chemotherapy in most developing countries is very challenging. At each step of planning and delivering chemotherapy as well as managing its potentially life-threatening toxicities, the oncologist gets little support. Free supply of cancer and supportive drugs in public funded hospitals is uncommon and erratic. The issues range from safe handling and storage of cytotoxic drugs, optimal intravenous access, inadequate nursing support, mortality from febrile neutropenia, and many more. Using the most effective and evidence based chemotherapy regimen and maintaining its dose intensity is often beyond the control of the oncologist. In India, the situation is somewhat better with more affordable generic drugs and a critical mass of medical oncologist and support staff in large cities. However, as one moves away from large urban center, full-time medical oncologists with support teams becomes a rarity.
In the USA and some European countries, cytotoxic chemotherapy and molecular targeted therapy are the exclusive domain of certified medical or hematology oncologists. However, in LMICs and in some developed nations, cancer patients receive chemotherapy, hormone therapy, targeted therapies and biological therapies not only from medical, pediatric, or hemato-oncologists, but also from internists, hematologists, pediatricians, surgical oncologists, radiation oncologists, and clinical oncologists.
The fragmentation of chemotherapy practice can be traced to its evolution over the last five decades. In the developing countries, dedicated medical oncology programmes and departments started very late and that too only in major urban centres. The gap was filled by the existing radiation and surgical oncology departments and many have continued with chemotherapy services. Continued fragmentation of chemotherapy practice also reflects a turf war between individuals, departments and professional societies to expand or maintain existing clinical practice in academic and private settings. As expected, contrarian views have emerged between and within professional societies. The health authorities remain undecided. In regions within the LMICs, where the community of certified medical oncologists has reached a critical mass, they have escalated their resentment against other specialists practicing chemotherapy. The fraternity of medical oncologists has bonded well and is growing. But to provide comprehensive and safe services to an ever increasing number of patients, they need to devise strategies to prevent clogging of the services by the increasing use of palliative 3rd and 4th line chemotherapy and targeted therapies. Let the tribe of medical oncologists grow fast and with them hemato-oncologists and pediatric oncologists. Innovative palliative approaches such as metronomic chemotherapy  need to be tested and employed more often. This would benefit patients with far advanced cancers and also free up physical and human resources for chemocurable cancers including hematolymphoid and childhood cancers. Increasing workload and expectations of cure in an overall resource constraints settings needs to be systematically addressed to prevent burnout in medical oncologists and haematooncologists in LMICs.
| > Cancer surgery and surgical oncology|| |
Presently, surgeons with a wide variety of training, certification, and experience perform cancer surgery around the world. In most developing countries, though surgical oncology is now a well developed discipline, the scenario is dominated by general surgeons, ENT surgeons and gynecologists, who double up as part time cancer surgeons. With limited training in complex cancer surgeries and multimodality management of cancers, they often limit their practice to surgical biopsies, excision, or resection of early stage cancers of surgically amenable sites such as breast, oral cavity, larynx, colon and stomach. Surgical management of patients with more advanced but operable cancers such as those of oral cavity or those with early stage cancers in organs requiring greater surgical experience or perioperative support is seriously compromised in the developing world. The multimodality locoregional treatment of such patients is seriously compromised. In contrast, the developed world is witnessing rapid transition of cancer surgery practice to super-specialized cancer surgeons of a particular site or organ. The transition phase in the west has produced evidence for improving clinical outcome with the surgeon's training, certification, experience, and surgical volume.  While the evidence presently is not very robust, it is increasingly influencing policy decisions with increasing emphasis on specialized training, surgical volumes, surgical outcome audits, and credentialing of surgical oncology services. A recent Lancet Oncology Commission on Cancer Surgery highlights that >75% of cancer patients worldwide do not have access to safe, affordable, or timely surgery. This is projected to cause over 6 trillion US Dollar losses in terms of cumulative gross domestic product by 2030.  The solutions suggested by them include "better regulated public systems, international partnerships, super-centralization of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training.
In LMICs, the problem of too few cancer surgeons is compounded by major infrastructure deficiencies, poorly developed referral systems and high out of pocket expenses. Some LMICs also face the typical high income country problem of balancing the cost effectiveness and lure of new robotic and laparoscopic surgical approaches.  The Indian cancer surgery scenario is unique. On one hand there are a few dozen highly skilled surgical oncologists at par with the world's best and on the other hand there are thousands of less well trained and part time cancer surgeons. The workhorse are the few hundred trained surgical oncologists who despite major handicaps in reconstructive surgery and perioperative support are invaluable for the multidisciplinary teams. They are enterprising and competitive, taking cancer surgery services to cities and towns across the country.
There is a limit to which the work efficiency and schedules of existing surgical oncologists and their departments can be stretched. Nor do we have a magic wand to produce the required number of well-trained and qualified surgical oncologists in the near future. What could be a pragmatic solution to tide over the current crisis? While surgical oncologists are expected to be reluctant to delegate their role to any lesser surgeon, a planned delegation and redistribution of surgical work as per its complexity may be a lifeline for the underserved patient population. A three-tiered cancer surgery service within the public health system needs consideration akin to what has been proposed for radiotherapy services in the developing countries.  The first-tier could be developed by upgradation of skills, knowledge, and infrastructure in the existing departments of general surgery, ENT, maxillofacial, and gynecology in major hospitals across the country. They could provide invaluable services of timely diagnosis, work up, and performing less complex cancer surgeries. The tier 2 centers comprising of the less developed regional cancer centers (RCCs) and some government hospitals with multidisciplinary oncology wing, should have requisite infrastructure and trained manpower to deal with the common cancer presentations in the country. Depending on the number of surgical oncologists in the department, further surgical specialization in few cancer sites should be encouraged. Tertiary centers like selected RCCs and apex cancer centers should have all resources to undertake all forms of cancer surgeries, including complex resections and reconstructions, and uncommon surgeries where surgical volumes influence clinical outcome. Faculty strength in these centers should be adequate or augmented to allow single anatomical or organ site specialization.
Unfortunaletly it is not uncommon in developing countries to see patients with a badly done mastectomy, grossly sub-optimal radiotherapy in early stage cancers or ineffective delivery of chemotherapy for highly chemocurable cancers.
We need pragmatic solutions to enable growing number of cancer patients to have access to cancer specialists and their services. Their services should be within the reach of a common man while maintaining a minimum standard of safety and efficacy. The timelines for resolving contentious issues and making basic provisions for the unmet need is really hard to predict. But can we make patients wait for decades for the grand changes to be effected and show results. Within the context of the national cancer control programme, setting sight on shifting target is difficult but possible.  But as Misra et al. have rightly pointed "we must find solutions that focus on each country's unique political, cultural, and socioeconomic factors." 
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