International Cancer Corps Volunteers Recount Their Experiences in Honduras

The Pediatric Oncology Unit at the Hospital Escuela, the main teaching hospital, in Tegucigalpa, Honduras. Photo Courtesy of Dr. Higinia Cardenes

In 2010, ASCO partnered with Health Volunteers Overseas (HVO), an international medical education organization, to launch a new program giving ASCO members an opportunity to provide training and to exchange knowledge with clinicians who provide cancer care in developing countries.

The first site of the International Cancer Corps program opened in Tegucigalpa, Honduras, and volunteers were able to interact with physicians, nurses, and residents in training at three facilities, all located in the capital city: the Hospital Escuela (the main teaching hospital, affiliated with the University of Honduras School of Medicine), Hospital San Felipe (a public hospital that serves as the national referral center for all serious oncology cases), and the Cancer Center Emma Callejas (a private, nonprofit facility).

Nine volunteers were assigned to Honduras, including three who made two separate trips in 2010. Two of these volunteers share their experiences here.

Fredric V. Price, MD

In May 2010, Dr. Price, a gynecologic oncologist at Pittsburgh Gynecologic Oncology, spent 1 week in Honduras, accompanied by Linus T. Chuang, MD, a gynecologic oncologist at Mount Sinai School of Medicine.

There was a very large number of patients with gynecologic cancer at Hospital San Felipe during my time there in 2010. In their 20-bed women’s surgical oncology unit, 14 beds were reserved for gynecologic oncology patients at all times. As such, the surgical oncology residency-training program was and is still in need of gynecologic oncology training.

They performed an average of two radical hysterectomies a week, in addition to surgical management of vulvar lesions, pelvic masses, and uterine cancer. The radiation oncology department had 60 to 80 patients under daily treatment for cervical cancer.

The medical oncology unit was filled with many patients with gynecologic cancers who were receiving chemotherapy as primary or adjuvant therapy, in conjunction with radiotherapy, and as palliative care. There is a large palliative care oncology ward, which was largely composed of patients with untreatable gynecologic malignancies.

Patients are admitted from throughout the country and especially as transfers from Hospital Escuela, the major public teaching hospital in the country. The lack of a functional tumor registry makes it diffi cult to know how many patients have actually required care for gynecologic cancer at Hospital San Felipe, but a tour of the hospital convinced us that the need was great.

At the time there were significant obstacles to provision of appropriate treatment, resulting from the lack of coordination of care. There was no formal patient disposition conference, so patients were treated by specialty according to their path of entry into the system.

Communication between specialists was haphazard at best and largely nonexistent. The practice of discussing patient management across specialties is common in our experience in the United States, but sorely lacking at Hospital San Felipe. By our assessment, excellent but isolated services are available in pathology, medical oncology, surgical oncology, and radiation therapy.

General practitioners provide palliative care for many patients with advanced disease. Patients would derive a great benefit if the specialists collaborated, and our most important accomplishment was bringing together the specialists for a multidisciplinary tumor board on the last morning of our stay. In fact, simply by being in the hospital and reviewing cases with the residents and some attending physicians, we were able to open communication by soliciting involvement of specialists from other disciplines.

One important basic deficiency in the care for Honduran women with cervical cancer is the inability to deliver radiation therapy by direct application of isotopes to cervical tumors: clinical brachytherapy. Many more patients could be treated with success if this capability is developed.

One great frustration is that equipment including cesium isotope is already in Hospital San Felipe in the form of a Selectron ® remote afterloading device. The software is no longer being supported for this 15-year-old equipment, which is still quite effective in treating locally advanced cervical cancer.

The local medical radiation physicist was trying to write his own software, and the Chief of radiation oncology was willing to apply the treatment, so this capability might be available in the future. High-dose rate (HDR) brachytherapy uses a shorter treatment time (three treatments for 15 minutes each), as compared with the low-dose rate (LDR) Selectron® system currently on site, which requires two treatments at approximately 36 to 48 hours each.

A HDR program would be ideal, because the LDR brachytherapy program will soon be overwhelmed by the volume of patients who require this modality. It will be impossible to maintain 60 to 80 patients using LDR brachytherapy.

HDR brachytherapy, the standard modality at most Western cancer centers, requires a huge initial outlay of capital in addition to sophisticated computerized dosimetry.

Maintenance agreements are also expensive, as is radiation quality control, all of which may make an HDR program impractical in Honduras for the near future.

Teaching Opportunities and Alliances As guests of Professor José Ángel Sánchez of the Department of Medical Oncology at the Hospital San Felipe in Tegucigalpa, we were introduced to the residents who are in training to be surgical oncologists at Hospital San Felipe in Tegucigalpa. At this main oncology referral hospital for Honduras, we provided lectures to 25 medical students, seven surgical residents, and three to five attending oncologists. These lectures were followed by operating room teaching and supervision.

We conducted daily teaching conferences with the residents. In addition, Dr. Chuang gave a presentation to the Honduras Society of Oncology at their monthly meeting about management of ovarian cancer.

From the beginning, didactic sessions were supplemented by an extremely fruitful teaching alliance between volunteers and trainees.

Within the first few hours of the trip, we became aware of the high caliber of the resident physicians regarding their motivation to learn, intelligence, ability to speak English, and high level of clinical skill based on extensive experience in gynecologic oncology.

Questions came continuously and spontaneously in a refreshing interchange of ideas and concepts. Often our discussions related to basic clinical management and differences between U.S. and Honduran approaches to gynecologic cancer. Many of the questions revealed a remarkable sophistication, touching on some of the latest and most relevant controversies confronting our subspecialty.

We also had the opportunity to teach in the operating room. These experiences were very revealing to us. We saw a high level of surgical skill among the upper-level residents. We also were impressed by the readiness of the operating room to manage long and complicated cases (e.g., a hemipelvectomy for recurrent liposarcoma). We also were left with the impression there were significant problems in preoperative preparation, which pointed out areas of deficiency that we view as teaching opportunities for volunteers on future trips.

Many of these problems are not necessarily the result of resource deficits, and they can largely be improved by better coordination of existing expertise in the cancer center at Hospital San Felipe.

This trip represents a valuable first step in developing a sustained program for visiting gynecologic oncologists in Tegucigalpa. There are opportunities for the provision of clinical services, teaching, and surgical and medical care to patients, as well as for the development of long-term local human resources to improve care for women with gynecologic malignancies throughout Honduras.

Through improved understanding about the situation in Tegucigalpa and through development of personal relationships with the physicians, we are prepared to help.

Melanie B. Thomas, MD

Dr. Thomas, a medical oncologist at the Medical University of South Carolina, spent 2 weeks in Honduras in August 2010.

When I volunteered in Honduras, it was a very new program. I was the first adult medical oncologist volunteer; previous volunteers since program inception had been surgeons and pediatric hematologist-oncologists. José Ángel Sánchez, MD, one of the local program leaders, was a fantastic host and colleague. He is a true visionary, and is passionate about creating a medical oncology training program for Honduras.

Most of my time was spent with the surgical oncology residents at Hospital San Felipe, a medium-sized public hospital in the capital city Tegucigalpa where most of the oncology patients are seen. The 2 weeks I spent in Tegucigalpa were extremely enjoyable and offered an opportunity to learn first-hand about current medical care at a variety of settings in Honduras.

This experience was an invaluable opportunity to become directly involved with the physicians, students, residents, and patients, and to begin to understand the many challenges and options to improve medical education and cancer care in Honduras.

The surgical oncology residency program at Hospital San Felipe was established approximately 4 years ago, and has residents in each year of training. The residents were very knowledgeable, self-motivated, and extremely eager to learn through active solicitation of new knowledge. They appreciated the multidisciplinary nature of oncology care and welcomed involvement in their training from colleagues in medical, surgical, and radiation oncology.

The working conditions are quite challenging, with physical facilities, as well as the diagnostic and therapeutic equipment, older than what would be standard in the United States. However, despite these challenges, the residents demonstrated strong critical-thinking skills, understood the value of evidence-based medicine, and appeared to consistently strive to provide the best possible care within the limitations of their environment.

Most notably, every resident and student I met was committed to practicing in Honduras and to dedicating their careers to serving the Honduran people; they clearly are a tremendous asset to the country.

Most residents expressed interest in conducting clinical research, and they are required to complete a research project of their choice as a condition of graduation. They would very much benefit from regular conferences focused on the process of conducting research and on incorporating critical evaluation of the literature into their training. They also would benefit from input from faculty in biostatistics, epidemiology, and research design.

Going forward, there are many challenges in Tegucigalpa that will affect efforts to develop a medical oncology training program. Some of these issues include difficulty with obtaining funding for trainees and program leadership, generating interest in the current internal medicine residents to pursue oncology, and coalescing interest expressed by local medical community leaders in helping with the necessary logistics to create and sustain this volunteer program. The best use of future volunteers’ time would be for them to function as visiting specialists as part of a structured oncology training program.

About the Authors:

Dr. Price is a gynecologic oncologist at Pittsburg Gynecologic Oncology and winner of the HVO Golden Apple Award, which is awarded to HVO volunteers who demonstrated a strong commitment to HVO’s educational mission by working on curriculum development, teacher training, didactic or clinical training, or the enhancement of educational resources.

Dr. Thomas is an Associate Professor and the Grace E. DeWolff Chair in Medical Oncology at the Medical University of South Carolina.

Training Continues: Ethiopia and Vietnam the Next Stops for the International Cancer Corps

The International Cancer Corps (ICC) is a volunteer humanitarian program that gives ASCO’s members an opportunity to support cancer care medical centers in low- and middle-income countries, share their medical expertise, and build long-term, supportive relationships with the clinicians who provide cancer care in these countries. ASCO has partnered with Health Volunteers Overseas (HVO), an international medical education organization that has 25 years of experience working with other professional medical societies to develop similar education and training programs.

The ICC program launched in early 2010 with the opening of the fi rst site in Tegucigalpa, Honduras. Volunteers in Tegucigalpa have provided signifi cant training and education in the areas of pediatric oncology, hematology, gynecologic malignancies, and gastrointestinal and genitourinary cancers. Building on the success of the program in Honduras, ASCO is pleased to announce the opening of a second ICC site in Addis Ababa, Ethiopia, and plans to open a third site in Hue, Vietnam later this year.

The cancer care program at Tikur Anbessa (Black Lion) Hospital in Ethiopia was established almost 2 decades ago by Solomon Bogale, MD, who was, at the time, the only clinical oncologist in the country.

There are now four oncologists and one hematologist serving a population of 80 million people. Recognizing the need for more trained specialists, the Ethiopian government has committed to developing cancer care capacity at fi ve additional hospitals around the country. One of the primary goals of this partnership will be to support the launch of a new clinical oncology residency program.

The Program Director, Kenneth D. Miller, MD, of Dana-Farber Cancer Institute, assisted Dr. Bogale with drafting the curriculum, and it is their hope that ICC volunteers will be able to supplement the training courses. Volunteers will also help to address other high-priority training needs including: management of cervical and breast cancers; diagnostic training for pathologists and radiology technicians; allied health training for nurses, medical physicists, and radiotherapists; development of a national cancer control plan; and education in cancer prevention measures.

The ICC program in Vietnam is still under development but is expected to begin accepting volunteers by Fall 2011. The Program Director, Quyen Chu, MD, FACS, of Louisiana State University Health Sciences Center, partnered with Phung Phuong, MD, at Hue College of Medicine and Pharmacy to outline some high-priority needs.

The medical center provides care to the 20 million people residing in the central and highlands regions of Vietnam and sees approximately 60 to 70 new cancer cases each month, the most common types of cancer being lung, gastrointestinal, breast, cervical, ovarian, and lymphoma. Some of the potential training opportunities include education in the management of the aforementioned cancers, pathology, immunology, chemotherapy administration, and palliative care.

ASCO is extremely proud of the work that is being accomplished through this program due, in large part, to their partnership with HVO and the remarkable support that ASCO members are showing.

For additional information about the International Cancer Corps program and to learn how to volunteer in Honduras, Ethiopia, and Vietnam, stop by the Health Volunteers Overseas booth (Booth #4016 in the Oncology Professionals Hall, Hall A, Level 3, South Building) or the International Assistance Desk in Concierge Services (North Building, Grand Concourse Lobby).