Mar 02, 2017
By Prakash C. Neupane, MD
University of Kansas Medical Center
Since I was born in Nepal and spent my young life there, I have always been interested in the nation’s issues. Several years after I completed college and medical school in Nepal, I moved to the United States for residency and stayed for my subsequent fellowships in hematology and medical oncology. At a certain point, I started looking back and thinking about cancer care in Nepal, with its population of approximately 28 million people. This reflection led me to make new connections, renew my old connections, and develop a strong interest in the education of young physicians in Nepal.
The local Nepali oncology society, SAARC Federation of Oncology (SFO Nepal), applied to host an ASCO Multidisciplinary Cancer Management Course (MCMC) in 2010. I was honored to serve as course director for MCMC in two locations in Nepal in March 2010. This opportunity to work with ASCO led me to a much deeper involvement with a larger group of physicians and patients in the country and, consequently, increased my interest in getting involved in a much deeper way in the education of cancer physicians in Nepal.
Since participating in the MCMC, I have been engaged regularly with local oncology groups. I help plan annual educational meetings, and travel every year to Kathmandu to participate as faculty, on occasion with my colleagues from the University of Kansas Medical Center. I continue to work at realizing my dream of creating a formal training program in Nepal.
Oncology training in Nepal
The National Academy of Medical Sciences (NAMS), which started in Nepal in 2013, oversees the first and only medical oncology training program in the country. The site is located in the heart of Kathmandu in the oldest hospital in Nepal, Bir Hospital, which is also under the academic umbrella of NAMS.
The program started in 2013 with two trainees, but did not have any new trainees in 2014 and 2015; the program, under the leadership of only one faculty, Dr. Bishnu Paudel, looked for help. The training program was briefly suspended by the Medical Council of Nepal in late 2015, but was reinstated in 2016 with the addition of two faculty members to NAMS to help it meet the local accreditation requirement. NAMS has residency programs in various areas, including internal medicine, general surgery, and subspecialties of internal medicine and general surgery.
NAMS’ flagship hospital, Bir Hospital, is a government-funded hospital, serving mostly low-income residents of Kathmandu as well as far-lying communities of Nepal. Bir Hospital takes care of a vast number of Nepali annually for acute conditions, chronic medical conditions, and trauma.
Oncology care at Bir Hospital is jointly run by the radiation and medical oncology practices. Patients are treated by medical oncology faculty and several radiation oncology faculty members and residents who also practice some medical oncology. Lack of resources, unaffordability of care, and unavailability of high-tech specialty services make medical care very challenging in this hospital. International guidelines created by organizations such as ASCO, the National Comprehensive Cancer Network, or the European Society of Medical Oncology are only helpful when adequate resources, drugs, and technology are available. At Bir Hospital, a serious lack of teaching faculty, research, guidance, and resources hamper the training program constantly. For example, the hospital has an antiquated radiation therapy machine that seldom works well enough to complete a treatment course without interruption.
ASCO’s International Cancer Corps comes to Kathmandu
The support from ASCO’s International Cancer Corps (ICC) and Health Volunteers Overseas (HVO) will be very valuable in helping to train graduates from the Bir Hospital program and improve the quality of their education. Beginning in winter 2017, ICC volunteer faculty with diverse backgrounds in oncology will serve as resources for the duration of training. My hope is that the relationships between volunteers and trainees will not end at the end of the 2-week program, but will continue long after volunteers return to their countries—with the help of digital communications, volunteers can continue to hold informal and formal consultations and to continue teaching. ASCO/HVO support for the ICC program will likely attract more applicants for the Bir Hospital oncology training program and make it more competitive.
Volunteers will also help create local treatment guidelines for various disease areas, customized to locally available resources, technologies, and more affordable regimens. I hope to see volunteers serve as catalysts to create multidisciplinary cancer conferences and open dialogue between specialties on collaborative patient care and use of evidence-based practices whenever possible. I expect that these types of initiatives will lead to a new group of oncology graduates who are open-minded and have high-quality training.
Medical knowledge is disseminated by initially impacting the immediate vicinity and then gradually seeping out, multiplying the effects as more and more physicians in different locations are able to share knowledge. Training well-qualified oncologists in programs such as ICC helps them, in turn, to train other health care providers, and improve cancer care in Kathmandu and, eventually, the entire country. ASCO members’ involvement as volunteers not only will strengthen local training programs, but will likely inspire clinical researchers to generate local data and study clinical patterns that may be very different than in the western world; long-term, these kinds of studies will help identify unique epidemiology, cancer causes, and pathology unique to Nepal.
Strengthening oncology in the midst of natural disasters, structural challenges
On April 25, 2015, Bir Hospital suffered major structural damage during a 7.8 Richter scale earthquake. Rural health infrastructure crumbled and the city health care system became more crowed. Medical care was focused on trauma and basic health care for months, and the entire Bir Hospital temporarily moved to a newly opened trauma center building. Cancer care was not anyone’s priority for many months. Gradually, a new normal set in after the repair of some of the buildings and the demolition of others. A new and ambitious plan to build a new Bir Hospital has been developed, but will likely take a very long time to complete.
The ICC and ASCO International have a major impact around the world. These educational programs not only help participants improve their cancer care knowledge in the immediate future, but foster long-term relationships between the country’s physicians and ASCO volunteers; these relationships can lead to collaborations that may continue for many more years to come. ASCO’s MCMC, International Clinical Trials Workshop (ICTW), and International Palliative Care Workshop (IPCW) have opened the minds of many clinical practitioners—in Nepal and in other countries—to many areas of oncology. ASCO, as the largest clinical oncology society in the world and a leader in cancer care, research, and policy, can help shape cancer care internationally, particularly in low-resource countries. Travel grants have helped oncologists in many low-income countries to travel and connect with leaders in cancer care—activities that would have been almost impossible without ASCO’s help. ASCO’s educational symposia, MCMC, and palliative care and clinical trials training continue to help strengthen the training of international cancer physicians in clinical as well as research aspects of cancer care.
ASCO International programs are supported in part by the Conquer Cancer Foundation.