By Vanessa Eaton, ASCO International Affairs

Cancer care is challenging for patients in rural areas where health workers are not available. In the United States, for example, only 3% of medical oncologists are practicing in rural areas, and people must travel long distances to see specialists. They may also have trouble managing complications from care or follow up from treatment. Unfortunately, communities in rural areas are “without the capacity to screen, diagnose and treat patients with cancer, many of whom are diagnosed at later and less treatable stages.”¹  This lack of expertise and access means that patients with cancer in rural areas have a greater likelihood of dying from cancer than those living in cities.

Project ECHO is an initiative to expand health care to rural and underserved areas by delivering education to health care workers via tele-education programs. It provides low-cost, high-impact interventions through a model of delivering expert presentations combined with locally presented case discussions. The aim is to improve health care capacity in a broad sphere of health care needs, including substance abuse, hepatitis C, and cancer control. There are over 100 Project ECHO programs being run around the world as part of the Project ECHO Cancer Collaborative.²

ASCO has recently signed on to Project ECHO and completed its first initiative, ASCO Project ECHO Nepal (APEN), a 6-month program of six 1-hour sessions presented by international ASCO experts and local faculty.

Engaging in ASCO's Global Network

Nepal is a country of nearly 30 million inhabitants, with approximately 1.4 million in the capital city of Kathmandu (where the majority of care is concentrated).2 ASCO has a strong network of oncologists in Nepal stemming from a large number of recipients of ASCO’s International Development and Education Award (IDEA). IDEA is a mentoring program pairing early-career oncologists from low- and middle-income countries with mentors in the United States and Canada. Despite being a smaller country, Nepalese recipients account for 6% of IDEA alumni. In addition, ASCO collaborates with two institutions to send volunteers to Nepal on a regular basis for educational exchange through the International Cancer Corps with Health Volunteers Overseas.

APEN kicked off in March 2019 with an in-person Train the Trainer initiative for multidisciplinary care team development, supported by a grant from Celgene. Applicants were selected to participate in multidisciplinary teams and represented eight institutions, primarily from the Kathmandu valley. Participants were invited to register for the APEN pilot program and encouraged to include their colleagues.

Topics for the subsequent 6-month tele-education program were crowdsourced from the participants. The final six-session program included expert presentations on:

• Navigating psychosexual issues for women receiving radiation treatment, led by Anuja Jhingran, MD, FACR, of MD Anderson Cancer Center
• Evaluating medical literature and when to make practice changes, led by Ian F. Tannock, MD, PhD, FASCO, of Princess Margaret Cancer Centre and the University of Toronto, Canada
• How to start tumor boards, led by Abdul Rahman Jazieh, MD, MPH, of King Abdulaziz Medical City, Saudi Arabia
• How physicians in low-income settings cope with modern treatment modalities, led by Fredrick Chite Asirwa, MD, of the International Cancer Institute (ICI), Kenya
• What integrated palliative care looks like in a resource-limited setting, led by Snezana Bosnjak, MD, PhD, of the Institute for Oncology and Radiology of Serbia
• How to apply resource-stratified guidelines in low-resource settings, led by Ainhoa Costas-Chavarri, MD, FACS, of Centre Hospitalier Universitaire de Kigali and Rwanda Military Hospital, Rwanda

Project ECHO engaged ASCO volunteers from all around the world, with faculty dialing in from six different countries.

“I very much appreciate this initiative of ASCO to open a dialog about the issues in cancer care between experts of ASCO and the local teams,” Dr. Bosnjak said. “I was very happy that this dialogue was patient-centered and included not only discussion about tumor-directed approaches but also patient- and family-directed ones, such as issues related to supportive and palliative care.”

Local cases were presented from Bhaktapur Cancer Hospital, Bir NAMs Hospital, and Kathmandu Model Hospital.

APEN's Impact In Nepal 

Over 40 people from six institutions completed the APEN program. Approximately half of the participants were primarily involved with delivering gynecologic cancer care; other specialties included clinical oncology, surgery, urology, and pathology. Of those who participated in the end-of-program survey, over 90% could apply one or more changes to their work as a result of participating in each APEN session. One team indicated that they created a new tumor board, while others said that participating in the program helped them improve how they conduct an existing tumor board.

According to an APEN participant, following the first session, “Cervical cancer is the most common cancer in women of Nepal, and I was unaware of vaginal fibrosis following pelvic radiation and its huge consequences in psychosexual life leading to psychological disorders. This is preventable and treatable as well. With this knowledge, now I can counsel any women undergoing pelvic radiation about the possibility of vaginal fibrosis and stenosis and advise prophylactic vaginal dilatation. In rural areas of Nepal, oncologists or gynecologists are not available every time and patients with these conditions present to general practitioners or physicians. Doctors should be aware of post-radiation vaginal fibrosis and its psychosexual consequences. Now I can share my knowledge with other doctors working in different rural parts of Nepal.”

The pilot program identified challenges which will be addressed in future iterations, such as the variable quality of internet connections, which was a barrier for some to fully participate in the sessions.

Looking Ahead: Focus on Latin America

The next collaboration for ASCO and Project ECHO is with the City Cancer Challenge Initiative. In 2019, ASCO and City Cancer Challenge organized two in-person courses in Cali, Colombia, and Asunción, Paraguay, to discuss locally adapted guidelines in cervical cancer and breast cancer. ASCO Project ECHO Latin America (APELA) will consist of two tele-education programs, one in cervical cancer and one in breast cancer, that will bring together the groups from Cali and Asunción to explore relevant topics and present local cases. The sessions will be held in Spanish and facilitated by Higinia Cardenes, MD, PhD, of Weill Cornell Medicine (cervical cancer) and Hugo V. Villar, MD, FACS, of the University of Arizona (breast cancer).

Additional Project ECHO programs are under review. The program holds enormous potential to facilitate relationships between countries, share knowledge and lessons learned, and engage ASCO members from all parts of the globe.

References

1. Arora S, Hawk E. Ensuring equitable cancer care for all patients. The ASCO Post. Epub 10 May 2017.
2. U.S. Central Intelligence Agency. World Factbook – Southeast Asia: Nepal. Accessed Oct 23, 2019.