Jan 27, 2016
By David Raben, MD
You don’t know what you got until you see what others don’t. I can jaunt over to my CT-simulation machine, order a complex CT imaging scan, and contour my targets to treat (and targets not to treat). Then, within a few hours, working with a cadre of dosimetry specialists, deliver a unique and sophisticated, intensity modulated plan for my head and neck cancer patients. It’s a plan that elegantly surrounds their cancer while sparing normal organs impacting their quality of life for years to come. Our multidisciplinary team at the University of Colorado, along with nurse navigation support, coordinates infusion schedules, surgical interventions, chemotherapy infusion, nutritional counselling, and speech and swallowing support work together seamlessly. Simple. I am sure everyone has this capability.
I was privileged to be part of an ASCO sponsored international Multidisciplinary Cancer Management Course, seeking to offer guidance, instruction, and feedback in the cross specialty care of patients with cancer. This program would take me to Harare, Zimbabwe. After many months of long distance planning conference calls and discussions on the program, facilitated by the amazing support of Vanessa Eaton and Kim Shevchenko, program managers for ASCO International Affairs, I was off. It was quite a journey and I admit I had trepidations about what I might encounter. Working in concert with the Association of Radiation Oncologists and Radiologists of Zimbabwe (ARROZ), through the University of Zimbabwe College of Health Sciences, I took part in a 5-day event that brought together specialists from several African countries to design and improve communication and care. I worked alongside esteemed surgical colleague Anees B. Chagpar, MD, MPH, from Yale University, and medical oncology colleague Evangelia D Raziz, MD, PhD, from Athens, Greece to present a program focused on multidisciplinary cancer care and team building.
What did I expect? I certainly wasn’t prepared to visualize cancer patients, who having walked 300 kilometers from their village, sleeping outside on the grass around the entrance to the cancer center waiting for their chance to be evaluated. The waiting rooms were jammed packed, there were no cookies and fresh coffee or flat screen TVs for the patients (go figure?), and certainly no reception desk with a smiling staff member facilitating the consultation process. What I did see was incredible passion and yearning to offer the best cancer care possible and an intense desire to learn and engage. I was struck by the humility and generosity of our hosts including Sandra Ndarukwa, MD and Webster Kadzatsa, MD, both trained in medical and radiation oncology as is typical in European training programs, along with the rest of the faculty and nursing staff. I had a chance to tour the facilities, observe patient rounds, participate in case discussions with registrars (residents), and when time permitted, sip a cup of tea with my hosts as we got to know each other.
The focus of the course was didactics and discussions on breast, colorectal, and head and neck cancer diagnosis and management and why multidisciplinary care, within the realities of the Zimbabwe health care system, provides value for the patient. Practicing oncology for the past 21 years, it has been a long time since I have actually felt that someone was hanging on my every word (rather than checking their smart phone for texts), but here in Harare, the attending physicians seemed so grateful for our expertise, hung on our every word and continually asked probing questions about how we might manage particular cases. A radiation oncologist by trade, I was most interested in understanding just what treatment planning and delivery capabilities existed within the health care system at the main cancer clinic in Harare. I learned that the Health Ministry had recently purchased several state of the art radiation machines. However, the facility lacked the licensing for critical software that would allow for the delivery of intensity modulated radiation therapy (IMRT), so older 3D radiation approaches are still used. Importantly, I observed many patients arriving from great distances with very advanced cancers who often were hospitalized while undergoing extensive treatment of over a ~6-week period. At Colorado, we have led efforts to deliver stereotactic body radiation (SBRT) in 1-5 fractions in a precise and safe manner. I wondered if SBRT might be possible within their system if trained properly and if the licensing software was available. Patients could be treated rapidly and safely allowing them to return to their villages quickly and, from a cultural perspective, perhaps minimize the stigma felt by these patients when they received a cancer diagnosis. It was humbling to know that I could discuss locally advanced cancer management till the proverbial cows came home, but without the needed software, physics, dosimetry, and quality assurance training, techniques like SBRT, which would potentially reduce cost and time for patients, aren’t feasible.
So where does this leave me? Along with wonderful memories and new friendships, I am committed to begin efforts to assist in raising the needed funds (around $500,000) to obtain the necessary software packages, return to Zimbabwe with physicists and dosimetrists to assist in IMRT and SBRT training, and develop an interactive review of treatment plans for locally advanced cases—an international chart rounds so to speak. So thanks to the ASCO International multidisciplinary program for allowing me to begin this journey abroad. It has offered me a chance to give back on a different level and for that I am grateful.
“We should certainly count our blessings, but we should also make our blessings count.” Neal A. Maxwell
David Raben, MD, is a Professor of Radiation Oncology at the University of Colorado Health, in Denver. An ASCO member since 1998, he is a member of the MCMC Working Group and has served as an Editor on the JCO Editorial Board.