The word “American” may be the first word in ASCO, but the Society does not end there. Approximately one-third of ASCO’s more than 30,000 members reside outside the United States. These international members represent a global community of cancer care providers and researchers in more than 100 countries. Over one-half of ASCO Annual Meeting attendees have their passports stamped at U.S. Customs in order to hear the latest research and education in the field. From Afghanistan to Zimbabwe, ASCO members are bringing care and comfort to patients with cancer worldwide. 

New name, expanded mission 

On World Cancer Day, February 4, 2013, ASCO announced the formation of ASCO International, a portfolio of international programs that connects members, organizations, and countries with oncology knowledge and research opportunities. The program’s ultimate goal is optimizing care for every patient with cancer in the world. In pursuit of this ambitious goal, the Society has committed to doubling its support for ASCO International over the next four years.

“ASCO International engages ASCO members in a global exchange of knowledge, builds bridges to improve the care of patients worldwide, and works to reduce disparities of patient outcomes,” said Nagi S. El Saghir, MD, FACP, of the American University of Beirut Medical Center, Lebanon, and 2013-2014 Chair of ASCO’s International Affairs Committee. “The programs equip members and physicians worldwide with knowledge through courses and workshops, grants, mentoring, promoting research, improving specialty training standards, leadership development, volunteering, and encouraging quality care and multidisciplinary cancer management.”

These programs are not intended solely for the benefit of developing countries or even solely for oncology specialists. ASCO International works on behalf of all medical professionals in high-, middle-, and low-income countries who contribute to the care of patients with cancer. To achieve these goals, ASCO counts on its members who volunteer in many ways—from the leadership level to hands-on participation in the field—and coordinates activities worldwide with international, national, and regional oncology and medical societies.

Increasing educational opportunities 

Educational courses comprise the lion’s share of ASCO International programs. Since the launch of ASCO International, these programs have expanded to include more sites and new formats. 

Case-based discussion, multidisciplinary education 
Multidisciplinary Cancer Management Courses (MCMC) provide essential training in the management of cancer types that are common to the country or region where the course is being held, aiming to improve the clinical skills of the physicians, nurses, pathologists, and other professionals in attendance, as well as deepening the understanding of multidisciplinary cancer care and what this means in daily practice. Often the lasting impact of MCMC courses can be found in strengthened tumor boards, referrals, and consultations, and other opportunities for clinical teamwork.

Since ASCO’s first MCMC in 2004, the course has evolved from a traditional lecture-based format to an interactive patient-centered one. Customized to reflect the priority needs of the host country or region, the program follows a patient from his or her initial presentation through diagnosis, communicating prognosis, tumor board discussion, treatment recommendations, and supportive care. The use of audience-response technology also helps to ensure that these sessions are interactive. ASCO member volunteers from around the world serve as course organizers and faculty. The presentation “is longitudinal, as in real life,” and reflects the diversity of the cancer-care team, explained Hugo Villar, MD, FACS, of the University of Arizona, who has served as an MCMC  Director on numerous occasions and is a Past Chair of ASCO’s MCMC Working Group. “The initial visit is presented by a primary physician, biopsy findings are presented by a pathologist, imaging by a radiologist, etc. Major issues of how to communicate bad news, palliative care, recurrence, and end-of-life care are highlighted.”

The new format debuted in Paraguay in May 2012, and attendee feedback on the new program has been extremely positive. The majority of participants from the MCMC courses in Paraguay, Kenya, and Bolivia agreed or strongly agreed that the clinical case presentations were useful and highly relevant to them, according to course evaluations. One participant of the 2013 MCMC in Kenya commented that “the case-based presentation and discussions were the richest aspect of the conference.”

In a related “MCMC Train the Trainer” program, attendees learn to conduct their own educational courses at their local institutions. These sessions focus on elements of multidisciplinary cancer treatment, effective teaching methods, and practical skills for course implementation. These courses allow local leaders to create a “legacy of promoting quality care for patients,” Dr. Villar said.

Training for nonspecialists 
Many patients in low- and middleincome countries struggle to find cancer-specific care, either because there are only a few trained oncology specialists practicing in the area or because oncology services are concentrated in one or two distant cities. In Kenya, for example, five medical oncologists serve a population of 42 million. In response to the rise of cancer incidence and mortality in countries with the fewest oncology specialists, ASCO’s International Affairs Committee created a task force in 2011 to examine how ASCO could support the training needs of generalist physicians and nurses in regions where the need for such care is greatest.

Along these lines, ASCO International has been particularly active in palliative care training. For example, for the past three years, ASCO International has been working with the Ministry of Health of Ghana, the African Oxford Cancer Foundation, and ASCO volunteers to train doctors, nurses, pharmacists, and other professionals Ghana in palliative care,  small teams of trainees who integrate palliative care into their. Overall, more than 80% of care workshop participants report greater access to pain medications, improved communications with patients and their families, and a stronger sense of purpose in the care they provide to patients with cancer. “I will make a conscious effort to use more reassuring and understanding words to calm [my patients] and make them feel that someone cares and understands,” wrote one participant in the Ghana workshop.

ASCO International hopes to extend this work into other cancer domains, including cancer prevention and surveillance.

A varied educational portfolio
In addition to these efforts, ASCO International supports educational programs in a variety of other topic areas. Each depends on a cadre of ASCO member volunteers who provide their knowledge of oncology and knowledge of the country or region to make the training as effective as possible. 

ASCO’s Advanced Cancer Courses, for example, focus on a particular topic in-depth, often drawing on ASCO educational products. In designing these courses, the Society and its volunteers work with other medical organizations outside the U.S. to tailor the training content and identify faculty. The advanced topics have included cancer care in older populations, cancer prevention, and cancer genetics.

One of the most popular Advanced Cancer Courses is the International Clinical Trials Workshop (ICTW), which provides condensed clinical cancer research training to oncology professionals in economically emerging countries, where research activity has been rapidly increasing over the past decade. The two-day workshop educates research team members on best practices of clinical trial implementation, marrying global standards in the conduct of clinical research with local challenges and perspectives. Presentations include the roles of research team members, data management, ethics, fundamentals of trial design, regulatory issues, patient accrual strategies, and publishing tips. Often participants bring research protocols for discussion with senior ASCO members.

Twenty-four organizations outside the United States offered officially licensed Best of ASCO meetings in 2013. Sponsoring organizations have access to abstracts and educational content originally presented at the ASCO Annual Meeting, and work with ASCO International to customize a program based on the most prevalent concerns of the host country or region. In areas where resource limitations or insufficient coverage for patient care can prevent local providers from attending the ASCO Annual Meeting, international Best of ASCO meetings bring the highlights to them.

Education and training at the hospital level—the International Cancer Corps

While its courses can have a broad, national impact, ASCO also perceived a need to provide education and training in specific hospitals where “real world” barriers to cancer care were being faced. As a result, in 2008, ASCO partnered with Health Volunteers Overseas (HVO), an international medical education organization, to create a program that pairs ASCO member volunteers with medical centers in low- and middle-income countries that serve as their nations’ major cancer referral hospitals. The International Cancer Corps (ICC) provides a platform for exchanging medical expertise and building long-term, supportive relationships between ASCO, these vital medical institutions, and the clinicians who practice there. 

For the past two decades, HVO has worked to increase health care access in LMCs through clinical training and education programs in child health, primary care, trauma and rehabilitation, essential surgical care, oral health, infectious disease, nursing education, and burn management. Active in more than 40 hospitals in 25 countries, HVO-affiliated medical volunteers train, mentor, and provide critical professional support to health care providers. 

The first International Cancer Corps site was started in Tegucigalpa, Honduras, in 2010, where ICC volunteers have provided 32 trainings on oncology nursing, surgical oncology, cervical cancer, and student and resident education. Oncology nurses at Hospital San Felipe report improved practices in the safe handling of chemotherapy, and the hospital also holds video tumor boards with U.S. volunteers, where residents have improved their presentation skills and provide detailed pathology discussions. 

The program has continued to expand and now includes six major cancer referral centers in six countries on three continents; the sites now include Asuncion, Paraguay; Thimphu, Bhutan; San Jose, Costa Rica; Tegucigalpa, Honduras; Addis Ababa, Ethiopia; and Hue, Vietnam. To date, volunteers have made 92 separate visits to these sites, many returning as repeat volunteers.

Inspiring the next generation 

The dearth of cancer specialists in lowand middle-income countries can make it extremely challenging for an earlycareer oncologist to find support and mentors in their areas of interest—or in any related field. The leadership of ASCO recognized that trainees and early-career oncologists require special support if they are to become future global leaders of the field. As a result, a number of exceptional opportunities are offered in the form of awards, mentorship, and knowledge assessment.

International awards
The Conquer Cancer Foundation of the American Society of Clinical Oncology offers two awards specifically for early-career oncologists in resource-limited countries who have less than 10 years of professional experience in the field post-training. 

The International Development and Education Award (IDEA) provides support for oncologists residing in low- and middle-income countries to establish strong relationships with ASCO members who serve as scientific mentors, attend the ASCO Annual Meeting, and visit their mentor’s institution in the United States or Canada. Recipients also receive three years of complimentary ASCO membership and attendant benefits.

The International Development and Education Award in Palliative Care (IDEA-PC) award supports oncologists who meet the IDEA requirements and have a demonstrated interest in integrating palliative and supportive care services in their current institution. Recipients are matched with mentors who specialize in palliative care. 

The impact of IDEA and IDEA-PC reaches far beyond the selected participants. Recipients are expected to share their new knowledge with colleagues when they return to their home institutions, creating a network of expertise from which patients in these countries will benefit. On average, each IDEA alumnus shares the new information and skills with more than 50 colleagues in his or her country. This means that the 232 current IDEA and IDEA-PC alumni have contributed new knowledge to approximately 11,600 oncology professionals in clinics, hospitals, and universities around the world.

2012 IDEA recipient Mateus Sahani, of the Democratic Republic of the Congo, reports he is currently working on publishing an oncology article with his IDEA mentor, Dr. Linus Chuang, from the Mt. Sinai School of Medicine. More than half of IDEA participants remain in touch with their mentors five years after the program, and 78% are in touch with other professional contacts they met through ASCO, according to an alumni survey. 

IDEA-PC recipient Monica Malik, of India, says she is regularly in contact with her mentor, Jamie Von Roenn, MD, one year after the program. “Talking to my mentor provides a lot of motivation and encouragement for me to improve my work and tackle conflicts and obstacles,” Malik said. “She is truly inspirational.” In 2013 Dr. Malik was selected by ASCO to be the Society’s first Leadership Development Program participant from outside North America.

The Long-term International Fellowship (LIFe) was created as a way for mentors and mentees to deepen their collaboration by providing support for early-career oncologists in low- or middle-income countries to spend a year at their mentor’s institution in the United States or Canada. Mentors and mentees both contribute to the LIFe application and propose research activity that is relevant to the mentee’s home country. This immersion experience in clinical research provides invaluable training that, in turn, facilitates changes in cancer care in the mentee’s home region.

Applications for the 2014 IDEA and IDEA-PC opened October 1; for information on the LIFe award, visit conquercancerfoundation.org/idea and conquercancerfoundation.org/life for more information.

Virtual Mentors
Though the IDEA and LIFe programs indicated that international mentoring can have a real and positive impact, scaling up these programs to reach a wider segment of the oncology community was constrained by travel and other costs. To address this need, in 2012, ASCO International Affairs Committee member Abdul Rahman Jazieh, MD, MPH, of King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, suggested that ASCO consider a “virtual” mentoring program, linking mentors and mentees not with a plane ticket, but with communication technologies. This idea launched the pilot Virtual Mentors program to match early-career oncologists in low- and middle-income countries with expert mentors around the world, based on professional interest. The seven mentor-mentee pairs in this Virtual Mentors pilot communicated by email, phone, online social networks, and Skype.

“Guidance and mentorship is critical for the development of health care professionals. Virtual Mentors connects senior volunteer mentors with junior mentees in regions where no suitable mentors are available, using technology to cross geographic borders,” said Dr. Jazieh.

Based on the success of the pilot program and feedback from participants, seven additional mentor-mentee pairs joined Virtual Mentors in 2013. Efforts have been made to match mentees with mentors who have some knowledge of or experience with the challenges the mentee faces in his or her region, in addition to shared professional interests. ASCO will continue to refine the Virtual Mentors model and to use the model not only as a standalone program, but also to encourage continuing relationships between mentees and mentors in the IDEA program.

In-Training Exam
Today, medical oncologists are trained around the world. In 2004, ASCO and the European Society for Medical Oncology (ESMO) published recommendations for the training of medical oncologists and updated those recommendations in 2010. The “ASCO ESMO Global Curriculum” has been adopted by at least 10 countries, with many more referring to these standards as they develop their national training programs.

The growth of such training programs has sparked a growing interest in standardized tools that can help trainees and program directors evaluate progress and identify knowledge gaps against global standards. With this in mind, ASCO has made a concerted effort to make ASCO’s Medical Oncology In-Training Exam more available to training programs outside the United States. Indeed, participation by programs and fellows outside the United States and Canada has grown considerably since 2010, when 14 oncology fellows in Ireland sat for the exam. In 2013, 71 fellows from India, the Philippines, Ireland, Spain, Saudi Arabia, Qatar, Jordan, and Japan used the In-Training Exam to assess their oncology knowledge.

Content for the exam is developed using the American Board of Internal Medicine’s Oncology Board Examination as a starting point. While certification requirements vary significantly from country to country, the comprehensive and standardized (all participants take the same exam, regardless of geography) nature of the In-Training Exam yields a powerful teaching tool and learning opportunity. Subject areas include common solid tumors and hematologic malignancies, basic science principles such as genetics and cancer biology, supportive and palliative care, and pharmacology, among other topics.

ASCO offers the Medical Oncology In-Training Exam annually in February, with results distributed in April. Two dates are offered for fellows to sit for the six-hour web-based exam to ensure that institutions can maintain their clinical coverage while still offering this educational opportunity. Registration for the 2014 exam opened this November and will close in early January; learn more about the exam at asco.org/medoncite.

Discovering tomorrow’s solutions: International Innovation Grant

When confronting the challenges of cancer control in low- and middleincome countries, barriers such as cost and infrastructure mean that solutions developed in high-income countries are often impractical, if not impossible, to implement. Earlier this year, ASCO International and the Conquer Cancer Foundation of ASCO launched the International Innovation Grants to help investigators in these regions research and discover novel solutions that can improve cancer control for their populations. At least two proposals will be funded in 2014.

Whether the proposal addresses challenges in care delivery, cancer prevention, affordable treatment options, palliative care, clinical training, or other areas, applicants were encouraged to think outside the box and explore approaches and models beyond what would be considered standard practice in high-income settings.

A significant component of the application is “sustainability and scalability,” which requires applicants to consider how to measure the project’s success, how to disseminate knowledge and results gained from the project, and whether the project could be scaled up and implemented in additional sites, either within the applicant’s country or in other countries facing similar challenges. An ideal proposal would include an innovative project that speaks to a critical need in the country or region; that can feasibly be implemented with the grant funding and locally available resources; that can produce solid metrics for evaluating the results; and that has the potential to be transferable to other sites.

The 2014 International Innovation Grants application process has been completed; visit conquercancerfoundation.org/innovation for more information on the award.

A global approach to global problems

The worldwide burden of cancer continues to grow: the World Health Organization projects a 70% increase in new cancer cases and 17 million annual deaths from cancer by 2030, with the majority occurring in countries with the most limited resources.

With every expanded educational course, every newly funded grant and award, and every selfless volunteer, ASCO International will fight the tide of cancer in every country and for every person affected by the disease. 

“ASCO International recognizes the importance for the whole world to ride the train of advances in information technology; improve data storage, analysis, and utilization; understand molecular networks and the tumor microenvironment for better personalized care; and shift resource concerns toward value rather than cost,” Dr. El Saghir said. “ASCO International is committed to producing a positive impact in these areas through all of its programs." 

The ASCO members interviewed for this article wish to thank the staff of the International Affairs Department, who execute and manage the day-to-day operations of ASCO International, and without whom these programs would not be possible.