Oct 16, 2018
By Abiola Falilat Ibraheem, MBBS
My memory of the patients with cancer during my medical training in Nigeria is of those patients being placed at the end of the ward due to malodors or noisy groans from unremitting pain. Unfortunately, very little could be done for these patients. A cancer diagnosis in Nigeria is considered a death sentence, bringing shame and the belief that this infliction was from an evil force. These experiences inspired my journey to the United States with only one goal in mind—to be an oncologist and improve cancer care in my home country.
While cancer may be an equal opportunity disease, populations in low- and middle-income countries (LMIC) are increasingly becoming more at risk. The reason for this is multifactorial: adaptation of a westernized lifestyle, increasing life expectancy, and reduction in the incidence of fatal infectious disease but an increase in the prevalence of oncoviruses.1 It is therefore not surprising that the World Health Organization (WHO) predicts that 70% of new cancer cases will be in LMIC by 2030.2 Given that Nigeria is the most populous black nation in the world, home to 180 million people, this prediction hits very close to my heart.
In Nigeria, efforts have been made to establish cancer control by initiating preventative interventions and screening programs. Early screening will likely result in more early-stage cancers being diagnosed, which is commendable. However, early-stage disease in Nigeria does not have the same outcome as early-stage disease in the United States. A woman diagnosed with stage I breast cancer in Lagos, Nigeria, only has 70% 5-year survival3 in comparison to 99% 5-year survival in patients with stage I breast cancer living in the United States.4
I want to do my part to create a world where the survival of a patient is not dependent on their geographic location or whether they were able to migrate to a high-resource country.
Engagement From Academic Partners in High-Income Countries Is Critical
Abiola Falilat Ibraheem, MBBS
In response to rising cancer incidence and mortality rates in LMIC, organizational bodies developed global oncology taskforces to improve international collaboration on the quest for worldwide health equity driven by scientific discoveries from every corner of the globe. In addition, institutions and regions in LMIC formed notable bi-directional partnerships. Over the last 2 decades, ASCO implemented defining steps to ensure the growth of global research with programs that fund researchers in LMIC (the International Innovation Grant), support the professional development of early-career oncologists in LMIC (the International Development and Education Award and Long-term International Fellowship), and encourage international and U.S.-trained oncologists interested in global initiatives (the Global Oncology Young Investigator Award), among others.
Although many organizations, institutions, and groups have invested greatly in projects to train oncologists in LMIC, there is a vital need to train a new generation of U.S.-based global oncologists to work with colleagues locally in LMIC to develop sustainable capacity and infrastructure for clinical oncology care, research, and education.5 Only a few oncology fellowship programs in the United States have formal training or exposure to global oncology, therefore the average graduating oncologist is not prepared to face and react to global challenges. It is important to note that global oncology training is not synonymous with global health programs available in U.S. medical schools and residency programs.
Barriers to Training the Future Global Academic Oncologist
The existing requirements for medical oncology fellowships in the U.S. by the Accreditation Council for Graduate Medical Education (ACGME) make active participation in global cancer activities during the core 3-year fellowship a challenge. It is important for a fellow to spend significant time at the intended global site, but this duration of time is not accommodated by the ACGME, therefore warranting an advanced fellowship for this purpose.
I recently completed my fellowship training at the University of Chicago. With the help of my mentors, Dr. Olufunmilayo I. Olopade and Dr. Blase N. Polite, I designed my fellowship training to accommodate my vision as a global oncologist and global clinical trialist.
This derived curriculum focused on:
- Training as a general oncologist by understanding the biology and natural history of all tumor types and how therapy can be adapted in Nigeria;
- Putting into context culture and practice as it pertains to cancer care;
- Developing and maintaining relationships and partnerships with the local physicians in Nigeria;
- Planning effective interventions to maximize resources and improve outcome of services;
- Learning the science of implementation, dissemination, and sustainability of health care;
- Improving my ability to initiate and carry out ethical clinical trials in LMIC; and
- Understanding the pharmacodynamics of drugs, especially the effect of food on drugs, as this will be important in maximizing therapies and not compromising on efficacy of our drugs.6
A New Vision of the Global Academic Oncologist Is Needed
Identifying as a global oncologist appears challenging and vague. This may be because global oncology has been a secondary career focus for many. Furthermore, the job market for global oncologists is yet to be defined. What is the ideal job of a global oncologist? Most physicians who identify as global oncologists spend most of their time in their home institutions with minimal time spent in the global site of interest. These short visits may not be impactful, for what can a 2- to 4-week visit every year truly achieve?
We have to take a cue from our infectious disease colleagues who work in their global site of interest, embedding themselves in the community for long periods of times and integrating themselves in education, research, and capacity building of these sites. It is therefore not surprising that their efforts paid off, as we now see that globally, more people die of cancer than of tuberculosis, malaria, and HIV/AIDS combined. In order to make similar impact, the ideal global academic oncologist job should involve spending longer periods of time in the field working as a local oncologist, building capacity and conducting research.
To excel as a young global academic oncologist, the appointment at a U.S.-based home institution is necessary to access the resources provided to improve cancer care at the local site and also for career advancement in academia. Some institutions now offer inpatient hospitalist-oncologist positions that allow up to 50% protected time off to be spent at the local site at a pay cut. Even though this is progress for young global oncologists, it is still insufficient. It will put us in the position of having to justify to our patients in our local site that we need to go back to our privileged society and hope they will still be alive when we get back in 2 or 3 months.
What, then, is the ideal balance of time to practice meaningfully across borders and still maintain an academic career and sustain work-health balance? Given my advantageous background of being trained in Nigeria and my experience of having practiced in all the health care systems available in Nigeria, I propose that spending 3 months at the local site followed by 1 month in the United States as an inpatient hospitalist-oncologist is more ideal. During the time we will be away from our local patients, provisions should be made with our colleagues at the local site to ensure that our local patients also get the privilege of continuity of care. This wishful model is almost impossible in this era of health care penny pinching, where ideal protected time for the young global oncologists is deemed unrealistic without real funding. However, we need to remember our commitment to worldwide equity.
Practicing Across Borders: Foreseen Challenges
My plan to practice in the government sector of an LMIC is not without justifiable fears or concerns. As I hope for improved cancer care in Nigeria, I envision significant barriers, such as patient overload, lack of protected time, the use of paper charts and uninterpretable scribbling, lack of a healthcare support system, and the psychological challenge of shuttling rapidly between two worlds with different levels of care.
It is refreshing to know that I am not alone. We now have surgical oncologists, radiation oncologists, medical oncologists, and other specialists presently working or planning to work in an LMIC. My hope is that in the coming years, global oncology will not only be recognized as an academic career, but will actually have a training curriculum and practice infrastructure at the home institution to allow individuals such as myself to succeed.
- Mathers CD, Loncar D. PLoS Med. 2006;3:e442.
- Moten A, Schafer D, Farmer P, et al. J Glob Health. 2014;4:010304.
- Makanjuola SB, Popoola AO, Oludara MA. Radiother Oncol. 2014;111:321-6.
- Ries LAG, Harkins D, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2003. National Cancer Institute. Bethesda, MD. 2006.
- Grover S, Balogun OD, Yamoah K, et al. Front Oncol. 2015;5:80.
- Szmulewitz RZ, Peer CJ, Ibraheem A, et al. J Clin Oncol. 2018;36:1389-95.