In high-income countries, such as the United States, a shortage of oncology services is anticipated by 2020, primarily due to increased cancer incidence and improved survival. (1)Cooper RA. The medical oncology workforce; an economic and demographic assessment of the demand for medical oncologists and hematologist-oncologists to serve the adult population to the year 2020. http://www.asco.org/ASCO/Downloads/Cancer%20Research/Medical%20Oncology%20Workforce-Cooper%20Study. Pdf (accessed Feb 13, 2013). (4)Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract 2007; 3: 79–86.
Data on the number of cancer specialists in Latin America are scarce. In 2010, Peru had 200 oncologists (including surgeons, pediatric oncologists, and medical oncologists), 146 general radiologists, and 72 general pathologists. Therefore, the estimated rate of oncologists per 100,000 inhabitants is 0.67, assuming a total population of 29,549,517 predicted for 2015. (2)Chomitz KM, Buys P, Thomas TS. Quantifying the rural-urban gradient in Latin America and the Caribbean.World Bank Policy Research working paper 3634, June 2005. http://elibrary.worldbank.Org/docserver/download/3634.pdf?Expires=1360771624&id=id&accname=guest&checksum=7C7573A181EDDBC9DCFB3474A620A4D9 (accessed Feb 13, 2013). In 2012, Mexico had 735 surgical oncologists, 50 gynecologic oncologists, 269 medical oncologists, 151 pediatric oncologists, and 180 radiologic oncologists — with an estimated rate of 1.07 oncologists and 0.16 radiologic oncologists per 100,000 population. , assuming a total population of 112 million. (3)Esperanza Plan, National Plan for comprehensive cancer care and improvement of access to oncology services in Peru. Ftp://ftp2.minsa.gob.pe/normaslegales/2012/DS009_2012_SA_EP. Pdf (accessed Feb 12, 2013 ). (5)(accessed Feb 13, 2013). 45 Mexican Oncology Council. Human Resources Training. http://www.cmo.org.mx (accessed Jul 15, 2012). These rates show a in stark contrast to those in the US, where there will be about 3.75 oncologists (including medical oncologists, hematologist oncologists, pediatric oncologists, and gynecologic oncologists) per 100,000 population by 2020; Considering the increasing burden of cancer, this proportion is estimated to mean a 25–40% shortage of oncologists by 2020, compared to 2005. (6)AAMC. Forecasting the supply of and demand for oncologiststs: a report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies. http://www.asco.org/ASCO/Downloads/Cancer%20Research/Oncology%20Workforce%20Report%20FINAL.pdf (accessed Feb 13 , 2013).
In contrast to the USA and the European Union, Latin American countries do not have a unified basic curriculum for the training of clinical oncologists, and each country has its own requirements for specialty certification. The number of clinical oncology training programs, the number of new staff in training per year, and the annual incidence of cancer in various Latin American countries are shown in Table 5.
Oncologist Education in Brazil
According to the WHO, there are around 176 doctors for every 100,000 inhabitants in Brazil. Data from the Federal Council of Medicine (CFM) show that 0.71% of specialists in the country are oncologists and 0.69% are hematologists. (7)Scheffer M, Biancarelli A, Cassenote A. Non-Brazilian medical demography: general data and descriptions of inequalities. São Paulo: Conselho Regional de Medicina do Estado de São Paulo, Conselho Federal de Medicina, 2011.) As in all In Latin American countries, these specialists are concentrated in the urban areas with the highest economic affluence. (8)Scheffer M, Biancarelli A, Cassenote A. Non-Brazilian medical demography: general data and descriptions of inequalities. São Paulo: Conselho Regional de Medicina do Estado de São Paulo, Conselho Federal de Medicina, 2011.
The specialization in medical oncology, under the jurisdiction of the Brazilian Cancer Society (SBC) and the Brazilian Society of Clinical Oncology (SBOC), consists of a three-year residency program, preceded by 2 years of training in internal medicine. Residents gain more medical autonomy over time, progressing from basic patient assessment in the first year to comprehensive treatment and research skills development toward the end of the third year. Residents work primarily with patients admitted in the first year of residence and almost exclusively with outpatients in the third year, allowing exposure to the most common types of cancer in the country in different clinical situations. The curriculum encompasses clinical skills, teamwork ability, and the ability to organize the cancer care process, as well as plan and carry out the research activity. The clinical oncology curriculum is based on the most common cancers, and residents are trained as general oncologists. Oncology subspecialization is not frequent in most centers in Brazil.
Although palliative care has been an established medical discipline for almost 50 years, most Latin American countries lack an official training program. (9)Economist Intelligence Unit. The quality of death: ranking end-of-life care across the world. London: The Economist, 2010.) In Brazil, palliative care specialization requires a minimum of 1 year of training after completing an internship in internal medicine, geriatrics, pediatrics, oncology, anesthesiology, or family medicine; however, there is no established curriculum for palliative care training. (10)Conselho Federal de Medicina. Resolução 1.973 / 11: Conselho Federal de Medicina creates new areas of medical attention. Http://portal.cfm.org.br/index.php?option=com_content&view=article&id=21971:conselho-federal-de-cultura-nova-novas-areas-de-atuacaomedica&catid=3 (accessed Jan 19, 2013).
Twinning and Telemedicine
The objectives of twinning programs are to establish collaborations between centers with an abundance of available resources, such as medical technology and specialized personnel, and centers that lack them. Through twinning programs, resource-poor centers can access specialized training and develop strategies and protocols for treating cancer patients using the expertise and guidance of resource-rich centers. Telemedicine is the use of information and communication technologies to improve patient outcomes, increasing access to care and medical information. (11)Montenegro RA, Stephens C. Indigenous health in Latin America and the Caribbean. Lancet 2006; 367: 1859–69. (12)WHO Global Observatory for eHealth. Telemedicine: opportunities and developments in Member States: report on the second global survey on eHealth 2009. (Global Observatory for eHealth Series, volume 2). Healthc Inform Res 2012; 18: 153–55. One of the main advantages of tele-oncology is that it is based on twinning programs, by connecting centers in high-income countries with centers in low- and middle-income countries; Information exchanges between centers are done faster, easier, and cheaper with the use of telemedicine resources, such as Internet conferences. (13)Montenegro RA, Stephens C. Indigenous health in Latin America and the Caribbean. Lancet 2006; 367: 1859–69. Teleoncology can also help create important alliances between different centers in the same country or region. In Latin America, pediatric oncology has taken the lead in twinning programs and the use of tele-oncology in the treatment of cancer; (14)Montenegro RA, Stephens C. Indigenous health in Latin America and the Caribbean. Lancet 2006; 367: 1859–69. (15)Howard SC, Marinoni M, Castillo L, et al. Improving outcomes for children with cancer in low -income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology / Oncology (MISPHO) —part I. Pediatr Blood Cancer 2007; 48: 364–69. Several initiatives have improved local care cancer through the use of teleoncology (table 6).
A collaboration through teleoncology between St Jude Children’s Research Hospital (Memphis, TN, USA) and various pediatric oncology centers in El Salvador, Honduras, and Guatemala has helped guide treatment decisions and achieved better results in retinoblastoma . (16)Wilimas JA, Wilson MW, Haik BG, et al. Development of retinoblastoma programs in Central America. Pediatr Blood Cancer 2009; 53: 42–46. An Internet website created to improve pediatric cancer care through Using web conferencing in the Amazon region of Brazil allows patients to access care, without having to travel to specialized centers in São Paulo. ((Hira AY, Lopes TT, Zuffo MK, Lopes RD. ONCOPEDIATRIA: Projeto de Telesaúde em Oncologia Pediátrica. Http://www.sbis.org.Br/cbis9/arquivos/781.pdf (accessed Aug 27, 2012).
Role of the Pharmaceutical Industry and Clinical Research
The quality of clinical trials and the capacity of clinical research centers and staff have improved in the last decade in Latin America, largely due to collaboration with the industry. Trials are a key learning experience because they expose physicians and residents to the process of knowledge advancement, allowing them to understand how research protocols are designed and carried out. They also allow exposure to new and emerging technologies. In addition to sponsoring clinical trials, the industry has played a critical role in supporting or sponsoring mentoring programs, medical meetings, and research grants. Mentoring programs are developed in association with recognized institutions and have been shown to promote the professional growth of young oncologists. ((Riechelmann RP, Townsley CA, Pond GR, Siu LL. The influence of mentorship on research productivity in oncology. Am J Clin Oncol 2007; 30: 549–55.
To improve cancer patient care in Latin America, education and training should prioritize prevailing epidemiology and include cancer treatment from screening to palliation, with an emphasis on local needs. In view of the shortage of oncology personnel, educational initiatives are needed to train general practitioners and community health personnel to participate in cancer detection, and to expand their knowledge of diagnosis, treatment and cancer care. Twinning between centers, mentoring programs and promoting scientific meetings are important learning opportunities that should be promoted. Various initiatives by organizations such as the American Society of Clinical Oncology and the European Society of Medical Oncology can help residents of developing countries improve their knowledge and promote opportunities. of relating professionally. Another strategy to stimulate educational development and optimize available resources is the establishment of cancer centers in institutions focused on multidisciplinary patient care. Panel 2 lists the strategies that could be applied to meet the growing demand for cancer care. Caring for cancer patients and specialized professional education is a growing need worldwide, and Latin America must establish plans to meet this challenge.