Edited by: Sean Collins, Georgetown University Hospital, USA
Reviewed by: Keith Unger, Georgetown University, USA; Sonali Rudra, MedStar Georgetown University Hospital, USA
This article was submitted to Radiation Oncology, a section of the journal Frontiers in Oncology.
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The growing burden of non-communicable diseases including cancer in low- and lower-middle income countries (LMICs) and in geographic-access limited settings within resource-rich countries requires effective and sustainable solutions. The International Cancer Expert Corps (ICEC) is pioneering a novel global mentorship–partnership model to address workforce capability and capacity within cancer disparities regions built on the requirement for local investment in personnel and infrastructure. Radiation oncology will be a key component given its efficacy for cure even for the advanced stages of disease often encountered and for palliation. The goal for an ICEC Center within these health disparities settings is to develop and retain a high-quality sustainable workforce who can provide the best possible cancer care, conduct research, and become a regional center of excellence. The ICEC Center can also serve as a focal point for economic, social, and healthcare system improvement. ICEC is establishing teams of Experts with expertise to mentor in the broad range of subjects required to establish and sustain cancer care programs. The Hubs are cancer centers or other groups and professional societies in resource-rich settings that will comprise the global infrastructure coordinated by ICEC Central. A transformational tenet of ICEC is that altruistic, human-service activity should be an integral part of a healthcare career. To achieve a critical mass of mentors ICEC is working with three groups: academia, private practice, and senior mentors/retirees. While in-kind support will be important, ICEC seeks support for the career time dedicated to this activity through grants, government support, industry, and philanthropy. Providing care for people with cancer in LMICs has been a recalcitrant problem. The alarming increase in the global burden of cancer in LMICs underscores the urgency and makes this an opportune time fornovel and sustainable solutions to transform cancer care globally.
The growing burden of non-communicable diseases (NCDs) in the developing world has been highlighted by the World Health Organization (WHO) report in 2010 and in a United Nations (UN) declaration in 2012 (
Coleman and Love have addressed the need for a transformative approach to science, service, and society, emphasizing that the task of reducing the burden of disease among health disparities populations is arguably as integral a component of academic translational medicine as are laboratory and clinically based research (
Partnering with and enhancing ongoing global health programs is an essential tenet of ICEC. Given the ICEC focus on mentoring and workforce development, collaboration with existing efforts will be mutually beneficial. Potential collaborating organizations include (a) international agencies such as the Union for International Cancer Control (
The development of the model for ICEC is the result of decades of experience of a number of the authors from working in the underserved communities in the U.S. and globally. Examples include the PACT (
The ICEC has seven essential characteristics for a science-grounded strategy:
Decrease cancer incidence and mortality and improve quality of life globally. Use specific benchmarks and defined metrics to assess all interventions. Build an international effort from the outset with collaboration across countries, sectors, and disciplines. Emphasize local initiative built from community leaders or “champions.” The projects will be established from the bottom-up based on local needs and opportunities coupled with the ability of ICEC to help leverage local investment. ICEC will not build physical infrastructure. Establish research efforts including implementation science (defined in Section “Research”) and programs across the cancer control spectrum from prevention to treatment to follow-up to elucidating mechanisms of cancer biology. Aim for the availability of effective treatments including cure and palliation for every patient with cancer in the world within the next two decades. This is in concert with the Global Health 2035 goals ( Develop sustainable worldwide capacity and capability through public health approaches, applications of innovative economic and business models, greater knowledge sharing, and exploiting new information technologies. Work to effect a cultural change that values and rewards as an integral part of a career the efforts for working on human-service efforts.
Notably, this approach to cancer is applicable to NCDs in general. The public health and systems approach is consistent with that described by Kim (
The ICEC is an international mentoring network of cancer professionals who will work with local and regional in-country groups on projects to develop and sustain expertise and local solutions for better cancer care. The vision is a world in which everyone has access to cost-effective interventions to prevent and treat cancer and its symptoms in ways that are consistent with best possible practices for the local circumstances. Addressing and realizing this vision can benefit people everywhere because of the scientific, humanitarian, and diplomatic consequences of such projects.
A major issue in global health is whether national policy prescriptive approaches such as cancer plans, which are top-down efforts, should be the priority, or whether bottom-up, local community specific approaches are more likely to achieve our developmental goals over the long term (
Therefore, the ICEC model is to establish LMIC programs from the inside out and from the bottom-up. The focus is on
Figure
The focus of the ICEC is to work with
The process for how a facility or group within a health disparities region will work with ICEC to become an ICEC Center is illustrated in Figure
An application review will help determine the composition of the initial team from ICEC to meet on-site with the applicant. This on-site discussion includes a needs assessment and exchange of ideas that will help ICEC and Associate/Center develop a mutually acceptable multi-year plan. The new ICEC Developmental Center will be paired with a regional Hub. The initial ICEC Experts will be assigned from throughout the global network based on the initial needs of the Center. The Associate serving as the Principal Investigator Associate (may be Associate-in-training or possibly already more senior) and the team at their ICEC Developmental Center will begin the process of establishing multi-modality cancer care. This will likely be a multi-year process, possibly up to 5 or so years. There will be occasional visits among the Associate/Center and Experts, coordinated by their regional Hub, but mentoring will be primarily accomplished through scheduled teleconferences for “case” reviews for the patients who are being treated on the specific guidelines or protocols, which are being used for the mentoring and training. The Associate and Center will progress in capability for cancer management to where an initial Quality Assurance Site Visit is passed. Further program development and mentoring will involve some of the initial Experts for continuity and also the addition of others with the growing scope of expertise in the Center.
Ongoing evaluation of progress for all components of ICEC is essential for guiding development and to learn from experience. It is anticipated that formal research will be conducted that will range from implementation science to translational research to clinical trials to social and economic research. At a point in time when there is multi-modality care, data-management systems, and the ability to adhere to guideline- or protocol-based care a “clinical cooperative group” site visit will be passed, which indicates that the ICEC Center is ready to apply for full participation in worldwide clinical trials. ICEC is not an accreditation body so that approval of the ICEC Center’s participation in such studies would be the responsibility of the particular research program or agency. Once (a) the ICEC site visit is passed and a level of expertise achieved, (b) there is a Senior Associate as program leader and other Associates as members, and (c) the Center is a Full Member, the ICEC Center could become a regional Hub for ICEC.
Education and training are key activities of ICEC. It is expected that the Associates are completing or will have undergone formal training in their discipline, although it is recognized that the extent of training and specific credentials will vary. As noted above, a breadth of expertise will be required to mentor physicians, nurses, scientists, epidemiologists, and other healthcare and health policy workers from LMICs in public health oncology (
Given its central role in treatment and cure of malignancy often encountered at advanced stage in LMIC and in its palliative potential, radiation therapy will be a requirement. If not present at the outset there must be a clear plan and timeline to obtain this capability within the first few years. Establishing radiation therapy, diagnostic imaging, and laboratory capabilities in settings that may not have stable infrastructure (power, water, communications, etc.) provides an enormous opportunity for technological research and development, creating affordable treatment paradigms, and developing novel approaches for remote-access medicine and means of utilizing and deploying information technology. While ICEC will not supply equipment, we will bring together industry partners and economists to (a) address the need for appropriate technology, including cobalt units, brachytherapy, imaging, including basic CT and linear accelerators possibly of novel modular design so that complexity of treatment will progress as skills develop; (b) investigate sustainable economic models for affordable treatment with a goal of a course of cancer treatment for approximately $400, the approximate cost of a cataract operation in LMICs and in line with the challenge by Kerr (
The current career paths in academia involve clinical, laboratory, and translational research, education, public health/outcomes research, and patient care. While global health is being emphasized in undergraduate education and to some extent in training, it remains an area for substantial academic exploration since at present a very limited number of people are engaged in this aspect of healthcare as a routine component of their career. To that end, we believe that there is the need for a transformational approach to return this type of altruistic service to where it is an integral component of a healthcare career (
This requires pioneering institutions to create a
Figure
The unique aspect of ICEC is the assembling of a critical mass of global health expertise. There are already “twinning” programs among academic centers and facilities in LMICs and international programs with whom to partner and enhance breadth and depth. Sharing of expertise and resources means that the investment by any one Hub is not excessive while the system-wide aggregate is substantial.
As it now stands many twinning programs between resource-rich cancer centers and LMICs depend on the efforts of a few people. By having programs work together and share ideas, models, expertise, and resources, a robust networking system can be created that can have continuity and sustainability beyond a founder. The four boxes on the top of the figure describe what will be done while the box on the right side includes the long-term goals.
There is an increasing interest in global health attested by the rapid growth in the consortium of universities for global health (CUGH) (
Figure
Each expert panel in Figure
Initial diseases (and the public health problem and oncologic opportunity included)
Cervix (implementation of standard external beam and brachytherapy services, sexually transmitted disease, vaccine); Head and neck [smoking, combined modality therapy with radiation plus chemotherapy using cost-effective drugs (applicable in other cancers)]; Lung (respiratory diseases, potential for hypo-fractionated (few-fraction) radiotherapy and novel combined modality therapy with radiation plus chemotherapy); Breast (women’s issues, screening, genetic disease), hypofractionation, breast brachytherapy for early stage disease; Palliative care (reduce burden of care on families and healthcare system and reduce suffering, immobility, and potential abandonment for patient); Lymphoma (relates to a younger population and for which collaborative programs are in place).
Initial panels (there will be other Experts as needed for diseases above)
Radiation oncology Medical oncology Surgical oncology Palliative care physicians Medical physics, technology (including industry to develop new technology) Nursing (anticipated to be a key underpinning of Centers) Data management and Information Technology (using cell phone technology) Imaging (including teleradiology- basic radiology and CT) Pathology (including telepathology) Pharmacists (especially for palliative care and cost-effective chemotherapy).
The overarching development goal for ICEC is to provide partial salary support in the form of contracts/grants to enable altruistic service and global health to become an integral part of the spectrum of academic and professional careers. In that the goal is 20% of time, or 8 h/week on average over the year, ICEC will aim to have a matching program of ICEC support and in-kind contribution (equal match) thereby leveraging one funded ICEC FTE up to 10 Experts. The cost of any FTE supported will be based on the local pay scale with maximum limits set by the Board. (This will be at most the NIH FTE rate for resource-rich countries). Financial support for a position will make this career path possible, especially so in the changing face of healthcare; however, as critical or even more so than compensation is the career recognition and reward, which in academia includes promotion in rank, professional recognition and career advancement.
A unique aspect of ICEC will be drawing expertise from three tracks, each of which has untapped potential:
The ICEC conducts and enables research. Mentoring will help build capacity but there is much to learn about how to solve the economic and access problems of reaching the underserved and establishing the best treatments for their resource settings. Therefore, having capability to do research and accrue credible data, there is ample opportunity for the Associates and Centers to perform different types of research in addition to the more standard clinical trials. Some examples are as follows:
Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice. It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions. As a newly emerging field, the definition of implementation science and the type of research it encompasses may vary according setting and sponsor. However, the intent of implementation science and related research is to investigate and address major bottlenecks (e.g., social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact. The ICEC is addressing a problem that is unsolved and growing – cancer care in LMICs. It is piloting a complex system solution using collaboration, mentoring, and idea-sharing among countries, cultures, and disciplines that has transformational potential. High-quality data yielded from research will inform the evolution of this challenging process.
A key to establishing sustainable programs and to the ICEC model is support from professional societies. There is a clear interest in global education by the American Society of Radiation Oncology (
The various components of ICEC will be coordinated by ICEC Central with policies and procedures developed by ICEC Committees (Figure
Initial committees are
Experts and Application/Career Path ICEC Centers and Associates Hubs Operations/Information Technology-Information Management Scientific – which will consist of representatives from Experts, ICEC Centers and Associates and Hubs to determine research directions Industry – who will work with industry, including a pre-competitive model, to develop equipment and approaches for bringing technology and care to cancer health disparities populations Outreach and Development.
The ICEC is a non-government organization incorporated in the State of Delaware, United States and recognized the Internal Revenue Service as a 501 (c) 3 tax exempt entity. Given its primary focus of patient care, the mission of the ICEC is complementary to that of the Center for Global Health of the National Cancer Institute (
A recent assessment of investment in global health pointed out diseases that cause the highest burden as measured by disability-adjusted life years (DALYs) do not get much of the international investment. The NCDs produce approximately 45% of the DALYs but receive <5% of the aid (
In addressing issues of global healthcare, Nigel Crisp suggested that critical premises for an ideal model include an understanding of the societies in which these occur focusing on public health with community and outpatient-centered services, building locally defined solutions with reliance on local skills (
Healthcare expenditures continue to grow with economic models dominating how care is delivered and how professional compensation is determined. Perhaps not sufficiently part of the discussion and solution, observers have suggested that altruism is declining in medicine (
The establishment of ICEC itself is implementation science and ICEC will enable research to be conducted by and for the benefit of those in health disparities regions, which include those in resource-rich countries. Metrics will be established and appropriately modified based on experience to assess progress, develop novel strategies and share experience among the network of global partners. The breadth and depth of ICEC will be such that individual programs in LMICs are not dependent on single individuals so that long-term investment by the local community, industry and committed individuals has a high probability of success. We believe that the current crisis can no longer be ignored and that “it is too hard or too big a problem” are not acceptable answers. To quote Nelson Mandela: “It always seems impossible until it’s done” (
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
1These are referred to “geographic-access limited” in this paper that also includes cultural issues, poverty, and limited economic opportunity.