- Email: [email protected]
Training a new generation of surgical oncologists worldwide
Comment
*Francesco Petrella, Lorenzo Spaggiari
2
Department of Thoracic Surgery (FP, LS) and Department of Oncology and Hemato-Oncology (LS), University of Milan, Milan 20141, Italy [email protected]
3
We declare no competing interests. 1
Bendixen M, Jorgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016; published online May 6. http://dx.doi.org/10.1016/S1470-2045(16)00173-X.
4
5
Yan TD, Cao C, D’Amico TA, et al, International VATS Lobectomy Consensus Group. Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensus statement. Eur J Cardiothorac Surg 2014; 45: 633–39. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013; 95: 426–32. Park BJ, Melfi F, Mussi A, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 2012; 143: 383–89. Gagner M. Small incision, big surgeon: laparoscopic liver resection for tumors without a doubt: Comment on “Laparoscopic Liver Resection for Malignant and Benign Lesions: Ten-Year Norwegian Single-Center Experience”. Arch Surg 2010; 145: 40–41.
Training a new generation of surgical oncologists worldwide
Marazzi/Science Photo Library
The ability to address the rising global burden of cancer requires the presence of an adequately trained surgical oncology workforce, which, in turn, is dependent on formal training pathways and sustainable certification processes. However, there is enormous variation in training of surgical oncologists globally. In many countries, there is no formal training curriculum to equip surgeons to understand contemporary management principles in oncology, nor is there a certification process that assures the public of their specialised oncology capabilities beyond that of general surgery training. The Lancet Oncology Commission states that there are “profound equity and economic gaps in global cancer surgery. Many patients globally do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen the systems could result in as much as USD$ 6 trillion in lost cumulative gross domestic product by 2030”.1 This month, the Society of Surgical Oncology (SSO) and the European Society of Surgical Oncology (ESSO) have co-published two Articles about the training of surgical oncologists and the global disparities of training.2–5 One of these Articles4,5 analysed the variations in training regimens across the world and found substantial variations exist, that total surgical training length is long (varying between 8 and 17 years), and that several countries do not have the capability to offer fellowship training in surgical oncology. The availability of a curriculum that proscribes a uniform minimum of surgical oncology training standards can initiate the process of addressing these global inconsistencies. The two leading global surgical oncology societies (SSO and ESSO) have developed such a curriculum, consisting of a minimum set of training 700
domains and requirements that can be adapted for different regions of the world. We acknowledge the inherent variations in training across the world due to disease patterns and social, cultural, and economic influences. Notwithstanding these differences, the proposed modular curriculum is conducive to global acceptance and adoption. Worldwide, cancer management has become multidisciplinary, often resulting in improved cancer-specific outcomes as well as patient quality of life. Indeed, surgical treatment will increasingly not be the initial cancer treatment for patients with locally advanced or regional metastases. Despite the evolving treatment landscape, a surgical oncologist’s input forms a vital component of multidisciplinary treatment planning not only for patients with early-stage disease, but also for patients with advanced and metastatic disease.6 This requires the surgeon to be educated and trained as an integral partner of a multidisciplinary team.6 However, globally, surgical oncology training programmes are extremely heterogeneous with different emphases placed on acquiring knowledge in all multidisciplinary domains of oncology.2,4 We need a more streamlined and comprehensive curriculum so that surgical oncologists understand the indications, risks, and benefits of systemic and radiation therapy in the best combination and sequence of a multidisciplinary care plan. This training should also equip the surgeon to be a clinical investigator, participating in clinical trials and contributing to evidence-based care. A global curriculum could serve as the platform to streamline training and equip the surgeon to be competent in all multidisciplinary domains of oncology. www.thelancet.com/oncology Vol 17 June 2016
Comment
The SSO and ESSO have had major leadership roles in the curriculum content and certification process of training programmes for surgical oncology.7–11 The SSO has committed resources and programmes dedicated to educational outreach and global collaborations.11 In the USA, the training and certification of surgical oncologists has been formalised. Candidates completing a 2-year approved fellowship training programme in surgical oncology are certified by the American Board of Complex General Surgical Oncology after passing both a written and oral exam.8,9 Several other countries (including many low-income and middle-income countries, eg, India) have formal surgical oncology fellowship programmes but the presence of such structured training pathways is not globally uniform. What differentiates surgical oncology from other areas of surgery is the oncology training and expertise needed to address all aspects of cancer management in a multidisciplinary fashion. Thus, the surgical oncologist is an oncologist who performs surgery but can also incorporate advances in oncology management into the treatment plan of their surgical patient with cancer.6,7 Hence, the training requirements for surgical oncologists should reflect what is expected of them in practice. We hope that the proposed curriculum2,3 will train the current and future surgical oncologist to be proficient in all treatment domains of oncology.6,7 As stated by Ronald Weigel, in his SSO presidential address: “Surgical oncology has a brilliant future if we
are willing to evolve beyond operative therapy of the cancer patient”.10 The published global curriculum can go a long way in assuring that bright future for all surgical oncologists and their patients. *Charles M Balch, Graeme J Poston University of Texas MD Anderson Cancer Center and University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (CMB); and Aintree University Hospital, University of Liverpool, Liverpool, UK (GJP) [email protected] CMB is Past President of the Society of Surgical Oncology and GJP is Past President of the European Society of Surgical Oncology. We declare no competing interests. 1
2 3
4
5
6 7 8 9 10
Sullivan R1, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16: 1193–224. Are C, Berman RS, Wyld L, Cummings C, Lecog C, Audisio RA. Global curriculum in surgical oncology. Ann Surg Oncol 2016; 23: 1782–95. Are C, Berman RS, Wyld L, Cummings C, Lecog C, Audisio RA. Global curriculum in surgical oncology. Eur J Surg Oncol 2016; published online April 27. DOI:10.1016/j.ejso.2016.04.005. Are C, Caniglia A, Malik M et al. Variations in training of surgical oncologists: proposal for a global curriculum. Ann Surg Oncol 2016; 23: 1782–95. Are C, Caniglia A, Malik M et al. Variations in training of surgical oncologists: proposal for a global curriculum. Eur J Surg Oncol 2016; published online May 4. DOI:10.1016/j.ejso.2016.04.004. Klimberg VS, Balch CM. The distinctive features of surgical oncology as a specialty. Chin Clin Oncol 2014; 3: 44–48. Poston GJ. Global cancer surgery: The Lancet Oncology review. Eur J Surg Oncol 2015; 41: 1559–61. Michelassi F. SSO Presidential address: subspecialty certificate in advanced surgical oncology. Ann Surg Oncol 2010; 17: 3094–103. Tyler DS, Michelassi F. Finish line or beginning? Welcome the new board-certified surgical oncologists. Ann Surg Oncol 2016; 23: 1403–08. Weigel RJ. 2015 Presidential Address: Society of Surgical Oncology. The next 75 years. Ann Surg Oncol 2015; 22: 2455–61.
Joining forces for children with cancer in Latin America
www.thelancet.com/oncology Vol 17 June 2016
Argentina provides an important example of the successful implementation of a paediatric cancer registry, the Argentinian Oncopaediatric Registry (ROHA).3 ROHA was launched in 2000 as a non-governmental initiative and was subsequently absorbed in 2011 by the Argentinian National Institute of Cancer. Cancer registries not only provide information on the epidemiology of childhood cancer (eg, peculiarities in the incidence of promyelocitic leukemia, retinoblastomas, or Epstein-Barr virus-associated tumors), but also highlight specific characteristics of the regional population (eg, ethnicity, migration, or specific genetic clusters4). Data from ROHA showed that 75% of children with cancer were treated at public institutions, and many of them had to migrate from
National Cancer Institute/Science Photo Library
The proportion of children surviving cancer in high-income countries has surpassed 80%, but for children in low-income and middle-income countries continues to be less than 40%.1 Narrowing this survival gap in paediatric cancer poses an enormous challenge. Latin America consists of 21 sovereign states with an estimated 604 million inhabitants. With 25% of the population younger than 15 years, this translates to more than 18 000 cases of childhood cancer every year, or approximately 12% of all childhood cancers worldwide. However, because only 21% of the countries in Latin America maintain a population-based cancer registry,2 it is virtually impossible to estimate the impact of childhood cancer on the society and economy in Latin America.
701
*Francesco Petrella, Lorenzo Spaggiari
2
Department of Thoracic Surgery (FP, LS) and Department of Oncology and Hemato-Oncology (LS), University of Milan, Milan 20141, Italy [email protected]
3
We declare no competing interests. 1
Bendixen M, Jorgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016; published online May 6. http://dx.doi.org/10.1016/S1470-2045(16)00173-X.
4
5
Yan TD, Cao C, D’Amico TA, et al, International VATS Lobectomy Consensus Group. Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensus statement. Eur J Cardiothorac Surg 2014; 45: 633–39. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013; 95: 426–32. Park BJ, Melfi F, Mussi A, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 2012; 143: 383–89. Gagner M. Small incision, big surgeon: laparoscopic liver resection for tumors without a doubt: Comment on “Laparoscopic Liver Resection for Malignant and Benign Lesions: Ten-Year Norwegian Single-Center Experience”. Arch Surg 2010; 145: 40–41.
Training a new generation of surgical oncologists worldwide
Marazzi/Science Photo Library
The ability to address the rising global burden of cancer requires the presence of an adequately trained surgical oncology workforce, which, in turn, is dependent on formal training pathways and sustainable certification processes. However, there is enormous variation in training of surgical oncologists globally. In many countries, there is no formal training curriculum to equip surgeons to understand contemporary management principles in oncology, nor is there a certification process that assures the public of their specialised oncology capabilities beyond that of general surgery training. The Lancet Oncology Commission states that there are “profound equity and economic gaps in global cancer surgery. Many patients globally do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen the systems could result in as much as USD$ 6 trillion in lost cumulative gross domestic product by 2030”.1 This month, the Society of Surgical Oncology (SSO) and the European Society of Surgical Oncology (ESSO) have co-published two Articles about the training of surgical oncologists and the global disparities of training.2–5 One of these Articles4,5 analysed the variations in training regimens across the world and found substantial variations exist, that total surgical training length is long (varying between 8 and 17 years), and that several countries do not have the capability to offer fellowship training in surgical oncology. The availability of a curriculum that proscribes a uniform minimum of surgical oncology training standards can initiate the process of addressing these global inconsistencies. The two leading global surgical oncology societies (SSO and ESSO) have developed such a curriculum, consisting of a minimum set of training 700
domains and requirements that can be adapted for different regions of the world. We acknowledge the inherent variations in training across the world due to disease patterns and social, cultural, and economic influences. Notwithstanding these differences, the proposed modular curriculum is conducive to global acceptance and adoption. Worldwide, cancer management has become multidisciplinary, often resulting in improved cancer-specific outcomes as well as patient quality of life. Indeed, surgical treatment will increasingly not be the initial cancer treatment for patients with locally advanced or regional metastases. Despite the evolving treatment landscape, a surgical oncologist’s input forms a vital component of multidisciplinary treatment planning not only for patients with early-stage disease, but also for patients with advanced and metastatic disease.6 This requires the surgeon to be educated and trained as an integral partner of a multidisciplinary team.6 However, globally, surgical oncology training programmes are extremely heterogeneous with different emphases placed on acquiring knowledge in all multidisciplinary domains of oncology.2,4 We need a more streamlined and comprehensive curriculum so that surgical oncologists understand the indications, risks, and benefits of systemic and radiation therapy in the best combination and sequence of a multidisciplinary care plan. This training should also equip the surgeon to be a clinical investigator, participating in clinical trials and contributing to evidence-based care. A global curriculum could serve as the platform to streamline training and equip the surgeon to be competent in all multidisciplinary domains of oncology. www.thelancet.com/oncology Vol 17 June 2016
Comment
The SSO and ESSO have had major leadership roles in the curriculum content and certification process of training programmes for surgical oncology.7–11 The SSO has committed resources and programmes dedicated to educational outreach and global collaborations.11 In the USA, the training and certification of surgical oncologists has been formalised. Candidates completing a 2-year approved fellowship training programme in surgical oncology are certified by the American Board of Complex General Surgical Oncology after passing both a written and oral exam.8,9 Several other countries (including many low-income and middle-income countries, eg, India) have formal surgical oncology fellowship programmes but the presence of such structured training pathways is not globally uniform. What differentiates surgical oncology from other areas of surgery is the oncology training and expertise needed to address all aspects of cancer management in a multidisciplinary fashion. Thus, the surgical oncologist is an oncologist who performs surgery but can also incorporate advances in oncology management into the treatment plan of their surgical patient with cancer.6,7 Hence, the training requirements for surgical oncologists should reflect what is expected of them in practice. We hope that the proposed curriculum2,3 will train the current and future surgical oncologist to be proficient in all treatment domains of oncology.6,7 As stated by Ronald Weigel, in his SSO presidential address: “Surgical oncology has a brilliant future if we
are willing to evolve beyond operative therapy of the cancer patient”.10 The published global curriculum can go a long way in assuring that bright future for all surgical oncologists and their patients. *Charles M Balch, Graeme J Poston University of Texas MD Anderson Cancer Center and University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (CMB); and Aintree University Hospital, University of Liverpool, Liverpool, UK (GJP) [email protected] CMB is Past President of the Society of Surgical Oncology and GJP is Past President of the European Society of Surgical Oncology. We declare no competing interests. 1
2 3
4
5
6 7 8 9 10
Sullivan R1, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16: 1193–224. Are C, Berman RS, Wyld L, Cummings C, Lecog C, Audisio RA. Global curriculum in surgical oncology. Ann Surg Oncol 2016; 23: 1782–95. Are C, Berman RS, Wyld L, Cummings C, Lecog C, Audisio RA. Global curriculum in surgical oncology. Eur J Surg Oncol 2016; published online April 27. DOI:10.1016/j.ejso.2016.04.005. Are C, Caniglia A, Malik M et al. Variations in training of surgical oncologists: proposal for a global curriculum. Ann Surg Oncol 2016; 23: 1782–95. Are C, Caniglia A, Malik M et al. Variations in training of surgical oncologists: proposal for a global curriculum. Eur J Surg Oncol 2016; published online May 4. DOI:10.1016/j.ejso.2016.04.004. Klimberg VS, Balch CM. The distinctive features of surgical oncology as a specialty. Chin Clin Oncol 2014; 3: 44–48. Poston GJ. Global cancer surgery: The Lancet Oncology review. Eur J Surg Oncol 2015; 41: 1559–61. Michelassi F. SSO Presidential address: subspecialty certificate in advanced surgical oncology. Ann Surg Oncol 2010; 17: 3094–103. Tyler DS, Michelassi F. Finish line or beginning? Welcome the new board-certified surgical oncologists. Ann Surg Oncol 2016; 23: 1403–08. Weigel RJ. 2015 Presidential Address: Society of Surgical Oncology. The next 75 years. Ann Surg Oncol 2015; 22: 2455–61.
Joining forces for children with cancer in Latin America
www.thelancet.com/oncology Vol 17 June 2016
Argentina provides an important example of the successful implementation of a paediatric cancer registry, the Argentinian Oncopaediatric Registry (ROHA).3 ROHA was launched in 2000 as a non-governmental initiative and was subsequently absorbed in 2011 by the Argentinian National Institute of Cancer. Cancer registries not only provide information on the epidemiology of childhood cancer (eg, peculiarities in the incidence of promyelocitic leukemia, retinoblastomas, or Epstein-Barr virus-associated tumors), but also highlight specific characteristics of the regional population (eg, ethnicity, migration, or specific genetic clusters4). Data from ROHA showed that 75% of children with cancer were treated at public institutions, and many of them had to migrate from
National Cancer Institute/Science Photo Library
The proportion of children surviving cancer in high-income countries has surpassed 80%, but for children in low-income and middle-income countries continues to be less than 40%.1 Narrowing this survival gap in paediatric cancer poses an enormous challenge. Latin America consists of 21 sovereign states with an estimated 604 million inhabitants. With 25% of the population younger than 15 years, this translates to more than 18 000 cases of childhood cancer every year, or approximately 12% of all childhood cancers worldwide. However, because only 21% of the countries in Latin America maintain a population-based cancer registry,2 it is virtually impossible to estimate the impact of childhood cancer on the society and economy in Latin America.
701