Lawrence S Lessin, Medical Director, Department Of Continuing Medical Education And Quality Training, Washington Hospital Center, USA, Madhavan V Pillai , Adjunct Professor Of Oncology, Thomas Jefferson University, Philadelphia, USA, Savitri Singh-Carlson, Assistant Director, Graduate Program And Associate Professor In Nursing, California State University, Long Beach, USA and Jeanne Sewell, Nursing Professor At Georgia College, Milledgeville, USA
In November 2013, more than 5,000 Indian oncologists, oncology nurses, social workers and other cancer caregivers convened for a four-day congress in New Delhi, India, that was focused on the assessment and enhancement of cancer care in India and the education of health care professionals. This article outlines the findings of that meeting and the role that OERC–India can play in advancing oncology learning in India.Download PDF
The Indian Cancer Congress 2013 (ICC) was the first such combined meeting organized by a consortium of the four major oncology associations in India to critically review the status and discuss the future of cancer care in India (indiancancercongress2013.org). The Indian Society of Oncology (ISO), Indian Society of Medical and Pediatric Oncology (ISMPO), Indian Association of Surgical Oncology (IASO) and Association of Radiation Oncologists of India, (AROI) worked together to plan and conduct this historic conference. ICC 2013 was deemed a great success and the next meeting (to be held every four years) is planned for Bangalore in 2017.
ICC 2013 was designed to engage all of the major disciplines involved in cancer prevention, screening, diagnosis, multidisciplinary therapy and palliative care. Indian societies of medical, surgical and radiation oncology, as well as oncology nursing and basic cancer researchers, had jointly planned the ICC over the preceding three years with input from the thought leaders of Indian oncology. Oncology education was a major theme of the meeting and the Open Educational Resources for Cancer in India (OERC–India) team from the United States was invited to lead several educational sessions.
The team, led by oncologists Dr Madhavan Pillai of Jefferson University Kimmel Cancer Center in Philadelphia and Dr Lawrence Lessin of the Washington Cancer Institute, included Dr Savitri Singh-Carlson and Ms Jeanne Sewell, both nurse educators, and Anil Srivastava, an expert in online education, of the Open Health Sciences Laboratories in Rockville, MD. Amb Balakrishnan of New Delhi headed up the patient advocacy and public education sessions. The OERC group lectured, participated on panels and led discussions on online learning, oncology nursing, continuing medical education, public education and the principal plenary presentation, “OERC–India as resource for professional education”.
Moreover, the broad range of ICC presentations by Indian and international experts provided the OERC–India team with a comprehensive status assessment of the major aspects of cancer control and care in India and underscored the need for increasing provider capacity and competence through education.
We learned that the age adjusted incidence rate for all types of cancer in India ranges between 106–130 per 100,000 people among men and 100–140 for women. These incidence figures are predicted to increase seven-fold by 2025. With the current patient load of one million new cancer patients every year, the ratio of cancer patients to oncologists in India is 1,600 to 1 compared to 100 to 1 in the United States. Steps have already been taken to increase the oncology provider capacity by at least four-fold in the near future, so that India will have more oncologists, oncology nurses and allied health care workers but this will still fall short of actual need.
With the exception of major centres such as TMC and AIIMS where high quality care is provided, the vast majority of cancer patients will continue to be managed by non-oncology doctors and nurses who deal with other diseases as well. A system of regional cancer centres was begun several years ago with a “hub and spoke” model, relating smaller hospitals to regional cancer centres with a plan to link providers via infrastructure and online expert systems. At the ICC, the OERC–India team learned that the majority of cancers in the Indian population are detected and diagnosed in late stages when incurable and that a major professional and public educational effort should be focused on screening and early detection so that tumours can be diagnosed in early stages when they are potentially curable.
With the rapid progress in cancer care resulting from advances in molecular biology, nanotechnology and information infrastructure, new data is generated at amazing speed, which makes for a challenging task for health care professionals to stay current in their knowledge and skills. This is even more difficult for those providers who are generalists. India should be able to leverage its advanced information technology system to provide access to continuously updated information through all available devices, such as smart phones, tablets and computers. To help address this challenge, OERC–India (OERCINDIA.MERLOT.ORG) has been created with potential connectivity to all IT platforms. This web portal is a free online repository of educational resources now available through California State University’s MERLOT (Multimedia Educational Resources for Learning and Online Teaching). Its principal goals are to assist Indian health care professionals to gain basic oncology information from reliable sources and to remain current in their respective fields of cancer care. OERC– India has been endorsed by India’s thought leaders in clinical oncology and oncology nursing. OERC–India will also have resources to be used for the education of patients, families and the lay public. When the site for India’s general public is fully developed, it is expected to be available in all Indian languages.
From its inception, OERC has been closely affiliated with INCTR (International Network for Cancer Treatment and Research) led by Dr Ian Magrath (who serves on the OERC Executive Committee) and is based in Brussels. The OERC–India plenary presentations at ICC by Drs Lessin and Pillai, in fact, opened with a 2-minute video by Dr Ian Magrath outlining the mission and goals of INCTR and its relationship to OERC. The plan for OERC–India and its objectives have been previously described in detail in INCTR’s annual publication, Cancer Control 2013.
Thus, OERCIndia.merlot.org was effectively launched at the ICC, with Dr Badwe of Mumbai, Medical Director of Tata Memorial Hospital, assuming the position of Editor in Chief and appointing editors for medical, surgical and radiation oncology, as well as oncology nursing and prevention and screening from the TMC faculty. Dr Rajagopal of Kerala will serve as Editor for palliative care and Amb Balakrishnan, Editor for patient advocacy and public education.
OERC–India is an open and free metadata repository of high quality educational materials selected by and for Indian cancer health care providers, based on the assessment of educational needs as determined by Indian oncology educators and thought leaders. As with the main OERC site (OERC.merlot.org), OERC India will continue to be hosted and supported by the professional education and technical staff at MERLOT and the California State University system. Indian oncologists and nurses at the ICC greeted the OERC–India launch with great enthusiasm and confirmed their collective intention to undertake the ongoing needs assessment, contribute educational materials and curricula to the site and to actively utilize the educational modules for the preparation of teaching programmes. Meetings with leading patient advocacy and public education leaders confirmed our perception that the “culture of cancer” in India was in need of an extensive long-range public education campaign to “demystify” cancer and its treatment and to move the Indian “war on cancer” into the public domain with education, transparency and advocacy.
The ICC oncology nursing workshop was well received by oncology nurses practising in various public and private settings. This was especially evident in the large numbers who attended the one day workshop session that focused on research, safe chemotherapy administration, psychosocial impact, communication, palliative and preventive care. It was clear that the establishment of oncology nursing as a specialty had begun in India and several curricula had been developed at regional centres. Discussions and questions during the ICC presentations focused on nurses’ working environment, the lack of resources in most clinical settings as well as limited resources for advancing educational levels or preparation for the role of oncology nursing from basic nursing education post-graduation. Most oncology nurses in India graduate with a basic nursing education and need advanced education on oncology nursing content, for example, chemotherapy pharmacology and administration, symptom and side effect management and palliative care. Some cancer institutions provide oncology educational modules for newly hired nurses, whereas there are a few institutions that provide a one-year programme for advanced oncology nursing education.
This is an opportunity for OERC–India to provide free open education learning modules, curricula and seminars, nurse educators and administrators at these institutions can download and use. This notion was received well by nursing college professors and administrators. A need to follow-up on this first visit is due and is planned for the near future. Indian oncology nurses who attended the workshop were keen on leaving their contact information with Professors Savitri Singh-Carlson and Jeanne Sewell as part of the demographic data collection, so that they could be contacted later requiring educational needs. This information will be used as a follow-up to assess the Indian nurses’ needs before developing any specific curriculum.
It was also clear to the OERC team that a strong commitment from government to a “war against cancer” was in its early stages, with a need to mount a major national anticancer public education campaign. This was validated in the ICC public cancer advocacy sessions led by Amb Balakrishnan and visits by the OERC team with government officials and at private institutions. The economic impact of cancer as a leading cause of morbidity, mortality and lost productivity for a population of 1.4 billion people was well understood. However, mechanisms to stem this suffering and economic loss were in early stages of development.
The OERC team repeatedly emphasized at ICC sessions that from the public health standpoint, cancer prevention and early detection are overwhelmingly more cost-effective than diagnosis and treatment of cancer in late stages. It is estimated that greater than 70% of cancers are related to preventable or reducible environmental and behavioural factors such as use of tobacco products, betel nut, grilled and smoked meats and fish, chemical preservatives, pollution of air and water, sexually transmitted diseases, obesity, etc. A national long-term cancer control plan, which focuses on cancer prevention, public education and early detection through effective screening, should be a top priority for government and the public health and oncology communities in order to lower cancer incidence, morbidity and mortality over the coming decades. American observers pointed out that in the United States, major progress against cancer began in 1974 with President Nixon’s “War Against Cancer”, then 40 years of progress, and that India is now in the early stages of this process and can benefit from our experience, our extant cancer information and educational materials and that India can accelerate progress leveraging the advanced state of India’s information technology.
A second aspect of Indian oncopolitics relates to the tensions among the oncologic specialists – medical, surgical and radiation oncology – some of whom are still debating the relative importance and merits of their specialty-specific management of cancers. Several of the ICC sessions discussed the importance of interdisciplinary team management of cancers, but this approach is lacking in all but the most advanced cancer centres such as Tata Memorial, the All India Institute of Medical Sciences and several leading regional cancer centres. Some sessions at ICC gave the impression of an “intellectual chauvinism” regarding the relative contributions of surgery, radiation oncology and medical oncology to cancer care, rather than committing to the interdisciplinary care model, where pathologists, diagnostic and interventional radiologists, molecular geneticists, oncopsychologists, palliative care specialists and other therapists all play a role in developing individualized treatment plans for patients, and then carrying out the plan according to consensus guidelines. This interdisciplinary care approach will require the ongoing development of India-specific consensus guidelines for the management of each cancer type and stage, such as those developed by the NCCN in the United States. Access to such guidelines and supporting evidence-based materials can be assisted via OERCIndia.MERLOT.org, a programme developed by and for the Indian oncology educational community.