1. Introduction

Global cancer incidence is predicted to increase by nearly 50% over the next 20 years, with a majority of cases occurring in low- and middle-income countries (LMICs) [1, 2]. Cancer prevention, diagnosis, and care delivery are complex and resource-intensive. The current personnel and supply infrastructure required to address the increasing cancer burden in LMICs is grossly deficient [3]. Medical oncologists in LMICs see an average of over twice as many new consults per year as compared to their counterparts in high-income countries [4], with less than half of LMIC providers having dependable access to essential chemotherapies [5]. In addition, it is estimated that more than 90% of cancer patients in LMICs lack access to radiotherapy [6]. The European Society of Oncology recently published a report assessing the distribution of the multidisciplinary cancer care workforce, finding LMICs fall short of benchmarked capacity across all disciplines [7].

There is growing recognition that providing cancer care in low-resource settings requires specific competencies within each specialty [8]. To address the impending shortage of medical oncologists, both the American Society of Clinical Oncology (ASCO) and the European Society of Medical Oncology (ESMO) now include a core curriculum for global health within their standards for medical oncology training [9]. Likewise, the Canadian Association of Radiation Oncology and the American Society for Radiation Oncology (CARO-ARRO) have developed a postgraduate global health competency curriculum for radiation oncology [10]. While just under half of National Cancer Institute (NCI)-designated cancer centers reported dedicated global health programs, over 80% of these had some level of global oncology training and reported trainee interest in global oncology across multiple specialties [11].

MD Anderson Cancer Center is a leading institution for multiple specialty training programs in oncology. However, at the time this study was conducted, it did not have formalized global oncology training. The purpose of our study was to survey trainees to catalog the ongoing global oncology activities across the institution and to determine trainee interest in a formalized global oncology training curriculum.

2. Materials and Methods

3. Results

Ninety-one trainee programs, constituting around 318 individuals, were contacted to complete the survey. Seventy-two trainees (22.6%) from 17 programs completed the survey.

3.1. Interest and Experience With Global Health and Global Oncology

Thirty-three (45.8%) of the 72 trainees who completed the survey indicated an interest in global health, including seven (21.2%) from hematology/medical oncology, six (18.2%) from radiation oncology, three (9.1%) each from surgical oncology, gynecologic oncology, and pediatric oncology, two from cancer prevention research, and one each from breast surgical oncology, neurologic oncology, urologic oncology, onco-hospital medicine, cancer anesthesiology, transplant-oncology infectious disease, and investigational cancer therapeutics. Trainees had completed a mean of 1.3 years of training (range: 0.5–4.0) and had a mean of 1.9 years of training (range: 1.0–4.0) remaining.

Of the 33 respondents with an interest in global health, 14 (42.4%) had no prior experience with global health. Nineteen reported some prior global health experience, including prior clinical experience (13; 39.4%), research experience (8; 24.2%), experience with advocacy (6; 18.2%), and/or general readings/staying up to date on issues (11; 33.3%). Only eight (24.2%) had experience specific to global oncology. The median number of years of global health experience was one year, with five having no experience, two having an experience of a few months, five having one year of experience, four (12.1%) having three years of experience, and one each having 2, 4, 7, 11, and 15 years of experience. Of the 20 trainees, 10 (50.0%) had done work in sub-Saharan Africa, 7 (35.5%) worked with underserved populations in North America, 5 (25.0%) worked in Latin America and the Caribbean, 3 (15%) in South Asia, and 2 (10%) in the Middle East and North Africa (Figure 1).

Respondents demonstrated varied interpretations of the definition of global oncology; of the 33 trainees interested in global health, 13 (39.4%) described global oncology as provision and study of cancer care in LMICs, while 10 (30.3%) defined it more broadly as serving underserved people around the world regardless of geography and including high-income countries. Five (15.2%) defined global oncology as any work related to cancer that involves an international partner, and 4 (12%) as multicenter/multinational studies related to cancer.

3.3. Career Aspirations and Perceived Obstacles

Of the 33 respondents interested in global oncology, 30 (90%) indicated that they wished to include global oncology activities in their future careers. Of these, nearly half (14; 42.4%) intended to dedicate 10%–20% of their time to global oncology work, 10 (30.3%) intended to spend < 10% of their time, and 4 (12.1%) 20%–50% of their time. Two respondents expressed a desire to dedicate > 50% of their academic time to global oncology work (Figure 2).

Twenty-six of the 33 trainees interested in global health answered the open-ended question about their perception of the important issues in global oncology. Key themes in the responses included a focus on health equity and disparities in cancer care between LMIC and high-income countries related to cancer prevention, early detection, and access to diagnosis and treatment; importance of developing long-term and sustainable relationships with partners in LMIC; the importance of mentorship, protected time, and funding in pursuing a career in global oncology; and the negative impact of COVID-19 on current global oncology efforts (Table 1).

Table 1. Perceived most important issues in global oncology.

Sustainable efforts in low-resource settings. Adequate prevention programs in low-resource settings

Implementation of early detection interventions known to work; working with pharmaceutical companies to make treatment more affordable; training of front-line providers to recognize signs and symptoms of cancer to improve referral; raising awareness in the general population about cancer as a survivable disease; signs and symptoms of cancer

Appropriate mentorship and identifying the right connections with other interested academics globally

Workforce creation; sustainable programs; funding long-term; impact of political landscape on programs; sustained interest of high-income nations; lack of trust of LMICs in therapies

Patients are living longer as a direct result of public health measures and better treatments for infectious diseases, thus the cancer burden in LMICs is rapidly increasing, far outpacing current treatment capacities

Care capacity including screening/diagnostics, supply chain management, and provision of care

Access to clinical trials

Lack of infrastructure; awareness and governmental support; education and training

Access

Disparities between treatment options offered in LMIC versus HIC

Lack of resources

Technologic disparities

Outreach

Inequitable access to care

Access to care; timeliness of care

Disparities

Cultural challenges

Differences in healthcare systems and infrastructure across the globe. Differences in access to care

Access to resources in rural areas (in both high- and low-income countries)

Funding and time off from training to attend the global health oncology initiative

COVID-19 restrictions for travel; dedicated time for trainees to get involved so that they can carry this forward into their careers; centers that are consistent in their care for low-income countries instead of only short-term missions; funding is of course always a hurdle

The COVID-19 pandemic and the limitations in travel; funding; time with regards to participating

Setting up a mentorship or training program with the infrastructure to provide longevity of the transfer of ideas, and clinical and research collaboration

Funding; COVID-19-related travel restrictions; lack of senior mentorship in global oncology

COVID-19

Do not know

4. Discussion

This work summarizes the first survey of interest in global health and global oncology among trainees at The University of Texas MD Anderson Cancer Center. Notably, 90% of respondents wish to make global oncology a part of their future career; however, few had any prior experience with global oncology activities. Our findings highlight the keen interest of trainees across a variety of programs focused on cancer care to develop clinical, capacity-building, and research global oncology projects. However, faculty mentorship and protected time for these trainees to pursue their global health interests were perceived to be limited. Trainees were interested in additional training in global oncology, whether through attending global oncology grand rounds and journal clubs, pursuing formal coursework, or a formal global health certificate as part of their program. Most of the trainees had a mean of almost 2 years of training remaining, giving an opportunity to launch global oncology initiatives that may enrich current trainees’ education.

Increased interest in global health has been documented across medical education. A 2021 survey [12] reported that 65% of medical students had an interest in a global health career, yet only 31% had participated in a global health rotation as students. A large majority of students ranked the opportunity to participate in global health as an important aspect of selecting a residency program, with only a slightly smaller proportion recognizing the importance of programs having a formalized curriculum. Similar to our results, the majority of trainees interested in participating in global oncology activities did not have prior experience.

In response to this growing interest, global health training programs and fellowships have increased in number [13–15]. Dedicated tracks in residency aim to increase trainee exposure to global health opportunities and promote scholarly activity [16]. Prior global health research and/or clinical experience has been associated with a 3-4-fold increase in medical trainees’ interest in pursuing a future global health career [17]. Our results indicated that trainees hope to rely on experiences in their fellowships to prepare them to make global oncology part of their careers. Programs can harness trainee enthusiasm and provide global health experiences and training with a constructive and conscientious curriculum. Most impactfully, these programs have been shown to increase international collaboration and result in increased resources to partnering sites [18, 19]. Dedicated global health research programs are instrumental in not only increasing a trainee’s research productivity in their future careers but also in the creation of future global health leaders and educators [20, 21].

Global health is also quickly being recognized as an academic subspecialty and a potential career track for trainees [22, 23]. Major academic organizations have produced guidelines for career success in global health, highlighting the need to develop education programs, create scholarly contributions, and secure research funding [24, 25]. Our results show trainees echo these priorities, emphasizing the importance of practicing global oncology with academic rigor, scholarly work, and teaching. However, in order to prepare trainees for success in their early careers, mentorship and training specific to global health are required [24, 26]. Society organizations, such as ESMO, ASCO, and CARO-ARRO, have already produced curricula and competencies in global oncology that can be readily adopted by training programs. Expansion of the global oncology curriculum is still needed in fields such as surgical oncology, surgical subspecialties, and pathology.

Prior to finalizing the conclusion of these results, several limitations warrant discussion. First, our results are based on a relatively small proportion of potential respondents. The survey response rate was only 22.6%; however, the possible self-selection of survey respondants likely represents those interested in global oncology and provides meaningful insight into the group most likely to lead such initiatives. This may bias a report of exaggerated global health enthusiasm. However, prior research suggests exposure to global health fosters continued interest and thus we believe that as global oncology initiatives grow, we will see more and more rally to these important programs. Second, while these data included a vast variety of training programs, it is limited to a single institution. This may skew results towards trainees interested in an academic career based on biases of trainees choosing to train at a large academic center and may not accurately represent the larger oncology training community. Various undergraduate training programs were contacted to complete the survey; however, respondents were all postgraduate trainees, missing important information on a large group of individuals (nursing students, surgical technology trainees, etc.) essential to global health efforts. Future studies may consider expanding the cohort to include trainees from public health, dentistry, nursing, and other health professionals to capture the full spectrum of global health interest across medicine and affiliated fields. It could potentially strengthen the case for broader institutional support of global health initiatives.

Despite these limitations, these survey results have helped to inform the programmatic development of global oncology at MD Anderson. The House Staff Senate created a specialized Global Oncology Subcommittee that now organizes monthly global oncology grand rounds in partnership with the Global Academic Programs. This subcommittee has cataloged existing faculty projects that trainees may participate in, as well as advocate for the creation of additional global oncology opportunities across campus. Efforts are also underway to increase the number of faculty with protected time devoted to global oncology and to collaborate with faculty outside of MD Anderson to increase the number of mentors available to trainees.

Furthermore, the survey results were the first step to justifying the development of an institutional global oncology curriculum, the MD Anderson Global Cancer Care (GCC) Track. This trainee-led initiative, supported by program directors, cancer center leadership, and the general medical education (GME), is a 2-year program that provides a robust educational curriculum, structured multidisciplinary mentorship, and global oncology research training to create future leaders in global oncology. The curriculum was developed in accordance with the competencies established by the ASCO Academic Global Oncology Task Force [24] and includes CARO-ARRO didactics. Upon completion of the curriculum and a clinical elective, educational project, or research project, trainees earn a certificate of Track completion at graduation. The first five fellows (2 radiation oncology trainees, 2 gynecologic oncology trainees, and 1 medical oncology trainee) were accepted into the program last year.

5. Conclusions

There is significant interest in global health among trainees in oncology specialties. In addition to curriculum development, trainees desire strengthened mentorship, research, and clinical opportunities. Efforts in these areas should be pursued with the hope of improving opportunities for the United States-based trainees and facilitating future work with local LMIC collaborators to address the needed cancer care in low-resource settings.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

Mustafa Al-Qaraghli, Junior specialist at the University of California at Davis, Department of Surgery. contributed to paper edits and submission.

Funding

This study was supported by the National Institutes of Health (Grant nos. P30CA016672 and (T32CA101642).