Education, Training and Ongoing Updating for High-Quality Cancer Care: Programs and Technology for Tumor Boards and Case Discussions

Background: The rapid advance in new knowledge of cancer etiology, creation of treatment guidelines, new technologies and medicines into routine practice and the need to understand cost and efficacy that underlie policy are daunting. Remaining current must be accomplished on top of increasingly busy clinical care requirements and patient numbers requires novel solutions. Education and training opportunities are available from professional societies, cancer programs, paid courses and written reviews, though person-to-person mentorship and expert opinion are vital to navigate the vast amount of information. Aim: To provide experience-based insight into addressing the challenge for professionals to maintain one's expertise in cancer care in countries at all income levels. Methods: The International Cancer Expert Corps and partner organizations are establishing a global and multisectoral network that builds human capacity and capability to establish sustainable cancer programs that function at world-class standards ( www.iceccancer.org ). The model utilizes in-person, in-country visits along with ongoing connectivity through telemedicine video conferences. The pioneering education Chartrounds program ( www.chartrounds.com ) is an example of initiative taken by those “in the field” which began in the U.S. and has recently expanded to include separate Web sites for India, Africa, and Latin America. Results: Chartrounds.com, a free Web-based conferencing platform providing disease-site based educational peer review sessions, exemplifies how global expertise can be shared, altruistic education is willingly provided by world-renowned experts and a method of providing practice changing education is possible while the responsibility for the decision-making and treatment implementation remain with the individual treatment center. Weekly experience by Chartrounds and ICEC is defining the complexity of telecommunications, especially problematic with low capacity bandwidth that tests the capacity for effective teleconferences requiring high-quality voice and image data. Conclusion: The enormous body of knowledge needed by cancer practitioners to provide state-of-the-art cancer care requires creative solutions for education, mentorship and telecommunications. That major research institutions such as the National Cancer Institute has invested in developing TELESYNERGY enhances the quality of cancer care and research that are necessary at the global level. Newer platforms are rapidly emerging and artificial intelligence and machine learning will soon assist with education and quality assurance tasks. For UICC members, recognizing present and emerging solutions is critical to best invest in resources and necessary personnel skill-sets to “leapfrog” into the newer enabling technology and approaches to help bring the best possible cancer care into resource-limited environments. The content is the personal opinion of the authors and not their organizations.

Development and Implementation of a Telemedicine Platform for Radiation Oncology Training and Peer Review

Background: Telemedicine has been posited as a potential means of bolstering radiation therapy delivery in developing nations. World Aid Exchange (WaidX) is an innovative intercontinental telemedicine platform oriented to oncology specialties. This platform, devoted to reducing the digital divide on health practice, provides telecommunication services between health care facilities in developed and developing countries. It conveys the ability to safely share radiologic images and patient medical records for diagnostic and care purposes. It was successfully piloted in Mwanza, Tanzania in 2015. Since then, it has been implemented in varied settings such as Ethiopia, Djibouti and Brazil. After conducting a site visit and a focused needs assessment, we recognized the need for teleconferencing with the Radiation Department of National Center of Oncology, Yerevan, Armenia, to share expertises in general patient management and contouring and planning for radiotherapy. Aim: To develop a TeleRadiotherapy platform that enables: 1: Conference calling for tumor boards to review radiotherapy plans, discuss disease management and conduct remote quality control 2: Real-time sharing of diagnostic images to guide clinical decision making 3: E-contouring activity performed by parties in Yerevan and New York on radiographic images, with minimization of time lag in contouring 4: Generation of a database for clinical data (i.e., radiation dose, toxicity, disease stage) that serves as a departmental registry and a tool for future research use 5: Access to lectures delivered by physicians, nurses, therapists and physicists both in Yerevan and New York on varied aspects of radiotherapy Methods: The initiative was funded through a competitive grant established within the Department of Radiation Oncology at Cornell. The TeleRadiotherapy system is comprised of 2 physical units, equipped to support networking and telephony integration. An application was used to establish a simplified direct connection between mobile phones in New York and fixed phone extensions in Yerevan. A customized version of Veyon was used for remote connection to a contouring station. Zoom was used to establish the teleconference. Remote operators in Weill Cornell Medicine were trained for using the system. Results: The first teleradiotherapy interaction between Yerevan and New York occurred on February 7th, 2018. Demonstration of contouring on the Oncentra treatment planning system in Yerevan revealed ease of use. The brush tool displayed less drag time than the point-by-point contouring tools. Diagnostic images were easily shared without compromise of the image resolution. Conference call quality was high. This conference has opened a series of biweekly chart rounds, between the two institutions. Conclusion: Teleradiotherapy is feasible with excellent voice quality, image sharing capability and real-time contouring. The database is under construction. We are developing a new model for learning, training and collaboration in radiotherapy using WaidX, to enable rapid knowledge and technology transfer for a more equitable access to high-quality cancer care worldwide.

Workforce Capacity and Capability Building Through Metrics-Based Mentoring Partnerships

Background: Globally, cancer is the second leading cause of death. Low- and middle-income countries (LMICs) especially lack the sufficient healthcare and oncology workforces needed to screen, diagnose and treat individuals with cancer. While traditional academic and training programs designed to produce healthcare professionals in these countries fill a critical role, few programs exist that maintain, develop, and increase the knowledge, skills, and professional performance of current healthcare and oncology workforces. Mentoring partnerships and twinning programs can provide ongoing education and training that strengthen and build workforce capacity and capability for the full scope of cancer care. Aim: The goal is to achieve resource-appropriate multimodality cancer-care using guideline- and protocol-based education and training and also to develop the capability to conduct world quality research. The model utilizes in-person, in-country site visits lasting from several weeks to months and ongoing connectivity through weekly telemedicine video conferences. Methods: The International Cancer Expert Corps (ICEC) and partner organizations are establishing a network of global and multisectoral partnerships that builds human capacity and capability needed to establish sustainable cancer programs that function at world-class standards. The three-fold mentor-mentee approach ( www.iceccancer.org ) is built by 1) enlisting hubs of expertise to include academic medical centers/universities, private practices and an ICEC Central Hub, 2) enrolling the breadth of expert-mentors needed from a university, practice, professional society and interested individuals, and 3) identifying centers in LMICs - clinics/hospitals/and other care delivery sites in underserved areas, and associates - physicians/allied healthcare workers- seeking mentoring and education. Results: Recent implementation of the ICEC 5-Step Progression Plan provides guidance and serves as an assessment tool for measuring progress between the hubs-centers programs and expert-associate. Twinning programs (hubs-ICEC centers) have been established in multiple sites worldwide including in Africa, Asia and Eurasia. Conclusion: Implementation of the ICEC 5-Step Progression Plan provides a platform from which to track the current stages and progress of twinning mentor-mentee programs, and to evaluate new programs. This information guides the programs and also provides metric-based investment in global health. Critically as the skills in associates and ICEC centers grows, they achieve expert-mentor status and centers become hubs to serve the surrounding regions, thereby enabling geometric growth in cancer care to meet the needs of the growing global burden of cancer. The content is the personal opinion of the authors and not their organizations.

Basal Tumor Cell Isolation and Patient-Derived Xenograft Engraftment Identify High-Risk Clinical Bladder Cancers

Strategies to identify tumors at highest risk for treatment failure are currently under investigation for patients with bladder cancer. We demonstrate that flow cytometric detection of poorly differentiated basal tumor cells (BTCs), as defined by the co-expression of CD90, CD44 and CD49f, directly from patients with early stage tumors (T1-T2 and N0) and patient-derived xenograft (PDX) engraftment in locally advanced tumors (T3-T4 or N+) predict poor prognosis in patients with bladder cancer. Comparative transcriptomic analysis of bladder tumor cells isolated from PDXs indicates unique patterns of gene expression during bladder tumor cell differentiation. We found cell division cycle 25C (CDC25C) overexpression in poorly differentiated BTCs and determined that CDC25C expression predicts adverse survival independent of standard clinical and pathologic features in bladder cancer patients. Taken together, our findings support the utility of BTCs and bladder cancer PDX models in the discovery of novel molecular targets and predictive biomarkers for personalizing oncology care for patients.

Pathology and oncology in Africa: education and training for the future in cancer research– East African Regional Meeting

According to the World Health Organisation (WHO), deaths from non-communicable diseases (NCDs) will increase globally, with the largest increase being on the African continent. On our continent, projections have indicated that deaths from NCDs will exceed all combined communicable, maternal, perinatal and nutritional diseases as the most common causes of death by 2030. Hence, the importance of a functional and improved pathology system in the diagnosis of cancer cannot be debated.

Recently, the African Organization for Research and Training in Cancer (AORTIC) organised its East African regional meeting in Mwanza, Tanzania on 25–26 June 2015, with the focus being ‘Pathology and oncology: Education and training for the future in cancer research’. The main themes of the workshop were around improving cancer care and the role of twinning in Eastern Africa, in particular the Mwanza cancer project, telepathology, e-health and biobanking. The outcomes of a 2 day strategic meeting were developing an efficient and effective plan to guide the improvement in pathology training and cancer research in Africa.

Laser ultrasonic inspection of the microstructural state of thin metal foils

A laser-based ultrasonic technique suitable for characterization of the microstructural state of metal foils is presented. The technique relies on the measurement of the intrinsic attenuation of laser-generated longitudinal waves at frequencies reaching 1 GHz resulting from ultrasonic interaction with the sample microstructure. In order to facilitate accurate measurement of the attenuation, a theoretical model-based signal analysis approach is used. The signal analysis approach isolates aspects of the measured attenuation that depend strictly on the microstructure from geometrical effects. Experimental results obtained in commercially cold worked tungsten foils show excellent agreement with theoretical predictions. Furthermore, the experimental results show that the longitudinal wave attenuation at gigahertz frequencies is strongly influenced by the dislocation content of the foils and may find potential application in the characterization of the microstructure of micron thick metal foils.