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- Copyright © 2018 Kellie Alleyne-Mike. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
Hindawi Journal of Oncology Volume 2018, Article ID 7286281, 7 pages https://doi.org/10.1155/2018/7286281 Research Article The Caribbean Community Clinical Oncology Workforce: Analyzing Where We Are Today and Projecting for Tomorrow Kellie Alleyne-Mike National Radiotherapy Centre, St. James, Port of Spain, Trinidad, Trinidad and Tobago Correspondence should be addressed to Kellie Alleyne-Mike; kmike.tt@gmail.com Received 6 November 2017; Revised 13 February 2018; Accepted 1 March 2018; Published 15 April 2018 Academic Editor: Minesh P. Mehta Copyright © 2018 Kellie Alleyne-Mike. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose. To analyze the current physician clinical oncological workforce within the CARICOM full member states with an aim to make recommendations for building capacity. Methods. A questionnaire was prepared and emailed to professionals working in oncology in 14 CARICOM full member countries. It was designed to identify the number of specialists providing hematology, medical oncology, and radiotherapy services. Results. Ten countries (71.4%) supplied information. Oncology services were insufficient in the majority of countries. Hematology proved to be the most adequately staed ff with six countries (60%) having the recommended number of specialists. Medical oncology services were deficient in vfi e countries (50%). Radiation oncology services were the most limited with nine countries (90%) unable to provide the required quota of specialists. eTh majority of the workforce consisted of nonnationals (55%). The remaining practitioners were nationals, and of these 50% were regionally trained. Oncological care was primarily oer ff ed within the public sector. Conclusion. Oncological staffing within the CARICOM full member states is insufficient to meet the demands of the current population. Encouraging training through locoregional or international programs is key to obtaining the numbers required. Cancer registries will help provide data to influence public policy and improve the oncological healthcare system. 1. Introduction 2. Materials and Methods Regional cancer data for the Caribbean and Latin Amer- A questionnaire was prepared with questions relating to the ican region has been limited when compared to statistics available core oncological services being provided in each emanating from North America, Europe, and Asia. eTh country. The survey was conducted between September 2016 developing nations have relatively high incidences of cancer and February 2017. Participants were primarily identiefi d and increased mortality rates and are oeft n less equipped to from previous attendees to the biannual conference hosted manage the disease burden optimally [1]. eTh Caribbean is by the Caribbean Association of Oncology and Hematology. oen ft linked with Latin America in many studies, and thus Participants were medical professionals or allied healthcare data unique to that region have been difficult to isolate from professionals. the collective. This paper serves as a preliminary review of Respondents were emailed the questionnaire which the oncology workforce in the region with its focus being on included instructions for completion. Follow-up emails were the full member states of the CARICOM nations. CARICOM conducted if further information or clarification was neces- comprises developing states and was founded in 1973. It sary. Questions which referred to the human resource capac- consists of een member states and vfi e associate members ity were limited to the following groupings: medical oncol- with anumberofservicesincluding resource mobilization ogists, radiation oncologists, clinical oncologists (trained to support regional integration. In the context of identifying in both medical and radiation oncology), hematologists, resource limitations and methods for optimizing the use of and hemato-oncologists (instructed in both blood-based existing services, these organizations are critical. and solid tumor management). Questionnaires were sent to fift 2 Journal of Oncology personnel working in oncology in fourteen CARICOM full member countries, namely, Antigua and Barbuda, Bahamas, Barbados, Belize, Trinidad and Tobago, Dominica, Grenada, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, and Suriname. Montserrat was excluded from the primary analysis as this country is a British overseas territory and thus could not reasonably be compared to the remaining CARICOM members. The specialists identified had to be actively in clinical practice. Recommendations for specialists numbers in med- ical oncology were taken from estimations by an Ameri- Antigua Barbados Belize Dominica Grenada Jamaica St. Kitts St. Vincent Suriname Trinidad can Society of Clinical Oncology (ASCO) survey estimate and Nevis and the and and Grenadines Barbuda Tobago which suggested that 1.8 medical oncologists were required Actual 54122 15 121 10 per 100,000 inhabitants [2]. eTh projections for radiation 2 5 7 2 2 49 1 2 10 24 Recommended oncologists were made using guidance from the International Figure 1: List of existing medical oncologists and required numbers Atomic Energy Agency (IAEA) which gauged the require- based on a survey by the American Society of Clinical Oncologists ment for radiation oncologists as 1 per 100,000 inhabitants (1.8 oncologists were required per 100,000 inhabitants). [3]. Information regarding the number of teletherapy units in each country was sourced from the IAEA Directory of Radio- therapy Centres (DIRAC) [4] and the recommendations were basedonIAEAguidelineswhich suggested1machineper 180,00 inhabitants [3]. eTh numbers needed for hematology were sourced from an article review of an American Society of Hematology (ASH) panel discussion on that topic and proposed that 5 hematologists per 1,000,000 inhabitants would adequately meet the demand [5]. Information on population size and population density was collected using data obtained from the World Bank website [6]. Statistics on cancer incidence and mortality were sourced from GLOBO- CAN 2012. The estimated staff numbers were rounded up to the nearest integer. Tables and graphs were prepared using Microsoft Word. Antigua Barbados Belize Dominica Grenada Jamaica St. Kitts St. Vincent Suriname Trinidad and the and and Nevis and Grenadines Tobago Barbuda Actual 3. Results Recommended 13412 27 115 13 Complete information was received from 71.4% of the four- Figure 2: List of existing radiation oncologists and required num- teen countries except for The Bahamas, Guyana, St. Lucia, bers based on recommendations by the International Atomic Energy and Haiti which were thus excluded. All remaining countries Agency (1 per 100,000 inhabitants). Note. Patterned bars indicate had some level of oncology support. In St. Kitts and Nevis, countries in which radiation therapy is not oer ff ed due to the lack hematology support is offered by a visiting specialist residing of equipment. in the United States Virgin Islands. In the case of Belize a national, who now lives in the United States, oeff rs part- time support. In the other nations, there was at least one professional who resided in the country while providing support. Figures1,2,and3illustratethe numberofdoctorsin each country who are capable of providing specialist attention in each of the three chosen specialty efi lds: medical oncol- ogy, radiation oncology, and hematology, respectively. eTh physician tally for each bar graph allowed for the recognition 6 of dual specialties in separate graphs where physicians were dually trained. In the case of medical oncology (Figure 1), Antigua and Antigua Barbados Belize Dominica Grenada Jamaica St. Kitts St. Vincent Suriname Trinidad and the and and and Nevis Barbuda and St. Kitts and Nevis were the only countries Grenadines Barbuda Tobago Actual 14101 15 100 10 which appeared to surpass the required number of specialists. Recommended12211 14 1137 Dominica, St. Vincent and the Grenadines, and Grenada each met their recommended numbers while the remaining vfi e Figure 3: List of existing hematologists and required numbers based islands (accounting for 50% of the studied group) appeared on recommendations from the American Society of Hematology (5 to have an inadequate supply of specialists. Jamaica had the hematologists per 1,000,000 inhabitants). Clinician numbers Clinician numbers Clinician numbers Journal of Oncology 3 Table 1: This shows the distribution of radiation therapy machines per country and the recommended number per population size based on recommendations by the International Atomic Energy Agency (1 machine per 180,00 inhabitants). Existing external beam radiation therapy machines Country Recommended external beam radiation therapy machines Cobalt-60 LINAC Total Antigua - 1 1 1 Barbados 1 - 1 2 Jamaica 2 2 4 16 Suriname - 2 2 3 Trinidad 1 3 4 8 greatest need with only 30.6% of the medical oncologists the country of origin). eTh re was a greater percentage of nonnationals (55%) to nationals (45%). The latter of the two required being available. A total of four countries (Jamaica, groupings predominantly sourced local training in Jamaica Trinidad and Tobago, Suriname, and Belize) had less than (22%) where a specialist program was available for hematol- half of the recommended staff to fulfill the medical oncology ogyand oncology.TheUnitedKingdomwasnext inlinewith needs of the populations which they serve. In summary, there 13% of professionals accessing training in that country. When were vfi e countries which possessed an adequate number of reviewing nonnationals, the majority were from Cuba (22%) specialists accounting for 50% of this grouping. followed by the Netherlands and India (each with 6% of the In the case of radiation oncology services (Figure 2), vfi e grouping). nations (denoted by patterned bars) did not have machines Figure 5 illustrates the proportion of specialists working available to deliver therapeutic radiation. es Th e included St. publicly, privately, or in both sectors. Belize and Antigua and Vincent and the Grenadines, Dominica, St. Kitts and Nevis, Barbuda were the only countries in which more than 50% Grenada, and Belize. The remaining countries oer ff ed radia- of theoncological workforcewas concentratedintheprivate tion therapy but had inadequate staffing (except for Antigua sector. and Barbuda). Suriname with 80% capacity and Barbados Table 2 indicates some of the frameworks necessary with 66.7% were the closest in meeting their recommended to support oncology services and the number of countries quotas. Jamaica had the least radiation oncology staffing involved in each grouping. Only Trinidad and Tobago, for its population with only 7.4% of the necessary staff. Barbados, and Grenada reported the existence of a national In the case of Antigua and Barbuda, the available staffing cancer registry, with two other countries conrfi ming that again surpassed the required numbers. us Th nine countries, they were in the early stages of development. Sixty percent accounting for 90% of the grouping, had suboptimal human of the respondents indicated that hospital registries were resource capacity. Among the countries providing radiation available at some institutions. All treatment decisions were therapy services, a further analysis of the necessary equip- based on guidelines, and these tended to be international ment was undertaken. Based on IAEA recommendations on guidelines. In one country, Trinidad and Tobago, national the number of radiation therapy machines per population guidelines were developed in 2015. In two of the ten countries, size, it was found that the existing numbers were also the respondents indicated that all treatment decisions were inadequate to sustain the demand (Table 1). It should be basedonmultidisciplinary team (MDT)discussions.Inthe noted that the IAEA document referred to the availability remaining eight countries, the respondents reported that final of a Linear Accelerator (LINAC) as the machine of choice management decisions were sometimes but not always based for external beam radiation therapy. However, in some of on MDT reviews. eTh re were local health authority rules for the islands Cobalt-60 machines were used. Considering the the compounding of chemotherapy drugs in four nations. limited resource setting these were included in the analysis Radiation therapy was accessible in vfi e countries, and most and estimations for each country. of these countries were formalizing legislation for the same. When analyzing hematology services (Figure 3), the quota within the Caribbean was more favorable. Jamaica, 4. Discussion Barbados, and Trinidad and Tobago were the most equipped to meet the human resource demand for specialist services. The increased demand for healthcare systems by the rising They each appeared to surpass their recommended quotas by incidence and mortality related to cancer is substantial. er Th e one individual (7.1%) in the case of Jamaica, two in the case of are many different factors which must be addressed to meet Barbados (100%), and three (42.9%) in the case of Trinidad the challenge imposed on these countries adequately. Provi- and Tobago. Three other countries (Antigua and Barbuda, sion of adequate human resources, while not the only factor, Grenada, and St. Kitts and Nevis) had the necessary staffing. is one of the major obstacles to providing the healthcare The remaining four countries (40%) did not have the required required. eTh refore knowledge of the existing workforce is staff to meet the imposed demands. us Th 60% of all countries essential so that the deficiencies can be identified and plans possessed adequate hematological support. can be made to address the shortfalls. Figure 4 illustrates the distribution of nationals (based Estimating the required workforce is not a simple task, on the country of training) and nonnationals (based on and no one assessment method is ideal. However, attempts 4 Journal of Oncology Nationals Nonnationals 45% 55% Nationals India Australia Netherlands Canada St. Lucia Cuba Trinidad Egypt ５SVI Guyana Jamaica (a) Nonnationals Nationals 45% 55% Nonnationals South Africa Canada United Kingdom Jamaica United States Netherlands (b) Figure 4: This illustrates the distribution of (a) nonnationals (bas ed on the country of origin) to (b) nationals (based on the country of training). USVI: United States Virgin Islands. have been made by various international organizations which not be directly applicable to another population grouping. seek to provide estimates on the potential numbers which They may, however, provide guidance on capacity needs. can appropriately meet the required demands. As previously The results indicate that only one country (accounting for mentioned, in this study these estimates were taken from 10% of the countries reviewed) had an adequate provision theIAEAwithregardtoradiation oncology needsand of specialists offering radiation oncology services. The per- teletherapy machines, ASCO for medical oncology and ASH centage for medical oncology was more favorable with 50% for hematology [2–5]. It can be argued that the recommenda- capacity achieved. In considering hematology services, only tions made by the North American/European societies may 60% of the countries evaluated had the required capacity. (%) (%) Journal of Oncology 5 Table 2: This indicates some of the frameworks necessary to support oncology services and the number of countries involved in each grouping. Yes No Sometimes/usually Unknown National cancer registry 3 7 - - Hospital registries 6 4 - - Treatment based solely on international guidelines 9 1 - - Multidisciplinary management 2 0 8 - Patient cancer organizations 10 0 - - Local health authority rules for mixing cytotoxic drugs 4 6 - - Radiotherapy oer ff ed 5 5 - - Radiation legislation 2 7 - 1 regions. However, it should be noted that this is not the only obstacle to retaining sta.ff Nationals trained abroad as specialists are sometimes frustrated by the lack of equipment or supplies available to them on returning to their countries. These deficiencies hinder their ability to use their training optimally. Limitations such as the lack of oncology drugs or the absence of teletherapy machines prevent the physicians from fully applying their knowledge. In some instances, the Antigua and Barbados Belize Dominica Grenada Jamaica St. Kitts and St. Vincent Suriname Trinidad and education gained, therefore, remains theoretical and suffers Barbuda Nevis and the Tobago Grenadines from disuse as it cannot be put into practice. Obtaining and Public only retaining adequate specialist numbers is critical in dealing Both public and private with the growing burden of cancer care. Private only Multiple studies on the radiation oncologist density have shown that insufficient numbers are linked to increased mor- Figure 5: This illustrates the proportion of professionals working tality for some cancers [11–13]. u Th s the fact that radiation publicly or privately or offering services in both sectors. oncology support is deficient in nine of the ten countries surveyed and absent in five of that grouping is troubling. The need for access to radiation therapy for treatment is further This concern over the lack of adequate oncology staffing is reinforced by the evidence that the optimal utilization rate notaproblemthatisuniquetothe CARICOMregionas for radiotherapy has been estimated at around 50% and thus approximately half of all cancer patients will require this other nations also face similar challenges [7–9]. One obvious way to address the problem would be to have individuals treatment either as an adjunct to their primary management trained in the areas needed. This, however, is not without its orasthesoletherapy[14].This iswhyassociationssuchasthe IAEA have reached out to some developing nations including challenges as outlined in a report produced by the WHO [10]. Training programs do not exist within the CARICOM region the Caribbean with an aim to strengthen human capacities for radiation oncology. With regard to medical oncology in radiation medicine. They have also developed training and hematology, Jamaica has developed a training program modules geared at teaching in the applied sciences for in which physicians are taught management of both solid oncology through distance learning. These training modules tumor and blood-based malignancies in a combined cur- did not confer specialist qualifications but were expected to riculum. Programs like this are appealing to regions which be supplemental to formal training [15]. have staffing deficiencies as it allows for versatility in the In hematology, the number employed in Jamaica appeared to be more than the required amount. It should provision of care despite the few specialists available. eTh same can be said for clinical oncology programs where be noted, however, that the majority of these specialists are individuals are trained in radiation therapy in addition to dually trained to offer medical oncology services and that knowledge of systemic cytotoxic management. Like Jamaica, efi ld remains an area which is understaffed. u Th s reducing the other Caribbean islands can consider developing similar hematology staff numbers will cause a concomitant decline programs. Trinidad and Tobago is in the process of gaining in the provision of medical oncology care in that country. approval for the implementation of a similar program. In These hemato-oncologists in this setting were mainly locals. the absence of sufficient local/regional training programs, The same argument applies, in part, to Trinidad and Tobago where a similar situation occurs. eTh main difference is that international training sites can be accessed. eTh study shows that this is already a common practice as many nationals a significant proportion of the hematology services in that have been pursuing training abroad, but the retention of these country (50%) are provided by hematologists from Cuba who are solely trained in that specific specialty. es Th e specialists individuals is challenging. Skilled professionals are tempted by better remuneration packages which are oer ff ed in other were temporarily brought into the country and offer services (%) 6 Journal of Oncology covering both malignant and nonmalignant conditions. Ensuring that a country has all of the above serves only The training of local physicians in that eld fi will reduce the to treat the existing problem. We also need to be proactive in our approach, and that requires developing the appropriate need for foreign assistance. Antigua and Barbuda appear screening programs for early diagnosis and patient educa- to be self-sufficient in its oncological staffing by adequately tion to help aid prevention and improve patient outcomes. meeting and surpassing its recommended needs. us Th a case However, data forthe region areverylimited [20].Cancer can be made for extending their services regionally to areas registries are invaluable in gathering information which can where these services are absent. In such a situation, one can help guide the development of public policy. The fact that only make a case for specialists assisting in other islands as is three countries admitted to the existence of a registry means the case for St. Kitts and Nevis which receives oncological that more work is required. Fortunately the region is getting support from a visiting hematologist. However, for these support from organizations like the Caribbean Public Health latter twocountries,itwas alsofoundthatgreaterthan Agency (CARPHA), the International Agency for Research 50% of its oncological support was provided by specialists on Cancer (IARC), the National Cancer Institute (NCI), the working outside of the public sector. The services, therefore, Centers for Disease Control and Prevention (CDC), and the mayonlybeaccessible toasubsetofthe population who North American Association of Central Cancer Registries can aoff rd to access care which is not provided by the state. (NAACCR) who are all collaborating to assist with develop- It is imperative for all the countries involved that services ing and improving cancer registration [21]. Fortunately, many be accessible to all patients regardless of their economic of the other countries have started institutional registries background. in the absence of a national registry, and this certainly is a However, providing the optimal number of physicians positive start. trained in hematology, medical oncology, and radiation Government support is crucial in the implementation oncology is not all that is required to address the oncology of many of the areas discussed above. Cancer is still not a healthcare problem. The holistic management of the issue notifiable disease in many countries. eTh problem is that this requires a broader overview. Human resource necessities implementation is oen ft a lengthy process but having the data must include surgeons, pathologists, radiologists, medical to support it will certainly go a long way. Public policy and physicists, radiation therapists, dosimetrists, pharmacists, guidelines on mixing chemotherapeutic drugs and radiation radiobiologists, palliative care specialists, and numerous legislation are needed, and since they were not available in other key support sta.ff Virtual MDT discussions with col- most countries, this would have to be addressed. laborating institutions in the Caribbean are practiced in a minority of treating facilities. However, the staff also need Patient cancer organizations can be found on all the material and equipment to perform their duty optimally. islands. Many of these groups are effective in disseminating Deficiencies in the access to radiation therapy machines, X- information on cancer prevention and treatment. They are ray facilities, ultrasound, computed tomography, magnetic oen ft funded by nongovernmental organizations and can be resonance imaging, flow cytometry, immunohistochemistry, a valuable asset especially when resources are limited within molecular biology, and oncology drugs further cripple an a public sector framework. already compromised situation. eTh staffing and resource limitations in these other areas must also be evaluated and 5. Conclusion would complement the information gleaned in a study such as this. The CARICOM group of full member states, and by extension eTh amount of a nation’s budget which should be allo- of the rest of the Caribbean, continues to be an area with catedtowardshealth haslongbeenatopicofdiscussion limited data. This paper is the rst fi specicfi ally to review the [16]. eTh quantum of this funding which should be assigned status of the current hematological and oncological physician to oncology is even harder to specify. Countries have to be workforce solely in that region. Providing a pathway for locals selective when purchasing medication with a limited budget. to be trained in oncology through scholarship funding will Focusing on core drugs such as those outlined in the World encourage an increase in the human resource capacity, but Health Organization’s (WHO) list of essential oncology drugs retention of qualified staff can be challenging. The develop- may be a reasonable place to start [17]. In addressing the ment of locoregional training programs is preferable and will problem of excessive drug costs, not only do smaller nations be of signicfi ant merit. eTh region as a whole needs to record struggle with diminished budgets but the relatively low drug and analyze regional cancer statistics, and the development of quantities required by their populations also significantly cancer registries will help to supply the relevant information. limits their bargaining power. Individual countries must Developing countries need this data to help guide decisions therefore collaborate. Information such as that gleaned from on local protocol development in a setting where limited the WHO multicountry regional pooled procurement of fundingmustbeusedprudently. medicines report can be very instructive, and CARICOM as a region may benefit from pooling resources [18]. Some countries have already begun such collaborations, and others Conflicts of Interest may follow. Accessing some drugs through frameworks such as the Pan-American Health Organization (PAHO) strategic eTh author declares that there are no conflicts of interest drug fund can also be beneficial [19]. regarding the publication of this paper. Journal of Oncology 7 Acknowledgments Expenditure and Resource Allocation Cluster Evidence and Information for Policy, Geneva, Switzerland, 2016. 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Published: Apr 15, 2018