Taking the Groundshot to My Native Ground: Developing a New Model of Cancer Care Delivery in Nepal
By Bishal Gyawali, MD, PhD, 2020 Global Oncology YIA: Implementation Science
I have personally witnessed the vast gulf in cancer care and resources between high-income countries (HICs) and low-and-middle income countries (LMICs). I attended medical school in my native country of Nepal, furthered my oncology education in Japan, went back to work as a medical oncologist for 6 months in Nepal, and am now working as a clinical fellow in medical oncology in Canada. These experiences gave me an insight that addressing the global cancer burden would not require major technologic or drug advances, but simply the focus and ability to implement the things we already know to work. If most patients with cancer in Nepal were dying due to lack of access to curative cancer surgery, it wouldn’t make much sense for me to advocate for access to precision cancer therapies. I coined this concept of prioritization in global oncology as “the cancer groundshot,” which I published in The Lancet Oncology in 2018. However, I didn’t want to just propose the cancer groundshot as a philosophy—I wanted to take the concept to the ground, to actually get involved in doing the type of projects that the cancer groundshot advocates for. One low-hanging fruit in improving cancer care in an LMIC like Nepal, I had come to realize, was to treat patients at their local hospital. This sounds very simple, but it is vitally important.
Nepal is a country where 80% of the population lives in rural areas. This Himalayan country with a population of 33 million has fewer than 20 medical oncologists to treat cancer among the Nepalese people, in whom the incidence and mortality of cancer is increasing steadily. For a Nepalese patient with cancer, this disparity means that access to care is not as simple as going to the local hospital each week for chemotherapy. There are only two public cancer centers in Nepal that offer treatment: one in Kathmandu and the other in Bharatpur. In a country characterized by mountains and variable road conditions, those centers can be difficult to get to. Living expenses in Kathmandu are prohibitive, leaving some patients to travel more than 500 km to get 45 minutes of chemotherapy on a weekly basis. Some patients need to rent an apartment in Kathmandu to complete their chemotherapy or other cancer treatment; some stay in hotels or in the homes of relatives or friends. This is precious time spent away from their own family, or from work. Indeed, it has been my perception that such transportation, accommodation, and food expenses sometimes exceed the actual cost of treatment.
One of my patients was a young man from the far western part of Nepal. He needed chemotherapy every 2 weeks, and it would take him more than 36 hours to come from his home to Kathmandu to receive treatment. This disrupted his job, an additional burden on top of the cancer diagnosis and hassle of travel. The burden is even worse for women, who continue to take on the majority of childcare and household responsibilities (as they do in many countries around the world). Another patient, a woman from rural Nepal, stayed in Kathmandu with her relatives for more than 3 months to complete her chemotherapy. She had two little kids back home who needed her care, but she had to finish her treatment first and a weekly commute of that length was impossible.
The solution to this issue suddenly hit me when I became acquainted with the Canadian cancer care system, which utilizes the expertise of primary care doctors, trains them further in the basics of oncology care, and involves them in the cancer care delivery system as general practitioner oncologists. This has helped Canada deliver chemotherapy services in rural areas in coordination with centralized academic cancer centers. I thought a training program for primary care doctors, which builds their capacity to deliver basic cancer treatment in rural settings, would solve this important puzzle in Nepal as well. Having a similar system in Nepal, where the initial consult would be done at a big cancer center but the chemotherapy regimen would be delivered at a local hospital in continuous collaboration with oncologists in the cancer center, would definitely benefit patients and improve outcomes. A patient who has to deal with the physical, mental, and emotional burden of cancer would not have the extra burden (both time and expense) of travel and accommodation arrangements.
However, I didn’t have the resources to take any concrete steps towards addressing this problem. When I saw that ASCO and Conquer Cancer were offering a Global Oncology YIA specifically in implementation science, I knew I had to apply. I applied with a proposal to develop a curriculum and implement an education model focused on training primary care providers in low-income countries on the basics of chemotherapy, which will allow patients in rural settings to receive care closer to home. I was very excited when I received the news that my proposal was successful and I had been selected for the Global Oncology YIA.
The award will allow me to lay the groundwork for a new model of cancer care in Nepal. It will enable me to perform a needs assessment and collaborate with Nepalese doctors to develop a training curriculum in basic oncology care. The training will be delivered to primary care doctors who practice outside the two main cancer centers in Nepal, thus increasing the capacity of general practitioners throughout the country.
My collaborators and I obviously will not be able to complete the entire project within a year, but receiving the YIA will help us create a strong foundation to successfully launch the program. We have already received the ethics clearance and identified the local site principal investigator. Although the coronavirus pandemic and the accompanying travel restrictions have somewhat delayed our project, we remain motivated. Our ultimate goal is to make cancer care more accessible to patients, regardless of geography, both in Nepal and in countries like it around the world.
We thank ASCO and Conquer Cancer for supporting our project with the Global Oncology YIA. This small support is a giant motivation for early-career researchers like myself.