Winner: BONUS Essay Competition 2024

We are really excited to announce the winners for BONUS Essay Competition this year. Thanks to all medical students and junior doctors for submitting their essays, we have really enjoyed reading and found them interesting.

Our winners for the BONUS Essay Competition 2024 are:

Undergraduate Winner
Sneha Mehrotra
Year 3 Medical Student at King's College London

Graduate Winner
Dr Jasen Soopramanien
Foundation Year 3 Doctor at Nottingham University Hospitals NHS Trust

What can we learn from the practice of oncology around the world?

Sneha Mehrotra's Essay

Cancer is the second leading cause of death globally, and the burden continues to grow, exerting huge physical, financial, and emotional strain on individuals, families, and healthcare systems worldwide (1). Cancer affects people of all ages, races, and socioeconomic backgrounds, making it a major area of public health concern (2). Oncology is the branch of medicine that focuses on the diagnosis, treatment, and care management of cancer (3). Glaring health disparities are known to exist between countries and even within countries, resulting in a profound onus on public health and the economy (4). Cancer outcomes vary widely due to a multitude of factors, including variations in cancer patterns, national screening policies, presenting stage, access to good quality treatment, and cultural beliefs (5). Oncology involves a multidisciplinary approach, with a clear emphasis on shared health decisions with healthcare professionals and patients. Collaborative research efforts transcending national borders have led to significant developments in treatment modalities, with researchers and institutions contributing to shared knowledge, resources, and expertise. The importance of acknowledging and utilising diverse oncology practices is key to understanding cancer biology and developing effective treatments, which ultimately lies in the benefits implicated on individual lives, the economy, and reducing public health inequalities.

Due to the nature of the disease and its treatments, cancer patients are generally required to visit healthcare facilities more than patients with other diseases (6). It is the healthcare systems that fund, organise, and deliver cancer care, and the wider political, economic, and societal context in which they are set in that determines the accessibility, affordability, and equity of the interventions (7). Cancer is one of the most expensive disease domains, both from a direct healthcare cost (e.g., tests and treatments) and the indirect impact it has on patients and families (out of pocket expenditures) (8,9). A study by Altice et al., found that up to 45% of cancer survivors in the USA reported some form of behavioural financial hardship (10). In India, more than 75% of cancer care costs are paid out of pocket and many patients move to metropolitan cities to access tertiary care. The financial burden of travel, accommodation, and treatment, puts enormous pressure on individuals and often pushes families below the poverty line (11). In 2018, the Government of India introduced a revolutionary initiative, the ‘Ayushman Bharat National Health Protection Mission’, which aims to cover the costs of hospital care and treatment for the poorest 40% of India’s population and incentivises high quality cancer care provision by linking reimbursements directly to facilities adhering to evidence-based management guidelines (12). Promoted as the world’s largest healthcare initiative, this has the potential to deliver affordable and equitable cancer care across India (12).

Studies have shown that approximately 40% of cancer cases in the European Union can be prevented through risk prevention practices (13). The European Code against Cancer is an initiative for informing the public about behavioural recommendations to reduce cancer risk, and to promote participation in screening programmes under national guidelines (14). Cancer screening programmes and early detection services are major interventions to avoid premature mortality. According to the World Health Organisation (WHO), the establishment of a National Cancer Control Programme is key to achieving a substantial degree of cancer control, even when resources are limited, as it focusses on identifying and implementing priorities for action and research (15). While having well-established cancer plans outlined can be seen as a positive factor in lowering cancer incidence and mortality, there is no straightforward relationship between adopting or implementing a plan and achieving favourable public health outcomes. For example, Denmark, the UK, France, and the Netherlands are among the earliest countries to adopt comprehensive National Plans and Strategies, but these countries also have incidence and mortality rates above the EU average (13). In the UK, this may be attributed to huge pressures on the National Health Service, according to figures from Health Education England the ratio of healthcare staff to patients is falling behind most other European countries (16). Furthermore, socio-economically disadvantaged individuals may be less responsive in terms of accessibility and to public health interventions (17). Interestingly, in the early 2000s, the German Cancer Society evaluated the quality of cancer care, finding that Germany was only moderate compared to other EU countries (18), and concluded that a comprehensive, transparent, evidence-based system was necessary for assessing and controlling quality. This led to the initiation of a voluntary Cancer Centre Certification Programme, which encompasses the entire spectrum of care, from prevention and screening to the multidisciplinary treatment. The certification system began with breast cancer in 2003, and colorectal cancer centres in 2006, to being established for most cancers in 2017. Neighbouring countries, including Italy, Switzerland, and Austria have now started centres as well (19). By integrating top-quality guidelines and the latest medical knowledge into routine care for specific tumour types, the programme seeks to enhance the overall quality of cancer care across diverse regions. A key objective is to ensure transparency across all centres, facilitating comparisons between them using objective indicators, which fosters mutual learning among the networks (19).

A lack of access to resources to diagnose and treat cancer is a major hinderance in delivering equitable care (6). Furthermore, the lack of well-trained clinical oncologists can exacerbate the significant cancer health disparities (20). To improve this situation, international organisations such as WHO and professional societies such as ASCO and the European Society for Medical Oncology, could collaborate on studies to identify the availability of human resources for tackling cancer on a global scale. Training programmes could be instituted in regions with greater shortages of clinical oncologists, and collaboration between institutions and universities in high- and low- income countries can aid the development of oncology workforces (4). Investing in research and novel treatments alone is unlikely to result in global progress. Addressing healthcare system barriers, as India has exemplified, and dividing cancer care into specialist tumour-specific centres to encompass the full journey of oncology from prevention to treatment, as Germany has done, can optimise cancer care delivery globally.

References

1. World Health Organisation. World Health Organisation. 2022 [cited 2024 Feb 13]. Cancer. Available from: https://www.who.int/news-room/fact-sheets/detail/cancer

2. World Cancer Research Fund, American Institute for Cancer Research. Continuous Update Project Expert Report. Recommendations and public health and policy implications [Internet]. 2018 [cited 2024 Feb 13]. Available from: dietandcancerreport.org

3. WebMD Editorial Contributors, Felson S. WebMD. 2023 [cited 2024 Feb 13]. What Is an Oncologist? Available from: https://www.webmd.com/a-to-z-guides/what-is-an-oncologist

4. Mathew A. Global Survey of Clinical Oncology Workforce. J Glob Oncol. 2018 Dec;(4):1–12.

5. Choi HCW, Lam K on, Pang HHM, Tsang SKC, Ngan RKC, Lee AWM. Global comparison of cancer outcomes: standardization and correlation with healthcare expenditures. BMC Public Health. 2019 Dec 7;19(1):1065.

6. Jazieh AR, Akbulut H, Curigliano G, Rogado A, Alsharm AA, Razis ED, et al. Impact of the COVID-19 Pandemic on Cancer Care: A Global Collaborative Study. JCO Glob Oncol. 2020 Nov;(6):1428–38.

7. Aggarwal A, Lievens Y, Sullivan R, Nolte E. What Really Matters for Cancer Care – Health Systems Strengthening or Technological Innovation? Clin Oncol. 2022 Jul;34(7):430–5.

8. Sullivan R, Peppercorn J, Sikora K, Zalcberg J, Meropol NJ, Amir E, et al. Delivering affordable cancer care in high-income countries. Lancet Oncol. 2011 Sep;12(10):933–80.

9. Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol. 2013 Nov;14(12):1165–74.

10. Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial Hardships Experienced by Cancer Survivors: A Systematic Review. J Natl Cancer Inst. 2017 Feb;109(2):djw205.

11. Pramesh CS, Badwe RA, Borthakur BB, Chandra M, Raj EH, Kannan T, et al. Delivery of affordable and equitable cancer care in India. Lancet Oncol. 2014 May;15(6):e223–33.

12. Caduff C, Booth CM, Pramesh CS, Sullivan R. India’s new health scheme: what does it mean for cancer care? Lancet Oncol. 2019 Jun;20(6):757–8.

13. Espina C, Soerjomataram I, Forman D, Martín-Moreno JM. Cancer prevention policy in the EU: Best practices are now well recognised; no reason for countries to lag behind. J Cancer Policy. 2018 Dec;18:40–51.

14. Schüz J, Espina C, Villain P, Herrero R, Leon ME, Minozzi S, et al. European Code against Cancer 4th Edition: 12 ways to reduce your cancer risk. Cancer Epidemiol. 2015 Dec;39:S1–10.

15. World Health Organisation. National Cancer Control Programmes. Geneva; 2002 Apr.

16. Macklinn-Doherty A. Accountability in the NHS: the impact on cancer care. Ecancermedicalscience. 2018 Jul 19;12.

17. Bull ER, Dombrowski SU, McCleary N, Johnston M. Are interventions for low-income groups effective in changing healthy eating, physical activity and smoking behaviours? A systematic review and meta-analysis. BMJ Open. 2014 Nov 28;4(11):e006046.

18. Sant M, Capocaccia R, Verdecchia A, Estève J, Gatta G, Micheli A, et al. Survival of women with breast cancer in Europe: Variation with age, year of diagnosis and country. Int J Cancer. 1998 Aug 31;77(5):679–83.

19. Kowalski C, Graeven U, von Kalle C, Lang H, Beckmann MW, Blohmer JU, et al. Shifting cancer care towards Multidisciplinarity: the cancer center certification program of the German cancer society. BMC Cancer. 2017 Dec 14;17(1):850.

20. Yang W, Williams JH, Hogan PF, Bruinooge SS, Rodriguez GI, Kosty MP, et al. Projected Supply of and Demand for Oncologists and Radiation Oncologists Through 2025: An Aging, Better-Insured Population Will Result in Shortage. J Oncol Pract. 2014 Jan;10(1):39–45.
    

Jasen Soopramanien's Essay

Introduction

In 2019, the National Health Service Long-Term Plan set out the current challenges facing the NHS regarding cancer treatment (1). One of the major issues identified related to health inequalities, particularly in regard to geographical variations, with one senior executive citing as high as a 3.5 fold variation in access to curative treatment across the country (2). The consequences can already be seen, with a recent report from the International Cancer Benchmarking Partnership demonstrating that the United Kingdom had the lowest 1 and 5 year survival rates amongst comparable nations (3).

Ensuring high quality cancer care in rural communities is a global problem, with studies showing that this subgroup is at higher risk than urban counterparts (4,5). Many cases can go undetected and subsequently untreated due to the difficulty such patients experience in accessing specialty care services (6,7). Therefore, ensuring that access to cancer services in all areas is essential (8).

One way to tackle this issue is through digital health and the rise of tele-oncology. This paper will look at two examples, in the United States and Tanzania, in which tele-oncology can improve outcomes in detection, follow-up and palliative care. The benefits and limitations of each example will be weighed up, before considering the lessons that could be relayed to the NHS.

Case 1: Kansas, United States

Access to healthcare in rural Kansas has long been an issue. In order to tackle this, a team at the University of Kansas set up a tele-oncology service in a remote medical centre, located 250 miles from the nearest large city (9). The team was able to set up a video monitor, camera, microphone and speakers to enable virtual consultations to take place with a specialist Consultant located on the University campus. A healthcare practitioner was placed on site to guide devices, such as an electronic stethoscope, to enable the remote Consultant to perform an in-depth examination (9).

This set-up closely resembles a face-to-face consultation, allowing nearly every aspect of such a visit to take place, apart from palpation of the patient. This implementation was grossly well received by patients, with many satisfied with the improved ease of access to specialist medical care (10). Some patients did state they felt less comfortable not seeing a Doctor in person during the consultation, but these concerns were quickly allayed by having a confident and competent healthcare professional present at the clinic (11).

Case 2: Tanzania

In Sub-Saharan Africa, Doctors had noted difficulty in providing optimal care to palliative patients (12). A worrying trend had arisen with a high rate of palliative patients suffering unnecessarily from poor symptom control (13). The team at the Ocean Road Cancer Institute and Muhimbili University, Tanzania created a mobile app called ‘Mobile Palliative Care Link’, that was designed to enable improved symptom control and quality of life in palliative patients, through ease of access to communication with specialists and regular follow-up (14).

The app allowed patients to report their level of symptom control twice weekly according to the African Palliative Care Outcome scale, kept an up-to-date record of their medical consultations, while also providing an educational module about palliative care and providing emergency clinician contact details. The results showed a 100% agreement between patients and clinicians that the app improved the plan of care, allowed more efficient access to care, prioritised the care needs and improved overall outcomes and quality of life (14). 

Discussion

The two cases highlighted the implementation of tele-oncology in contrasting settings for patients at different stages of the cancer pathway, with both providing essential resources and support to the local community. In Kansas, the high level of technology used enabled consultations consistent with a face-to-face visit, which would be essential in early diagnosis and follow-up appointments. In Tanzania, the mobile app provided a simple solution to improved links with the multi-disciplinary team, simply making the specialists aware of any changes in symptom control early, allowing simple interventions to have a vast impact on the quality of life.

Despite the clear benefits, some limitations must be acknowledged. The set-up costs for the remote clinic in Kansas was incredibly high, particularly for the specialist equipment that would allow remote examination, such as upper airway cameras and electronic stethoscopes. Furthermore, it still relied on the competence of a trained healthcare professional on site for optimal management. In Tanzania, the main limitation arose from reduced network signal at times hindering patients’ abilities to upload their survey results. Furthermore, certain clinicians raised concerns that they were contacted too frequently for non-emergencies secondary to providing their contact details.

Overall, these cases highlight key learning points that can be translated to the NHS context to address a clear shortcoming in the system. Adaptations of both systems could be used within the United Kingdom, with the possibility of hosting digital clinics in remote town halls or general practices and developing smart phone apps to monitor patients. Within the NHS, this could be used to perform virtual initial 2-week-wait appointments, follow-up appointments and even facilitate multi-disciplinary team meetings with the patients and their families.

Conclusion

In line with the Topol Review into Digital Health in the NHS (15), tele-oncology would help to promote improved healthcare outcomes to those most at-need. While this paper has focussed on geographical limitations, many other reasons exist as to why patients struggle to attend in-person appointments, including frailty and reduced mobility, which commonly affects cancer patients. For many, simply the cost of travelling to the major centres can be too much (16). In order to provide equitable care to call, we must utilise digital health more in oncology services. Not only does this improve outcomes for patients, but it would help to save costs in the NHS, by recouping the costs of missed appointments.

References

1. National Health Service. The NHS Long-Term Plan. 2019.

2. Nawrat A. Pharmaceutical Technology. 2019. Westminster Health Forum: challenges facing NHS cancer treatment.

3. Arnold M, Rutherford MJ, Bardot A, Ferlay J, Andersson TML, Myklebust TÅ, et al. Progress in cancer survival, mortality, and incidence in seven high-income countries 1995–2014 (ICBP SURVMARK-2): a population-based study. Lancet Oncol. 2019 Nov;20(11):1493–505.

4. Amey CH, Miller MK, Albrecht SL. The Role of Race and Residence in Determining Stage at Diagnosis of Breast Cancer. The Journal of Rural Health. 1997 Mar 28;13(2):99–108.

5. Higginbotham JC, Moulder J, Currier M. Rural v. Urban Aspects of Cancer: First-Year Data from the Mississippi Central Cancer Registry. Fam Community Health. 2001 Jul;24(2):1–9.

6. Lyle J. Kansas Comprehensive Cancer Control and Prevention Plan. Kans Nurse. 2005;80(6):1–3.

7. Doolittle GC, Spaulding AO. Providing Access to Oncology Care for Rural Patients via Telemedicine. J Oncol Pract. 2006 Sep;2(5):228–30.

8. National Centre for Health Statistics. Healthy People 2010 Final Review. 2012.

9. Doolittle GC, Spaulding AO. Providing Access to Oncology Care for Rural Patients via Telemedicine. J Oncol Pract. 2006 Sep;2(5):228–30.

10. ALLEN A, HAYES J. Patient Satisfaction with Teleoncology: A Pilot Study. Telemedicine Journal. 1995 Jan;1(1):41–6.

11. Mair F, Whitten P, May C, Doolittle GC. Patients’ perceptions of a telemedicine specialty clinic. J Telemed Telecare. 2000 Feb 2;6(1):36–40.

12. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov 12;68(6):394–424.

13. Harding R, Selman L, Agupio G, Dinat N, Downing J, Gwyther L, et al. Validation of a core outcome measure for palliative care in Africa: the APCA African Palliative Outcome Scale. Health Qual Life Outcomes. 2010;8(1):10.

14. Ho YX, Morse RS, Lambden K, Mushi BP, Ngoma M, Mahuna H, et al. How a Digital Case Management Platform Affects Community-Based Palliative Care of Sub-Saharan African Cancer Patients: Clinician-Users’ Perspectives. Appl Clin Inform. 2022 Oct 16;13(05):1092–9.

15. Health Education England. The Topol Review: Preparing the healthcare workforce to deliver the digital future. 2019.

16. Parsons J, Bryce C, Atherton H. Which patients miss appointments with general practice and the reasons why: a systematic review. British Journal of General Practice. 2021 Jun;71(707):e406–12.