they have started called the Pragmatic Study Design or, you know, basically collaborative studies in low middle income country because it's one of the strategic initiatives of GCIG and Ross Glass Pool is leading on it. I'm on the subgroup as well. And I think there are some talks of doing some sort of collaborative studies using the IGCS platform or IGCS like a Kellyn score or something or the other. So I think even from a platform like GCIG, there is interest, perhaps, to have this IGCS fellows and whether they would want to engage and things. So there is some external groups or people as well. But I'm just thinking something coming from the fellows would be really great just to think that can we do it together. Yes, Dr. Afrey. So, yes, I, okay, we do work in a small setup and I, in Kenya, currently, we've been collaborating with some of the graduate, I mean, as graduated fellows, as well as the fellows in training, we do have these camps. And I think what we want to look at is what are challenges actually in terms of referrals, because some of us are really based at very small centers, where we have extreme resource limitations, you know, so our patients are not able to get the necessary treatment, even if we're able to offer the surgical parts somehow. And then there's the pathology, the chemo, the radio, and all that. So it becomes very difficult. There are lots of challenges from the issues on the ground to monetary to the necessary, I mean, the distance to where these referral centers are situated. And I think it would be good, actually, to see if other centers across other IGCS centers are experiencing the same thing. Because once we finish our fellowship, you know, we train in centers where we have high volumes of gynome cases. These are mainly, okay, I'll speak for Moi Teaching and Referral Hospital. This is a center which is, we have a very high volume of gynome cases, like in a week, we see about 60 to 80 patients in the clinics. And then we have a full theater list, two theaters that we run. We have other dysplasia clinics. So overall, it's like a very busy center, and you get a lot of hands on. But once you finish your fellowship, what then, you know, you've been trained and you want to offer these services, you know, if we don't practice, you lose the skills, and then you have patients on the ground who are extremely poor, your resource centers, I mean, where you're based, have no resources, you know, so now how do we move forward? What's, I mean, yes, you have the training. Yes, you have everything. Now, what do we do next, even if we don't have the resources? And again, in some cases, referrals become a challenge, because the patients themselves are not able to, the little money that would be required for referring these patients, but even if we were to refer these patients to these higher centers, in terms of treatment, again, they would need some sort of health insurance, or some sort of, some money, even if it's a government facility, which is, they don't have. So, is it only us who are experiencing these, what happens after fellowship, you know, and I think it's something that we'd really like to look at, and then of course, see what we can do to at least bridge this gap, you know, because it's very disheartening that you go, you do this, and then you want to go out there, you want to offer your services, and then you're stuck, you know. I couldn't agree more, Efren, that's a fabulous idea, and we want to help you too, like, so, I don't know who's on the call, but Joy, you are a graduated fellow, are you experiencing the same thing? That is true, because now I'm practicing in Mbarara, which is in the western part of the country, and it is a regional setting, and I quite see a number of gyne oncology cases, much as it is not fully, like, established, because where I've started from is a cervical cancer prevention clinic, so I basically don't have, like, space for the admissions, and also limited surgical equipment and space, yeah, so probably similar challenges. I don't know. Yeah, thank you. Okay. Yeah, yeah. I'm curious, Asima and Dr. Settler, what's your thoughts on, like, how would they, how can we turn this into a research project, which actually could actually turn into something that we can help them with as well? Is there any thoughts? We could just all think on this and, like, come back for ideas later too, but I do feel like there is, we have to help graduated fellows and maybe a referral system or something, is somebody doing this in a different setting that's working? Go ahead. Do you have a, I don't know, has anybody done this piece of work, just kind of, like, you know, it's a kind of audit, I suppose, for your IGCS fellowship program, that, you know, who is doing what after graduation, and have they been able to put what they learn in practice, and if not, why? I mean, these are more like an implementation research type of projects, but I just, or an audit project, but has anybody done anything? Do you have a data? Do you know what people are doing? We've done surveys, we've done surveys to see where graduated fellows are and how they are, you know, most of them are very, are still very involved in their current organization, but some of them do go off to other places, so. I think what I want to find out, that you're just putting it in terms of a research paper, would it be a qualitative research or would it be, you know, a survey based something quantitative, how many, I don't know, I have to think about it, I mean, Dr. Sotomayor, you know, the idea is, is it worth, how are we going to, how is addressing this part of this piece of research, which in a way is going to help bridging the knowledge gap? I don't know, I'm just, I have to think about it. You know, the crux of this is that there is enormous inequity in healthcare resource throughout the world. That's what this problem is all about. And I don't think any one of us is going to all of a sudden have a brilliant idea that's going to fix that problem and forevermore we'll get it right. So, we have to, I think, think about this differently and take small steps. And each small step is actually a big victory. You know, this IGCS training program is an enormous success. It's pretty young, but look at the progress that's been made with small steps. Little things that you can do. You have to break it into pieces that are tangible. And it is frustrating because when you finish a training program like this, you still have limited resources. And now you know how to help people and your hands are tied because you don't have the resources to do it. That's even more frustrating. But I'll tell you that the world is a better place today than it was several years ago before the IGCS training program came to be. So, we just have to do what we can, fight the fights that we can, and take pieces that we can do something about. We can't fix everything all at once. So, when designing these projects, we're not going to change how people think about managing ovarian cancer throughout the world, probably. We might, but probably not. But we might be able to drill down to some aspect of some disease to say, how about that? This disease seems to happen more often. That's gestational trophoblastic disease. It's an amazing goldmine in Africa, untapped. You guys have pathology there that certainly I've never seen. And that's fascinating. And there's an opportunity there. So, I think you just have to call. You have to just find the places where you can impact. And you're not going to impact everything. That's great. Actually, GTD is very... Go ahead, Dr. Eugene. Go ahead. Good morning and good afternoon. So, I was in the operating room. That's why I joined late. But I think I was following. It was good conversation and good input on some challenges in the low-resource settings. But the first of this kind is that the IGCS is providing everything possible so that the patients with cancers can be treated. So, we can't get all the necessary equipments or everything at one hand. But at least the human resource in the developing countries is more available. And even the ones that would advocate for getting all these equipments that may be needed or the drugs or the medication or putting at least the screening services at their centers. Because as you know that WHO and other stakeholders, they want to eliminate at least cervical cancers in the low-resource settings. So, it is these ambitions that we can use. And then at least if we do screening and treatment of pre-invasive diseases in these settings, you are able to reduce the burden of cervical cancer in our settings. So, I think the first and important thing is to get the knowledge. And then after getting the knowledge, you can transform story by story as the countries are growing in terms of income and in terms of human resource. So, I think there is no bad things to at least get more people trained to manage the cancers. As I can say here in Rwanda, this is the first of its kind. We don't have gynecologists and now through IGCS we are getting some. So, this that we even have to care for other people in the region. So, I think it's very important for us and for the region to have gynecologists. So, maybe about my projects that we discussed about cervical cancer, I mean the patient with gynecological cancer screening for nutrition. After having a discussion, I did a major review of the project and I now submitted for IRB, for Institution Review Board Review. So, I'm waiting to get the results and then I can start collecting data. So, I will maybe come after getting the IRB so that I can start collecting data. So, I'm trying to start my project as soon as I get the IRB approval. So, thank you for this discussion. That's very well said. Great, thank you. Asima, are you going to say something? Oh, you're on mute. Asima, you're on mute. I'm just kind of bubbles I think now in my brain. I'm just kind of thinking that, you know, it's just that even that collective voice of what you think should be the steps to implement the things that you learn in an adverse, you know, resource for or in your setting. I mean, people could be creative in thinking that, you know, this is not the standard way of doing things or setting up things may not work. But if I did this or I thought about this, I mean, you know, advocacy, reaching out. I'm just kind of, I have to think, but I'm just trying to think that sometimes these are opportunities to think outside the box. I mean, you now are empowered with the knowledge, but you can't do the things. So, basically, you have to do the things in a slightly different way or set up things in a slightly different way. And whether that is something, you know, just think about if you can't do screening this way, is it like you, I mean, you know, and an example is like when we hear in Nepal. Eco board that you know how, when you don't have frozen section. Can you implement a touch print cytology which is so easy to do for certain things. And or if you can't, if you don't have this can you do an alternative method of doing things. So I think these are some of the thoughts if you just scratch your brain and think about that maybe this is another way of doing things, just kind of thinking. Opportunity, isn't it. I think, to think differently. Yeah, I think maximizing the resources that you have recognizing that the resources you have are not exactly optimal, but making the most of it. It's an open book about whether or not those guidelines are really as thoughtful as they really should be, because whoever wrote them didn't necessarily know what it's like to be boots on the ground. When both hands are tied behind your back, you know, that's different story so tweaking that is an area of opportunity. And then I, as I have been part of these echo sessions. Quite often, what's come up is perhaps an example of somebody with advanced cervical cancer who has bilateral hydronephrosis, and they can't find a urologist, and they can't. Well, you know, when your resources are that limited. Believe it or not, doing the nephrostomy is not that difficult if you have an ultrasound, which just about everybody has. And so, you know, get doing a cervical nephrostomy. Poor man's percutaneous nephrostomy, but look at the results you tap that you know you decompress the urinary tract, you're able to give them sensitizing chemotherapy, and it took you about 10 minutes, because you're able to do that. And you're able to do that. And so, you know, get doing a series of your own, you know, percutaneous nephrostomy, poor man's percutaneous nephrostomy, but look at the results you tap that you know you decompress the urinary tract, you're able to give them sensitizing chemotherapy, and it took you about 10 minutes, because. And so you see, I think that it seems making the same point that there are these special opportunities where you just have to look beyond the limitation. Like the problem, yeah, you don't have the urologist know the problem is patient has bilateral hydro nephrosis. The solution is to unblock the hydro. Now, learn how to do it. And it's not hard, you have the resources at your disposal. And this can amplify into a million other scenarios in medicine, but there's one that I can think of that's come up. And most of the time people feel their hands are tied and patient dies. And actually, to go back to your other point, Dr. Stella about GTD, we get one of the who's on here from Nigeria, we are working with the group from Europe, and I SSD, and they are going to help them create a GTD. You know, center, so that all cases can come from Nigeria to the center. So, in the US and I think in Europe and whatever they have that if you ever get a GTD case it always goes to them, but I don't think in Africa, you have that. And it is something. I do want to just make a slight comment about the GTD thing in America, it's become so cookbook that it's only the refractory or the difficult case that gets referred most OBGYNs know how to treat low risk GTD, and they do. So in Africa, we'd love to see that it gets to that point where most of it is handled locally. But there, I think you're right to have these referral centers that are convenient and everybody knows about it. That will do a lot to improve the health people in that content. I mean, just kind of coming to Dr Stella's point I mean I was part of producing this resource stratified ASCO guideline on ovarian cancer, or, you know, pelvic masses and I think ovarian cancer, but, you know, just to kind of also think that how much is it applicable, actually, the adherence to the guidance, even where it matters, I think, I mean, there are a lot of things, actually, and thinking differently for each scenario. I mean, just kind of my example, I mean, in India, we people were randomly doing BRCA testing, but nobody was getting counseled. So we trained a group of nurses, you know, you know, basic, but whatever, to kind of develop a nurse led genetic counseling program, because the nurses are, you know, like stable in job, they don't move around, you have from primary to tertiary care, and nurses everywhere. So even to spread the awareness or counseling, so that we only did, or we had the idea because we don't have any trained genetic counselors in our country, or, you know, very less. So these are like alternative ways of doing certain things. And, you know, the hydronephrosis, what you're saying is another important thing. I mean, same in India, I was I'm just kind of thinking now. Dr. Amina, you have your hand raised. Yes. So Susan mentioned the, in Nigeria, they're trying to create the GTN center. And that really piqued my interest, because in Kenya, most of the times the patient, so the first contact, like Dr. Sela has just pointed out, the OBGYNs are able to treat, but then in our country, most of the times what you find is even when these patients are treated, so you'd have a high risk, or an ultra high risk patient who gets a single agent, while she should actually be on a multi agent treatment. And by the time they really get to us, these are patients who are very sick, who have a very high score, who have metastatic disease. And many times they die from the disease, because when I looked at so I have a manuscript, I'm just, I've just finished working on. And we've lost, in the last 10 years, we've lost 20% of the patients we've treated. And then we've always wondered, how can we have a GTN center, so that the patients can be referred there. And then that would probably maybe create avenue for more teachings, more CMEs, and people would actually learn what to refer, what to treat, how to go about things. So I'd really love to, to learn from Susan how they've gone about having the GTN center, because that's been shown to reduce mortality significantly in most of the studies. And this is the beauty of this group here. I mean, this is what I really want to see is for the Nigeria group to share this with your group to see how they're doing it. And honestly, I mean, it came out of an echo, it came out of an echo that one of the people just happened, one of the people from the Europe office happened to be on and he said, how can we help? And then he's like, that's how it started. So if you have that need as well, then we can, you know, I can talk to, it's Dr. Coulter, he's joined the, he joins the Jamaica Echo, and he's now joined some Nigeria Echoes. But we have a group at ISSTD and the Europe group, and they are all happy to collaborate and help. So I can talk with them, what we're planning on doing now for the Nigeria group is to have a, because they can't travel there, so they were going to do an online course. So that online course that we could say, okay, can we invite everyone from your group to join that course? But this is the beauty of this course. Yes, it's research we want to do, but also how can we help each other with what, what things you're doing in your country to improve? So Amina, email me and I will talk to Dr. Coulter about that. I will definitely do that. Thank you so much, Susan. Yeah, you're welcome. And that was your research project, how this started. Go ahead, Asim. I was thinking, even like, you know, if you can do a good, you know, some, what type of ovarian cancer surgery are you being able to do at your centers? Is, what are the barriers? How do you, I mean, there are a lot of things, I mean, you know, like, you know, when I was trying to set up cytoreductive surgery services, I mean, you know, it was such a big thing, but then the GI people, the gastrointestinal surgeons, they have been doing Whipple's operation. So, you know, it's not necessarily they had that sophisticated HDU-ITU backup, but they managed to do a Whipple's operation for so many years. And that was good enough to translate that sort of experience to the ovarian, or the kinds of surgical setup that, you know, maybe when people say that you can't, you don't have, you know, high end HDU-ITU to do these sort of surgeries, but you can actually do a lot. Still, if you, if there are people around you who have managed to do this sort of surgery, so there are, there are a lot of things to think about. I mean, as I say, it's just, yeah. So just an idea, as Dr. Stella said, so maybe if all the fellows could go back and have a look at the NCCN guidelines, and see which areas would, might need some changes, maybe then in the next meeting, we can come up and see how many people have found out how many things that might bring a change. And we can discuss about that, and maybe that can turn into a paper or a publication somehow. Because those guidelines are huge, but like, if we start from something, then something might turn up later on. Afrin, you had your hand raised, go ahead. Yeah, I just wanted to, just what Dr. Sima said, the ovarian cancer surgery. So here in Kenya, what we don't do a lot of upper abdomen surgeries. And it's very difficult, we've not even observed, I mean, once in a while, but it's very difficult. And I think it would be very interesting if there was a way we could at least, you know, have a in a while, but it's very difficult. And I think it would be very interesting if there was a way we could at least observe some of these surgeries, even if it means online, or if you could share some videos with us where we can try. I know we don't do it because again, the same issues that Dr. Sima said, you know, if you use post-op care for the patients, our equipment, our retractors, so it's a bit difficult for us to do upper abdomen surgeries. And we would be very much interested in doing, I think when I say this, I say this for all the fellows and graduated fellows, we've had quite an issue with that. Has anyone here looked at SurgeryU? It's part of being an IGCS member. You can go and look at all kinds of surgeries on SurgeryU. Do you know about that? Are you aware of that? Looking at something different, but then, you know, real how to do it practically on grounds, because it's just not the surgery, it's the perioperative environment. I mean, on the top, on the anesthesia, the nurses, and you know, there's so many other things which we are trying to create, like it's a research project on virtual learning platform for doing a lot of procedures. But I mean, yeah. It's my interpretation, and my interpretation may not be correct, but having visited and been participating with the various ECHO sessions, most of the time I find that the surgical capability in resource or settings is sometimes even better than the surgery that I've seen done in America. I think where trained gynecologic oncologists can be of value is in patient selection and, you know, recognizing the limitations of surgery for advanced disease where you want to do something, but surgery may not be, actually it might expedite someone's death. So selecting the right patient to operate on. But I find that the quality of the surgery sometimes is breathtakingly good in these low resource settings, because most of the places have really fine-tuned that because they can do it. That's a resource that a lot of places have. So I think patient selection is a big thing. And then, you know, the issue that you raised, Tasima, about the perioperative setting, you know, the planning, the patient selection is, to me, the most important. And then, you know, you have the limitations on the backside of what adjuvant therapies might be available. But I did want to put a plug in, though, that most of the places that I have participated with ECHOs do a fabulous job with surgery. Great. Again, I would like to tell everybody, please, please go and have a look at the didactic. There is a very good didactic on qualitative indicators in cytoreductive surgery that was given, and it has various types of information on surgeries and also, like, handbook that was, I think, given by Dr. Asima. So you can have a look at that as well to kind of have a basic idea. And then maybe, as Susan said, you can look at that as well. So those are very good informations that are available already in the IGCS website. So just have a look. Yeah, but I think maybe patient selection is a great, like, I think that actually would help a lot of things, actually, with referrals and things like that, too. You know, if you're in some of these lower, like, to go back to the earlier conversation, if you're looking at patient selection, who's the one that gets moved up to a referral right away? Well, this ties into the NCCN guidelines, and they're really algorithms. It's just kind of follow the bouncing ball. Patient goes into this box and that box, and this is what, you know, you do. But I still think that those guidelines for low-resource settings could definitely use some tweaking, especially with input from people who are used to having both hands tied behind their back. You know, I think that that would be highly valuable. And then it helps to inform the patient selection, what you do in these situations when you have limited resource. Yeah, so you are very true that this is also happening in the low-resource setting, that sometimes the best thing is the patient selections. And sometimes you may go in for an ovarian mass, and you find that's advanced disease, where we don't have a human resource that can even manage if you put the stoma on the patient. So we just do, like, remove the disease and then you give neoadjuvant chemotherapy, and sometimes you come for an interval debarking after the tumor has subsided, has reduced in volume. And this helps the patient, even if you are not able to do the complete cytoreduction at the first time. And also, we face, like, challenge of frozen sections during surgery to know, I'm going to do the complete staging, or is it a benign disease that don't need this? But it's a challenge. Sometimes you need to go back for complete surgery after you have done the first surgery. So the limitation is there, but as the settings is there, we always need to have to try to think about the next option for our patients. That's how we are doing it. Thank you. Great. Thank you. Any other? I know we have five more minutes. So this has been a great call just to kind of discuss, this is really what we want to have. Let's just discuss what potential ideas can come out of this group. And if Eugene, you do something, then maybe that will spark the interest in somebody else doing something in their country that will actually help the patients. So I think having conversations like this is a great way. But then just putting it pen to paper, what am I going to do with this? After this discussion, what are we doing? And then like bringing that to the group, letting us know what you're doing with that so others can learn from how you're doing it and how you're going about it. And working with Dr. Sim and Dr. Steller to say, is this the right way to go about it? What, you know, let me work with, am I doing it, approaching it the right way? So I think that's all very helpful. So I think from today, I think, you know, if you say some action points, so one is that we will start looking into an audit of our progress from our recommendations made last year. And I think that can easily be translated to a paper coming from our research publication group, but I think now is due for perhaps some activity in doing. Then ideas, I suppose, looking into the NCCN guidance and applicability or I need to find, you know, we need to or somebody can take leadership of finding out how to frame the research question or what sort of paper will that lead to. Ideas, I think the GTN you have told, then Dr. Steller's idea of whether that is a potential research project that we can think about, or the views or survey of hydronephrosis management of, you know, stage 3B or cervical cancer with hydronephrosis. What else did we think about ideas? Anybody else? Patient referral, patient referral options. I mean, that's part of the NCCN guidelines you say, Dr. Steller, that's all in there. Yeah. And then, you know, it's about what the IGCS fellows are doing. I mean, the roadblocks of practicing gynae oncology after being after training and, you know, mitigating strategies, I suppose, or, you know, I would think about applying the knowledge of what you learn in a fellowship program when it comes to implementation. Anything else? No, a lot of ideas, a lot to cover, but I like Dr. Steller's idea, just start small, start with one thing, and then it could, you know, by Amina, if you did something, or sorry, Afrin, if you did something on what's happening in your setting after you graduated, and maybe small improvements that you made based on your knowledge, then that can help future fellows, and, you know, it could snowball from there, too. We can do a survey on that, you know, just think about, you know, so maybe design something, circulate the questions that we're going to do in the survey, how we, you know, the way the surveys are generally created, whether we have some qualitative points, qualitative text box, whether there are some quantitative data in it, we can think about how to go about it. Anybody willing to brainstorm? I mean, you know, put it in the wider group as well. We could do it like a Google Doc, and people can just add questions to it, and then we could all compile it. Yeah, absolutely. Actually, that's a great idea. Let's just do a Google Doc, or actually it could be, go ahead, Seema. That's a very valid way of assessing, you know, the outcome of a fellowship program, I suppose, in other ways. Yeah. And then I will also, I know, surgery U, I tried to log into it just to show you guys how to get into it, but I'll send that to every, I'll send it to all fellows and graduated fellows how to get into it anyway, because there are all kinds of surgeries. You can just type it in, and then you'll be able to see a surgery. But to Dr. Sellers' point, you probably already know how to do surgeries. You all do know how to do surgeries, but there might be some technique you could learn on there as well. So I'll send that to everyone. Anybody else? Any comments? Any other comments? Donna, just for two minutes, did you manage to put up that screen just to kind of, yeah, it's like one look, and I just, so let's just refresh our memory that how many were submitted for our reviews and what happened with them. If we don't know, we just say don't know. Eugene is on the call, so he's... Dr. Eugene, any update on your paper? As I said, I presented my paper on the Institutional Review Board, and they told me to put some review, and then present it back. So I've done it, and then I've sent it to the Institutional Review Board, and then I'm waiting for the results so that I can start doing my research. Probably, maybe, if you want, I may send to you again the manuscript so that you can look at it, and how I did my review after presentation to IRB. So I'm still working on it, and then I hope to start maybe collecting data in the next one month or two months after having an Institutional Review Board authorizing me to continue with the research. That's great. So that means outcome is that after discussion in our IGCS forum, you have had some inputs to progress to the Ethical Board, right? Yes, yes. That's great. And then... I think Dr. Offring is also there. Hi. So I submitted my cervical cancer manuscript to DOR. I'm still awaiting the response. It should be in the next couple of weeks. The other one, the Every Woman's Study, I'm still drafting the manuscript. So last time I shared the abstract for the same. So once I'm done with the manuscript, I'll share that. So I'm working on the manuscript for the second study. Great. Then, next, what do we have? We don't have Dr. Christopher. Dr. Hosnia is also not there. Dr. Aisha, your hand is raised. Do you want to say something about your paper? Yes. Yes, thank you very much. Sorry, I was just able to join now. I was in clinic. So, yes, I was so impressed with the input from the IGCS research team at a very short notice. And they were able to help me correct my abstract, and I was able to submit it to the IGCS, and it was accepted. So I'll be presenting it at the next IGCS conference in Seoul. And I've also worked on the manuscript and sent it out to a journal, and it's being considered. Thank you. Over. That's great. Great news. Congratulations. Thank you very much. Journal, did you submit to? It's a journal in Nigeria, the Nigeria Postgraduate Medical Journal. Yes. Thank you. Great. Anybody else? Dr. Philip, I don't think they are here. Dr. Foley is here. Dr. Foley, any update about your paper? Yes. Mine was also accepted. The abstract was also accepted. And the IGC? IGCS. Annual meeting. Yes. So Dr. Foley, Dr. Aisha, I'm working on putting something on our website for any fellows or graduated fellows, abstracts that were accepted. So we'll figure out some place to put that on our IGCS annual meeting and then for all. For future as well. So we'll figure out a place to put everything. Thank you. Thank you. And for the rest, we don't have updates yet. But we can chase that up. I think this is good for our audit. Yeah. It's fabulous. It's great work. See, we started small. A year ago. And look at what's happened. That's great. Every little thing counts. It does. That's for sure. And like I said, We'll be able to put this in a place for all of you to see so that you can go back and look and see what others have done. See if it applies to you. See if something you can do in your setting. So. Just keep going. Thank you to Dr. Stella and Dr. Seema and Donna for. Great work. Thank you.

collaborative studies

research projects

low and middle-income countries

gynecologic oncology

resource-limited settings

patient referral systems

surgical techniques

patient outcomes