Keywords:
Oncology education - Brazilian Medical schools
Descritores:
Oncologia - Graduação - Escolas médicas brasileiras
INTRODUCTION
The World Health Organization estimates the incidence of more than 18 million new
cancer cases annually and has warned the international community about a fast increase
for the upcoming decades[1]. In Brazil, for the 2020-2022 triennial, the Ministry of Health estimated the incidence
of approximately 625 thousand new cases annually.[2]
Only low- and middle-income countries have currently a higher percentage of deaths
from communicable diseases rather than from noncommunicable diseases. It is estimated
that, by 2030, almost all countries will have gone through the transition to a profile
with a higher prevalence of non-communicable diseases.[3] The Brazilian epidemiological shift is expected to occur until 2033, based on data
from the Mortality Information System (SIM) and the National System of Notifiable
Diseases (SINAN).[4] Currently, the leading cause of mortality in the country is cardiovascular disease,
closely followed by cancer[5]. In approximately 10% of Brazilian cities cancer is already the first cause of death.[6] This scenario demands that health professionals, from all health care layers, should
be able to implement primary prevention, early diagnosis and cancer patient support.
This is the most effective and affordable strategy with the potential to impact on
cancer incidence, morbidity and mortality in the country.
Despite this unquestionable and growing need, there is a gap in Brazilian health professionals
Oncology training, as alerted by Silvestrini et al
[12] and by the Brazilian National Cancer Institute (INCA)[7].
Different aspects of oncology are usually covered by various disciplines throughout
medical graduation, as cancer involves multiple fields of medical practice. However,
this approach usually occurs in a fragmented way, with a very specific focus, making
it complex for students to build a comprehensive knowledge. Consolidating the main
oncology subjects around a single discipline in medical graduation is essential.
A working group between the Federal University of Minas Gerais and the Brazilian Society
of Clinical Oncology (SBOC) was developed in order to evaluate the teaching of oncology
in Brazilian medical graduation courses. The present work comprises a quantitative
survey of the current panorama on Oncology disciplines offered by medical graduation
courses. The present evaluation aims at supporting future directions for better Oncology
training in medical schools in Brazil.
METHODS
A descriptive review of the curricular program and pedagogical plan of each medical
course in Brazil was developed.
The data were listed in a spreadsheet and characterized as the frequency for variables
of interest in order to chart the portrait of oncology teaching in Brazilian medical
schools. A georeferenced map was built, with Khartis 2.3.0 program, for a better graphic
projection of the oncology course distribution throughout country.
RESULTS
The list of registered and active Brazilian medical schools in 2019 was assessed by
consulting the portal of the National Registry of Courses and Institutions of Higher
Education, e-Mec (https://emec.mec.gov.br/). The course program and pedagogical plan were obtained on universities/institutions
websites. For institutions where it was not possible to obtain those documents through
the institutional website, two attempts of each, either email or telephone, were done
trying to acquire the data.
Oncology or Cancerology or other subjects that jointly addressed the following topics
in the programs were considered in this analysis: epidemiology of oncological diseases;
basic concepts of oncogenesis; cancer pathology; prevention and early diagnosis; and
basics of treatment. The review of the course program consisted of obtaining the following
data for each institution: Brazilian state of the institution, administrative sphere
(private or public), presence of oncology disciplines and if it were mandatory or
optional.
We also assessed extracurricular strategies that promotes complementary oncology education.
The presence of study groups, also called academic leagues, was evaluated. The list
of active and registered oncology academic leagues in 2019 was obtained through the
Brazilian Association of Medical Leagues.
It was identified 345 medical schools registered in Brazil, according to e-Mec portal
(data from November 2019). 41 institutions from this total were excluded from the
study because they had no classes in the clinical cycle until the end of 2019 (those
are new courses that started between 2018 and 2019). 50 medical schools did not have
available information about the course program and/or pedagogical plan on their websites
and did not respond to the contact attempts. Therefore, the curriculum of 254 medical
schools were analyzed ([Figure 1]).
Figure 1 Number of medical schools assessed in the study.
Characterization of participating medical schools
The 254 medical schools that were included in the survey are geographically distributed
in the country as shown on[Table 1]
. Concerning the administrative management, 117 schools are public and 137 are private
([Table 1]).
Table 1
Characteristics of the evaluated medical schools.
|
Characteristics
|
Number of Medical Schools
|
|
Region
North
|
22 (8,7%)
|
|
Midwest
|
23 (9,0%)
|
|
South
|
49 (19,3%)
|
|
Northeast
|
51 (20,1%)
|
|
Southeast
|
109 (42,9%)
|
|
Administrative management
Public
|
117 (46%)
|
|
Private
|
137 (54%)
|
|
Total
|
254
|
Characterization of the Oncology discipline offer
Regarding oncology discipline among the medical schools evaluated, 58.7%, do not offer
the subject in their curriculum. Only 41.3% of the studied medical courses officially
have the discipline in their medical curriculum ([Figure 2]).
Figure 2 Offer, modality and average workload (WL) of Oncology disciplines in the medical
schools.
Among the 105 schools that offer oncology discipline, 91 (86.7%) offer it as mandatory
and 14 (13.3%), as optional. The average workload in oncology, including theory and
practice, is 57 h in mandatory disciplines and 48 h in the optional ones ([Figure 2]). It was observed a tendency towards a modular approach (such as Problem Based Learning
methodology, PBL), however, the teaching approach was not contemplated in the present
study.
The evaluation between the administration system and the offer of oncology disciplines
showed that the presence is higher in public medical schools. Only 36% of the evaluated
private schools have the specific discipline at their courses ([Table 2]).
Table 2
Distribution of the offer of Oncology disciplines by administrative system.
|
Administrative responsibility
|
Yes
|
No
|
Total
|
|
Public
|
55 (47%)
|
62 (53%)
|
117
|
|
Private
|
50 (36%)
|
87 (64%)
|
136
|
Regarding the geographical distribution of medical schools that embrace the discipline,
there is a predominance in Southeast (45.7%) and South (22.9%) regions, mainly in
São Paulo, Rio de Janeiro, Minas Gerais and Paraná. There is a strong shortage offer
in other regions, with emphasis on the Midwest and North regions, with only 4.8% and
5.7% of the institutions, respectively ([Table 3] and [Figure 3]).
Figure 3 Geo-referenced map of the oncology disciplines offers by Brazilian state.
Table 3
Distribution of the offer of Oncology courses by demographic region.
|
Demographic Region
|
Number of schools offering Oncology discipline
|
|
Midwest
|
5 (4,8%)
|
|
North
|
6 (5,7%)
|
|
Northeast
|
22 (20,9%)
|
|
South
|
24 (22,9%)
|
|
Southeast
|
48 (45,7%)
|
|
Total
|
105
|
Characterization of oncology academic leagues offer
There are 77 active oncology academic leagues in Brazil in 2020, according to the
Brazilian Association of Medical Leagues. A predominance of leagues is observed in
states in the Southeast region (46.75%), mainly in São Paulo, Rio de Janeiro and Minas
Gerais. There is a shortage of oncology leagues in the other regions, with emphasis
on 8% in the Midwest and 4% of the North regions' institutions have registered oncology
leagues ([Figure 4]). The number of active leagues described here is probably underestimated because
registration with the association is not mandatory, but it seems that the number of
oncology leagues correlates to the discipline offer in the country regions.
Figure 4 Geo-referenced map of the presence of oncology student groups (academic leagues)
by Brazilian State.
DISCUSSION
Cancer is an evolving threat expected to become the main cause of death in low- and
middle-income countries, such as Brazil, by 2030. According to the GLOBOCAN, there
are approximately 9.6 million cancer deaths worldwide yearly[1]. In Brazil, the annual cancer mortality data is from 2015, when the Ministry of
Health reported about 210,000 deaths from the disease per year[9]. In this perspective, the need to act towards prevention, early diagnosis, treatment
and support for cancer patients is critical and makes the adequate training of health
professionals a priority.
The results of this study corroborate the existence of a gap in Brazilian medical
education. The analysis carried out showed that only 41.3% (105) medical schools offer
oncology or related disciplines in their curriculum, with 13.3% of them offering the
discipline exclusively as an optional training. A second critical point is the limited
number of hours dedicated to oncology, averaging 57 h in mandatory and 48 h in optional
ones. This workload is significantly smaller when compared to other classic subjects
in the curriculum. As a consequence, a significant percentage of recently graduated
students (87%) consider the teaching of oncology insufficient during their academic
path, as described by Ferreira et al.[10].
The correlation between schools that have oncology disciplines and the administrative
system shows that oncology education is more prevalent in public medical schools (47.8%).
This phenomenon can be understood, in part, due to the exclusive fulfillment by most
institutions of the minimum curriculum of the Brazilian National Curricular Guideline
2014[11], which does not include the mandatory teaching of oncology in medical training.
The geographical distribution of schools that teach the discipline of oncology in
Brazil reveals a predominance in regions that concentrate the majority of new cancer
cases in the country[2]. However, there is an alarming lack of specific education in oncology in other regions,
with emphasis on the Midwest and North regions, as shown. In these regions, the incidence
of preventable cancers[2], such as cervical cancer, has a huge impact on the population and could be particularly
decreased with better medical training in oncology.
Although still far from ideal, it is important to point the recent increase in the
number of institutions which offer oncology disciplines. In 2012, Silvestrini et al.[12] reported a worrying scenario in which only 30% (33 schools) of a total of 110 institutions
included the approach of oncology themes in their curriculum. At that time, there
was already a clear concentration of these schools in the South and Southeast regions.
The majority of schools that offer oncology disciplines are still the public ones
(39.4% in 2012 and 47% in 2019), even with a significant increase of private institutions
in the last years. It is worth mentioning that there are differences in methodology
between the present and Silvestrini's previous work, but this does not preclude the
observation of the temporal improvement.
A growing approach to oncology themes through nontraditional methods has been observed.
Although not included in this study, a tendency of modular approach (Problem Based
Learning methodology, PBL) of oncology topics, such as prevention and early diagnosis,
were observed. In several institutions it was evaluated that the autonomous search
for knowledge of oncology[10], through academic leagues and extracurricular activities, tools designed to overcome
the curricular restrictions exposed here. The existence of 77 academic leagues corroborates
the students' perception about the insufficiency of oncological topics in the standard
curriculum, requiring the search for complementary training. It should be noted that
the presence of extracurricular activities does not replace the need to include oncology
subjects in the obligatory curriculum.
CONCLUSION
There is an alarming gap in Oncology training in Brazilian medical schools, and tackling
this issue is essential to improve cancer control in the country.
Bibliographical Record
Angelica Nogueira-Rodrigues, Ronniel Morais Albuquerque, Renan Orsati Clara, Ana Gelatti,
Augusto Cesar de Andrade Mota, Bruno Pacheco Pereira, Daniela Dornelles Rosa, Igor
Alexandre Protzner Morbeck, Maria Fátima Gaui, Maria Ignez Freitas Melro-Braghiroli,
Rafael Aliosha Kaliks, Rodrigo Ramella Munhoz, Sandro Roberto de Araújo Cavalléro,
Vladmir Cláudio Cordeiro-de-Lima, Clarissa Maria de Cerqueira Mathias. Oncology education
in Brazilian medical schools. Brazilian Journal of Oncology 2020; 16: e-20200037.
DOI: 10.5935/2526-8732.20200037
