Zineb Benbrahim, MD, MPH; Nawfel Mellas, MD; Megan Kremzier, MPH; and Frank D. Ferris, MD, FAAHPM, FAACE
From left to right: Dr. Joe El Khoury, Dr. Frank Ferris, Dr. Zineb Benbrahim, Dr. Hibah Osman, and Dr. Steven Radwany.
ASCO’s educational efforts to empower local professionals have a high impact on palliative management of cancer. This was the case with the International Palliative Care Workshop (IPCW) ASCO held in Fez, Morocco, in September 2017.
Morocco is an Arab country in North Africa. It covers 446,550 square kilometers and has a population of nearly 34 million. The median age is 29.3, and the sex ratio of the total population is split nearly evenly between males and females. Morocco’s estimated gross domestic product (GDP) in 2017 was $110.7 billion. Morocco suffers from both high unemployment rates (9.3% in 2017) and a large external debt, estimated at around $45.7 billion in 2017. About 15% of the population is below the poverty line (2007 estimate). As of 2014, Morocco’s health budget corresponds to 5.9% of the country’s GDP.3
As of 2017, the average life expectancy at birth in Morocco was 77.1 years (74 years for males and 80.3 years for females). The World Health Organization estimates that in 2014, the principal causes of mortality were cardiovascular diseases (34%); communicable, maternal, perinatal, and nutritional conditions (18%); other noncommunicable diseases (14%); diabetes (12%); and cancer (11%).4
Cancer Burden and Palliative Care Challenges in Morocco
There are about 30,000 new cancer cases a year in Morocco. The median age at diagnosis is 63 for men and 55 for women. The cumulative risk is 15.8% and 13.0%, respectively, in men and women. Lung cancer ranks first among men (21.0%), followed by prostate cancer (19.2%). In women, 40.5% of cases are breast cancer, followed by cervical cancer (10.5%). Patients are more often diagnosed at very advanced stages of the disease, emphasizing the need for palliative care implementation in the health care system. In fact, for breast cancers, the diagnosis is made at stages III and IV in 35% of cases, while for lung cancers 95.8% of the cases are diagnosed at stages III and IV.5
Development of palliative care in Morocco has been hindered by a lack of resources, but the future is promising. Indeed, the Ministry of Health and the Lalla Salma Foundation implemented a National Plan of Cancer Prevention and Control (NPCPC). One of the NPCPC’s 2010 to 2019 objectives is to have a nationwide palliative care network and support 100% of patients requiring palliative care.6 The medical schools in Morocco are also introducing courses and advanced training programs to improve the palliative care skills of health professionals. One of these distinguished programs was the ASCO IPCW.
The Impact of the ASCO IPCW
The second ASCO IPCW in Morocco was a collaborative effort between ASCO and the Association of Chifae for the treatment of cancer diseases through the Faculty of Medicine and Pharmacy of Fez and the Hassan II University Hospital. In addition to the typical IPCW, an advanced palliative care workshop was held on days 3 and 4.
Didactic lectures were given to more than 90 participants with diverse backgrounds, including oncologists, radiotherapists, and resuscitation and palliative care physicians. Most participants spend 50% or less of their time delivering palliative services to patients and more than half of their time working with patients with cancer.
ASCO facilitated and supported experts to deliver educational seminars. The workshop was chaired by Frank D. Ferris, MD, the executive director of Palliative Medicine, Research, and Education at OhioHealth. Other experts included Steven M. Radwany, MD, the program director of the Hospice and Palliative Medicine fellowship at Summa Health, and Hibah Osman, MD, and Joe el Khoury, MD, both from Balsam–the Lebanese Center for Palliative Care, in Beirut, Lebanon. The various backgrounds of the faculty ensured a global overview of palliative care, including management adapted to the regional context.
The course featured case-based presentations and interactive sessions on various aspects of palliative care, including pain management, symptom management, end-of-life care, and communication skills.
A post-course evaluation was conducted by ASCO IPCW course organizers on-site as well as through an online survey. Overall data suggest that the course was successful in meeting its educational and behavioral objectives. Most respondents reported an increase in their understanding or ability for each of the educational course objectives, which included concepts and principles of palliative care, early palliative pain and care pathophysiology, pain management, symptom management, communication with patients, and conducting family meetings.
Eighty-six percent or more of respondents reported an increase on each objective.
Regarding behavioral objectives, 91% of respondents committed to making a change to their practice based on what they learned. Commonly reported practice changes related to communication with patients and families, including listening to patients, communicating bad news, and organizing family meetings. Participants listed lack of resources, lack of staff, and lack of time as potential barriers to change. In addition, 12% of participants reported intent to make changes to pain management, and 9% reported intent to make changes to symptom management.
The IPCW courses fostered long-lasting partnerships and friendships and motivated the workforce to provide more palliative care in the country. We plan to evaluate the course impact after 1 year. If a sustained impact is demonstrated, we will plan more courses and encourage more attendees from the Middle East North African region. These additional courses will aim to better serve local needs across the region.
In conclusion, the state of palliative care remains critical in low-resource countries such as Morocco. Collaborative partnerships with international societies such as ASCO may be one of the most effective strategies to educate health care professionals and prepare them to face the challenges of providing effective state-of-the-art palliative care to their patients with cancer throughout their illness experience.
Acknowledgments: We would like to thank Vanessa Eaton, Sarah Bachmann, and Sarah Temin from ASCO for their help in the organization of the workshop and the publication of this paper.
About the Authors: Dr. Benbrahim is an assistant professor in medical oncology in the Faculty of Medicine and Pharmacy of Fez, Hassan II University Hospital, Fez, Morocco. Dr. Mellas is an associate professor, head of Department of Medical Oncology, Hassan II University Hospital, Fez, Morocco. Ms. Kremzier is senior evaluations coordinator in the International Affairs Department of ASCO. Dr. Ferris is executive director, Palliative Medicine, Research & Education, at OhioHealth.