2 CME REVIEW ARTICLE

Volume 74, Number 1

OBSTETRICAL AND GYNECOLOGICAL SURVEY
Copyright © 2019 Wolters Kluwer Health,
Inc. All rights reserved.

CHIEF EDITOR'S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of
36 AMA PRA Category 1 Credits™ can be earned in 2019. Instructions for how CME credits can be earned appear on the last page
of the Table of Contents.

A Review of Gynecologic Oncology in the

Global Setting: Educating and Training the
Next Generation of Women’s
Health Providers
Stephanie A. Sullivan, MD,* Elizabeth Stringer, MD, MSc,† and Linda Van Le, MD‡
*Clinical Fellow, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and †Associate Professor, Division
of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina Hospitals; and ‡Leonard D.
Palumbo Distinguished Professor, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of
North Carolina Hospitals and Lineberger Comprehensive Cancer Center, Chapel Hill, NC

Importance: Women in low- and middle-income countries (LMICs) are responsible for the stability of their fam-
ilies. Child survival is directly linked to the health and well-being of their mother. Cancer is the leading cause of
morbidity and mortality worldwide, and the incidence and mortality for women from cancer are projected to in-
crease over the coming decades. Gynecologic cancer outcomes are improved when women are cared for by
a gynecologic oncologist; however, there are limited specialized providers in LMICs. Increasing interest and in-
volvement from specialists in the United States will improve partnerships abroad and the care of women worldwide.
Objective: To summarize the importance of global gynecologic oncology care and the current data for US
trainees in obstetrics and gynecology to participate in clinical and capacity-building opportunities.
Evidence Acquisition: We performed a PubMed literature search for articles pertaining to the topic of global
health education in obstetrics and gynecology and gynecologic oncology specifically.
Results: Many obstetric and gynecologic residency programs offer international opportunities, but these are
less than those in other specialties and are more frequently focused in obstetrics. Many gynecologic oncology
fellowship programs offer international experiences for fellows; however, the time and resources required are lim-
ited. Several US and international programs are ongoing to improve capacity building for gynecologic oncology
in LMICs with local trainees.
Conclusions and Relevance: Training and care in gynecologic oncology care worldwide are improving
through efforts at multiple levels. Continued efforts are needed to improve US trainee international education
and experience.
Target Audience: Obstetricians and gynecologists, family physicians
Learning Objectives: After completing this activity, the learner should be better able to examine the unique
role of women in LMICs; identify the limitations in gynecologic oncology care in LMICs; value the importance
of global health exposure during medical training for U.S. physicians; and analyze initiatives that can improve
training in gynecologic oncology for global providers.

All authors, faculty, and staff in a position to control the content of
this CME activity and their spouses/life partners (if any) have disclosed
that they have no financial relationships with, or financial interests in,
any commercial organizations relevant to this educational activity.
Correspondence requests to: Stephanie A. Sullivan, MD, Division of
Gynecologic Oncology, Department of Obstetrics and Gynecology,
University of North Carolina Hospitals, CB 7572 170 Manning
Dr, Chapel Hill, NC 27599. E-mail: steph.adele.sullivan@gmail.com.
www.obgynsurvey.com | 40
WHAT IS GLOBAL HEALTH?
Global health as a discipline accounts for health is-
sues that transcend national boundaries, require global
cooperation for solutions, and stress the importance
for equity of health. Global health focuses on both clin-
ical care of individuals and prevention of disease in

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 A Review of Training in Global Gyn Oncology • CME Review Article 41

populations.1 Unlike international health, global health
encompasses all populations, with a special focus on
those living in areas with health disparities, which most
often occur in low- and middle-income countries
(LMICs) (Fig. 1).2 While LMICs make up only
38% of the world's economies, nearly all newborn
deaths, the majority of cancer deaths, and deaths from
noncommunicable diseases occur in these countries.2–4
Poor health leads to destabilized families and unreliable
economies and ultimately will have impact on global
security and freedom. Thus, in addition to our basic
core values of compassion, empathy, and generosity to-
ward others, there are economic, social, and security
reasons to improve global health.
Global Women's Health
Women in LMICs play a crucial role in their families
as members rely on them for a number of roles beyond
what is recognized in higher-income settings. Women
are primarily responsible for providing water, nutrition,
and a healthy, safe living environment.5 The survival of
children in LMICs has been found to be predicated on
survival of their mother.6,7 Young children are more
likely to die in the months leading up to their mother's
death when she is seriously ill and unable to care for
her child.8 When accounting for household chores and
childcare, women work longer than men by 30 minutes
in higher-income countries and by 50 minutes in
LMICs.9 Employed women are more likely than em-
ployed men to be contributing family workers by a mar-
gin of 20 percentage points.9
Given the pivotal roles that women play worldwide,
any illness that limits a woman's productivity impacts
the stability of her family and community.5 Before
antiretrovirals were available, the human immunodefi-
ciency virus (HIV) epidemic increased a woman's risk
of dying in pregnancy or the postpartum period and in-
creased preterm birth and the risk of a woman acquiring
a gynecologic cancer. When treatment became widely
available, maternal and infant survival improved, and
the detrimental effects of the HIV epidemic on a
population's economy have been mitigated.10,11 For
this reason, improvement in global women's health
enhances not only an individual's personal health
but also the health of families and communities.
Women have unique health concerns and deserve spe-
cialized services such as pregnancy care, family plan-
ning, and screening for malignancies. Not all women
are afforded access to a provider specialized in their
needs, and this limitation is particularly pronounced in
economically disadvantaged areas.12 Because of the
unique role women play in LMICs and the far-reaching
implications of poor health, specialized women's health
providers have a distinct opportunity and responsibility
to improve global women's health.
GYNECOLOGIC ONCOLOGY AND
GLOBAL HEALTH
Women's health interventions in LMICs have histori-
cally focused on prenatal and obstetric care as well as
family planning. There has been a recent call, however,
to increase gynecologic services including the preven-
tion and treatment of gynecologic cancer care by a
number of organizations such as the World Health Or-
ganization, Lancet, and the International Gynecologic
Cancer Society.13,14 Vesicovaginal fistula as a result of
obstructed labor is a significant gynecologic problem
for women in LMICs. Patients who suffer from this

FIG. 1. World Bank classification of country by income. World Bank classification of the world's economies utilizes estimates of gross national
income per capita, listed above for each classification. Gross national income per capita is calculated using the World Bank Atlas method. This
figure represents original work with source data obtained from the World Bank.2

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

42 Obstetrical and Gynecological Survey
condition endure considerable social, economic, and
physical consequences.15 Prevention and treatment
of women with obstetric fistulas require a multidisci-
plinary team approach involving policy makers, doc-
tors, midwives, and social workers, among others.16
The multifaceted nature of this problem and the com-
plex approach to improving care of women with obstet-
ric fistulas necessitate an in-depth discussion, which is
out of the scope of this work and therefore will not be
reviewed.
Malignant neoplasms account for the leading cause
of morbidity and mortality worldwide, with a higher
mortality-to-incidence ratio in LMICs than high-
income countries.17,18 Cancer is the second most
common cause of death in women worldwide behind
cardiovascular diseases.19 Cervical cancer is the fourth
most common cancer for women worldwide; however,
it is the second most common in LMICs. 87% of deaths
from cervical cancer worldwide, occur in LMICs.20
The incidence and mortality for cancer in women are
projected to increase globally over the next 20 years.20
As LMICs experience economic transitions accompa-
nied by improved treatment of infectious disease and
better perinatal health, health concerns will shift to
those associated with later age at first childbirth, lower
overall parity, and obesity, all of which are associated
with increased risks of cancer.
At present, 80% of the cancer burden occurs in
LMICs; however, only 5% of spending is focused in
these regions, leaving many women in LMICs without
access to care.21 In addition to difficulty with access,
there is evidence of negative cultural connotations asso-
ciated with a cancer diagnosis that serve as barriers to
appropriate care, such as the shunning of women with
cancer, a fear of abandonment by spouses, isolation
due to the misconception that cancer is infectious, and
the thought that cancer is a fatal disease without treat-
ment options.22,23 Resources for health care in LMICs
may be shunted to infectious diseases such as HIV/
AIDS, resulting in health systems that cannot manage
rising rates of malignancy, a phenomenon labeled the
“cancer divide.”21
Surgical services in LMICs are inadequate, with only
6% of worldwide surgical procedures occurring in
LMICs, and these patients face higher rates of case fa-
tality than their counterparts in higher-income set-
tings.14 The Lancet Commission on Global Surgery
was launched in January 2014 to address the increas-
ing need for information and action surrounding sur-
gical services in LMICs. The commission supports
6 core surgical indicators including access to timely es-
sential surgery, specialist surgical workforce density, sur-
gical volume, perioperative mortality, protection against
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
impoverishing expenditure, and protection against cat-
astrophic expenditure.14 There are very few surgical
training programs dedicated to gynecologic oncology
in LMICs, and those described target small groups of
gynecologists.24
Radiation facilities are also limited in LMICs.
Teletherapy machines (external beam radiation), when
available, are used for a significantly larger population
of people per machine than in higher-income areas,
which limits accessibility.25 The International Atomic
Energy Agency, a nongovernmental international orga-
nization dedicated to the peaceful use and oversight of
nuclear technology, reported that of 52 African coun-
tries only 23 were known to have external beam radia-
tion capabilities in 2010.26 Similarly, brachytherapy
(a key component to treatment of advanced cervical
cancer) was available in only 20 countries.26 This leaves
an estimated 198 million people living in areas without
access to appropriate radiation facilities, a stark con-
trast to the North American experience, which allows
for 6 machines per million people.25
Access to chemotherapy for all cancers is also limited
in LMICs, with fewer than 5% of those who need che-
motherapy receiving it; there are no robust data avail-
able for only gynecologic malignancies.27 One center
in Tanzania, for example, reported that the appropriate
chemotherapeutic drug was available only 50% of the
time, resulting in more than 70% of patents not receiv-
ing appropriate agents.28 Impediments to chemotherapy
administration include cost, regulation, limited pro-
viders, and sociocultural barriers.29
Cervical Cancer
Breast and cervical cancers are the most common ma-
lignancies for women living in LMICs, whereas world-
wide breast, colorectal, and lung cancers are the most
common malignancies for women.30 Eighty-five percent
of cervical cancer deaths in 2012 occurred in LMICs,
highlighting the large disparity among this particular dis-
ease (Fig. 2).32,33 Cervical cancer is an AIDS-defining
illness, and the mortality rates from cervical cancer are
highest in countries with the highest prevalence of HIV.
Paradoxically, as more women with HIV are treated, an
increasing number of women are living longer and dying
of cervical cancer. In 2016, 4115 women died of cervi-
cal cancer in the United States compared with Malawi,
which is 18th of the size of the United States, and where
2314 women die annually of the disease.34 The differ-
ence in mortality rates is directly related to access to
prevention services.
Prevention of cervical cancer is especially important
in low-resource areas as there are frequently insufficient
 A Review of Training in Global Gyn Oncology • CME Review Article 43

FIG. 2. Estimated cervical cancer mortality (2012). Estimated age-standardized rates per 100,000 of mortality from cervical cancer. Reprinted
with permission from reference.31

resources for treatment with surgery and radiotherapy.35
The American Society of Clinical Oncology pro-
posed a 3-strategy approach to reduce the cervical
cancer burden in LMICs, which includes HPV vacci-
nation (primary prevention), screening (secondary
prevention), and cancer management.36 National screen-
ing programs are not consistently supported, and even
when present, many programs fail to cover the majority
of women and could not limit cervical cancer mortality
to less than 5%.37 Failure of a screening program to
limit mortality is due a variety of factors including a
lack of qualified gynecologic providers to obtain and
interpret results.
Early cervical cancers can be treated with surgical in-
tervention including extrafascial or radial hysterectomy
with or without lymphadenectomy, whereas advanced
disease frequently requires radiotherapy, chemotherapy,
or both. Unfortunately, there are few data regarding
programs for cervical cancer management, including
palliative care, in LMICs.38 In the setting of improved
screening, surgical interventions are still a corner-
stone of therapy for persistent dysplasia and early
cancers. Thus, even with future improvements in access
to screening for cervical cancer, continuing surgical ser-
vices are needed. Cervical cancer procedures are among
the most needed cancer surgeries in LMICs for women;
implementation of the goals in the Lancet Commission
may help improve surgical resources for women in
low-resource areas; however, long-term data are limited.
Uterine and Ovarian Cancers
Aside from cervical cancer, not much is known about
other gynecologic cancers such as ovarian and endome-
trial cancers. There is evidence, however, that cancers
related to infections will decrease in the coming years,
whereas those related to diet, lifestyle, and hormones,
which include uterine and ovarian cancer, will in-
crease, especially in LMICs.39 Data from 2012 sug-
gest that as many as 58% of ovarian cancer cases
occurred in less developed countries.31 Improved atten-
tion to reporting, trial inclusion, and training will be
necessary to appropriately care for women in LMICs
faced with the increasing rates of uterine and ovarian
malignancies.
Gynecologic Oncology Providers
In developed countries, patients with cancer have ac-
cess to up-to-date treatment strategies and clinical trials,
which are not available in LMICs. Studies suggest
that patients with gynecologic cancer have improved
outcomes when they are treated by a gynecologic
oncologist.40–42 Specialty-trained gynecologic oncol-
ogists can offer complex surgery such as radical hys-
terectomy and manage advanced cervical cancers in
collaboration with radiation oncologists. The lack
of trained gynecologic oncology surgeons has been
identified as one of the most important reasons for
poor outcome and cure rates in LMICs. In a review

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44 Obstetrical and Gynecological Survey
of gynecologic oncology penetration in African, South
American, Central American, and Asian countries, gy-
necologic oncology services are meager. Studies have
also found that not only is there a lack of current spe-
cialists, but that also training opportunities are rare.
GLOBAL HEALTH EDUCATION IN THE
UNITED STATES
Cultivating interest in global health early in a US
physician's career impacts future global health interest
and involvement.43 Thus, a focus on trainee involve-
ment is critical to improving global women's health
and should be incorporated early in training, ideally,
during medical school. There is evidence that engaging
in international rotations affords students in high-income
countries the opportunity to improve their cultural sensi-
tivity, enhance communication skills, improve resource
utilization, and acquire an improved understanding of
working in areas with limited resources.44 Participa-
tion in global health training significantly enhances
a student's physical examination skills, allowing him/
her to become less reliant on other diagnostic testing,
thus improving clinical reasoning and resource utiliza-
tion.45 Additionally, students who engage in global
clinical rotations have been found to be more likely to
enter primary care and practice in underserved areas
in the future.46
The beneficial effect of international experiences is
not unique to medical students. United States residents
who participate in an international rotations show im-
proved understanding of different cultural practices
specific to medicine, global infection, traveler health,
and an appreciation for the importance of collabora-
tion in research.47 Surgical experiences in interna-
tional, resource-limited settings have been found to
provide opportunities to attain surgical proficiency in
surgical core competencies.48,49 International experi-
ence may also influence a trainee's career choice even
in residency; Duke University observed that internal
medicine residents who participated in their Interna-
tional Health Program were more likely to choose pub-
lic health or general medicine as a practice specialty.50
Little is known about what constitutes an appropriate
curriculum for global health training in a high-resource
country. It is recommended that medical educators de-
velop a consensus on the appropriate global health
training at each level.51 Heeding this recommendation,
several groups have published proposals for curriculum
development of global health education. The Global
Health Education Consortium (GHEC), founded in
1991, is a nongovernmental group of health educators
dedicated to global health education in medical school
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
and residency programs in the United States, Canada,
Central America, and the Caribbean. The GHEC facili-
tates curriculum development, clinical training, career
development, and education policy.52 A survey of
GHEC members found that members supported pro-
grams that offer locations abroad, case studies and
problem-based learning for clinical experience prepara-
tion, and community-based primary care as a core com-
ponent to preparation. International experiences were
recommended as a means for physicians to manage
community health programs and train nonmedical
team members and then use interdisciplinary faculty
teams to teaching global health.53 The Association
of Faculties of Medicine of Canada Resource group
on Global Health recommends that medical student
graduates should have proficiency with (1) the global
burden of disease; (2) health implications of travel,
migration, and displacement; (3) social and economic
determinants of health, population, resources, and en-
vironment; (4) globalization of health and health care;
(5) health care in low-resource settings; and (6) human
rights in global health.54 While it remains unclear which
curriculum provides the best competency for medical
students, educators continue to call for a standardized
medical school global health program.55
Global health residency curricula also vary widely
based on the specialty and program. The Global Health
Education Consortium has developed a guide to devel-
oping a global health training in residency that provides
examples and identifies resources for developing and
improving global health training.56 Many individual
programs have developed their own global health cur-
riculum; however, there remains a desire to provide
accredited rotations for residents by their respective res-
idency accreditation organizations.57 Global health fel-
lowships and research tracts have also emerged as
opportunities for trainees to gain additional experience
with clear curricula and defined experiences.58 These
opportunities, however, are generally not offered during
residency training and require postresidency training to
complete.
The Current State of Global Health Training for
Obstetrics and Gynecology Residents and Fellows
Obstetrics and gynecology (OB/GYN) providers are
best positioned to be leaders in global women's health.
Despite this, OB/GYN programs offer fewer opportuni-
ties for trainee global engagement compared with other
specialties.59–61 Eichelberger et al62 conducted a survey
of program directors for OB/GYN residencies regarding
global health experiences. Among those who responded,
34.3% stated that they offered formal didactics in global
 A Review of Training in Global Gyn Oncology • CME Review Article
women's health, and 27.6% offered a formal rotation in
global women's health. Programs with a dedicated global
women's health faculty member were more likely to of-
fer formal didactics.62 Another report found that 17%
of US OB/GYN programs offer a rotation in global
women's health, whereas a survey of Canadian OB/
GYN training programs reported that 36% of respon-
dents offered a global women's health curriculum.63,64
In comparison, general surgery programs report that
86% of their programs offered clinical rotations abroad.65
Among nonsurgical specialties, rates of global health
opportunities varied, with 9.3% of psychiatric residency
programs offering global health opportunities, and 53%
to 58.1% of pediatric programs offering some global
health experience.66–68 For pediatricians, a similar report
of increasing opportunities for global health experiences
was noted when a lead faculty was available.67 Of the
residency programs that describe global health opportu-
nities, elective rotations are the most commonly offered,
followed by research electives, then field-based train-
ing.63 See Table 1 for a summary of global health
training opportunities by specialty. Obstetrics and gy-
necology global health residency opportunities are
predominantly focused on the burden of maternal
and perinatal conditions with limited experiences ad-
dressing gynecologic cancer.63 There are interna-
tional experiences for gynecology oncology fellows,
however. The Northwestern gynecology oncology
fellowship offers an approved international rotation.
The University of North Carolina, The University of
Wisconsin, Michigan, New York University, and
Johns Hopkins have relationships with international
hospitals in LMICs where trainees may engage in
global health experiences.
The Accreditation Council for Graduate Medical Ed-
ucation (ACGME), an independent organization that
outlines program standards for postgraduate (residency
and fellowship) training in the United States, cur-
rently offers international rotation guidelines for US
TABLE 1
Global Health Training Opportunities by Specialty
Survey Response Rate,
Source Specialty if Applicable, %
Jayaraman et al65 General surgery
Kolars et al59 Internal medicine
Eichelberger et al62 OB/GYN
Millar et al64 OB/GYN
Clement et al60 Orthopaedic
Nelson et al68 Pediatric
Butteris et al67 Pediatric
Nayar et al61 Plastic surgery
Tsai et al66 Psychiatric
*Including didactic training, lectures, or formal curriculum.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
45
OB/GYN residents wishing to participate in interna-
tional rotations.69 Any experience that a resident under-
takes is done so during an elective rotation through their
institution. The ACGME-required documentation for
international rotations includes, among other things, in-
formation on the educational experience provided for
the resident as well as assurance that the rotation is
for education and not service. Recently, the AGCME
has moved to milestone-based competency assess-
ments, which are written by expert committee members
and used to provide expectations for performance and
programming in ACGME-accredited residency pro-
grams.70 The Association of Professors of Gynecology
and Obstetrics Committee on Global Health has de-
veloped competency-based objectives that have been
mapped to ACGME's Outcomes Project's educational
domains and the Consortium of Universities for Global
Health Competency domains.71 Such competencies can
be applied to other frameworks as well, such as mile-
stones. Similarly, other specialties lack specific global
health milestones; however, programs in emergency
medicine and pediatrics have described creating in-
ternational experiences aimed at achieving specific
milestones.72,73
When US trainees participate in global health experi-
ences, there is a bidirectional information exchange
benefiting the trainee as well as caretakers in the global
health setting. Capturing and cultivating this bidirec-
tional learning experience are an important component
to global health training. The International Gynecologic
Cancer Society has launched a comprehensive 2-year
training program designed for physicians in LMICs to
partner with gynecologic oncology mentors and institu-
tions to offer formal international gynecologic oncol-
ogy training.74 The Memorial Sloan Kettering Cancer
Center also offers a 2-year international gynecologic
oncology fellowship for local gynecologists in LMICs
who desire further training in gynecology oncology.
Senior gynecologic oncologists are needed to mentor
Any Training in International Experience or
Global Health,* % Rotation in Global Health, %
29 33 86
76.2 57.3
44.5 34.3 27.6
34.0 36.4
59 61
53 52
58.1
79 41 37.5
9.3
46 Obstetrical and Gynecological Survey
international trainees in these programs; given the ev-
idence that global health interest is cultivated in train-
ing, it is important for gynecologic oncology fellows
to have opportunities to engage in global health during
fellowship.43,75
Building Capacity for Gynecologic Oncology Care
in LMICs
Training local physicians to offer gynecologic on-
cology specialty care is the only sustainable approach
to increasing access to gynecologic oncologic care,
but to do this will require development of reliable in-
frastructure and support by local government as well
as support from countries where gynecologic care
is routine. Dr Johnston and colleagues76 recently
reviewed the current state of gynecologic oncology
training in LMICs, summarizing opportunities on
all continents. Ethiopia, Ghana, Kenya, Uganda, and
Zambia all offer local gynecologic oncology training
with support and collaboration from academic centers
in the United States. For example, the University of
North Carolina and the University of California
Irvine support the Zambian program, and the faculty
from Duke University and University of California
San Francisco mentor a Ugandan fellowship. In
Asia, training programs are available in Indonesia,
Malaysia, Myanmar, and Thailand. In Latin America,
gynecologic oncology training is offered in Argentina,
Brazil, Chile, Colombia, Costa Rica, Honduras, Mexico,
and Panama. It is recommended that the training
process include accredited consultants, a curriculum,
implementation of didactic lectures, and opportunities
to improve surgical skills. In a clinical commentary
by the Society of Gynecologic Oncology International
Committee, it is recommended that (1) “strong
champions” should be identified from the host and
visiting institutions; (2) communication and exchange
should be facilitated and frequent; (3) a formal
curriculum should be established; (4) metrics are
established to codify the success of the program;
and (5) formal certification is offered at completion
of training.77 It is also recommend that training and
certification engage support from the country's
Ministry of Health.
The International Gynecologic Cancer Society spon-
sors training of gynecologic oncology fellows in Da
Nang Vietnam, Mozambique, and Kenya. This model
includes monthly tumor board supported by Project
Echo and experienced gynecologic oncologists and pa-
thologists from all over the world. International gyneco-
logic oncology fellows are taught to operate, present
cases, and participate in tumor board discussion. There
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is frequent email communication between tumor board
members and the Da Nang gynecologic oncology fel-
low regarding cases. The Da Nang fellowship will be
completed in 2019, and after that, another fellow will
be trained.
Worldwide, women continue to suffer and die of gy-
necologic cancer. Delivery of gynecologic oncology
care in LMICs by US providers whether at the medical
student, resident, fellow, or attending level would have
great impact on patient outcome. More importantly, for-
mal training programs supported by curricula, experi-
enced surgeons, and local governments are paramount
to training local gynecologic oncologists to deliver cul-
turally appropriate care. The OB/GYN and gynecologic
oncology communities have already started to work to-
ward this end as noted by summary commentaries and
physician papers for many of our important societies.
It is important for all to recognize the importance of
global health and our contribution to this, whether this
is at home or abroad, and the importance of gyneco-
logic cancer services to improve the lives of women
worldwide.
Ethical Considerations for Global Health
Involvement and Training
As care for gynecologic conditions increases in-
ternationally by US providers, a number of ethical
challenges have emerged that are not frequently en-
countered in industrialized nations.78 These challenges
include obtaining informed consent, quality and quan-
tity of medical resources, the level of surgical compe-
tence, preoperative and postoperative care, protection
of human subjects in research, and sustainability.79–81
Trainee activities do not always improve a community's
health care or include a component of capacity build-
ing, as many trainees traveling to LMIC do so primarily
for personal development.82 Frequently, trainee involve-
ment in international experiences is short-term, which
raises questions of sustainability, strain on the local sys-
tem, and exacerbating inequities.83 The American Col-
lege of Obstetricians and Gynecologists Committees on
Ethics and Global Women's Health encourage health
care professionals to participate in international hu-
manitarian medical efforts; however, they emphasize
an understanding of the ethical challenges prior to par-
ticipation.84 The committee makes a number of recom-
mendations for health care providers participating in
global health related to these key ethical concerns in-
cluding a primary focus on patient care, an understand-
ing of the community context in which patients are
being treated, and the importance of capacity building
and sustainability (Table 2).84 Trainees participating in
 A Review of Training in Global Gyn Oncology • CME Review Article 47

TABLE 2
Ethical Recommendations for Health Care Providers Participating in Global Health
General ethical recommendations
• Patient care should be the highest priority in any global effort, and providers should consider the local context when making decisions
regarding what services should be offered and provided.
• Providers must understand the communities they are treating and the unique challenges those communities offer.
• Any international effort made should contribute to the long-term well-being of the patients and communities being served through
medical care, research, and an investment in sustainability.
Surgical specific recommendations
• Surgical providers should have the necessary competence and training to perform a procedure as the primary surgeon. Mentorship by
local professions is an appropriate resource for this determination and training.
• Surgical patients must have appropriate access to adequate preoperative and postoperative care.
• Providers must be willing to postpone or cancel surgery when the standards of ethical care are not met with the given resources.
Recommendations adapted from the American College of Obstetricians and Gynecologists Committees on Ethics and Global Women's
Health Committee Opinion.85

global health are likely to be exposed to different learn- REFERENCES

ing opportunities when their experience includes a
capacity-building component as compared with those
who are not involved in contributing to the long-term
well-being of the communities being served.86 The
capacity-building component of a trainee's global health
experience is crucial and should not be overlooked.
Other organizations offer similar advice to global
health trainees and providers,85 and any institution pro-
viding global health opportunities for trainees should
have an ethical component to their training program.
There has been a call to increase global health education
in medical schools; however, there has been little em-
phasis on ethical training.87,88 Among medical schools
that have a global health curricula, only 3.1% have a fo-
cus on ethical considerations.51
Providers must be vigilant about their commitment to
maintaining the highest standards of care within the
limitations of the communities they serve. This vigi-
lance should be emphasized from the earliest introduc-
tion of global health training with a focus on ethical
considerations beginning in medical school and resi-
dency training programs.
CONCLUSIONS
Gynecologic oncology global efforts have concen-
trated on cervical cancer screening programs, improv-
ing access to international experiences for US trained
gynecologists, initiatives for providers from LMICs to
train in the United States in gynecologic oncology,
and development of educational curricula for gyneco-
logic cancer specialists in LMICs.75 Engaging more
providers with an interest and expertise in gynecologic
oncology in global women's health will cultivate an en-
vironment where every woman battling cancer can see
an expert in their type of malignancy and receive care
at the highest standards.
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