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Understanding the bricks to build better surgical oncology unit at Maputo Central Hospital: prevalent surgical cancers and residents knowledge

Introduction Cancer is a growing concern in Mozambique. However, the country has limited facilities and few oncologists. Surgical oncologists are an unmet need. The aim of this study was to assess residents' knowledge in prevalent cancer domains and to identify and characterize prevalent cancers treated by surgery at Maputo Central Hospital, the largest hospital in Mozambique. The expectations were that the findings shall inform the development of a comprehensive curriculum in surgical oncology fellowship fit for the Hospital. Methods To identify and characterize prevalent cancers, we performed a retrospective analysis of individual cancer patient registries of Maputo Central Hospital (MCH), Mozambique. Information was recorded into data collection sheets and analyzed with SPSS® 21. To assess MCH residents oncologic knowledge, we invited Twenty-six junior residents (49% of all residents) of different specialties to take a 30 item multiple choice written test used elsewhere in previous studies. The test focused on the domains of Basis of oncology, Radiotherapy, Pathology, Chemotherapy, Pain management, Surgical oncology and Clinical Pathway. The test was administered anonymously and without prior notice. We analyzed the overall test and topic performance of residents. Results The study covered a period of 3 years and 203 patients. The most prevalent malignant tumors treated by general and thoracic surgery in MCH cancer registry were esophageal (7%), female breast (6.5%) and colorectal cancer (2.8%). Globally these malignancies were diagnosed at an advanced stage of the disease and required a multimodal treatment. The mean percent correct score of residents was 37.3%. The dimension with the highest percent correct score were clinical management (46%) and surgical oncology (28%) showed the lowest correct score. Conclusion In Maputo, Mozambique esophageal, breast and colorectal cancer were the most prevalent malignancies treated, with surgery, by thoracic or general surgery in MCH. The test scores suggest that, among residents, the knowledge in oncology needs to be improved, rendering support to the need of a surgical oncology training tailored to suit the local needs. Specific training should take into account local cancer prevalence, resources, their quality and the support of surgical oncology services with volume and experience.


Introduction
Cancer is a growing concern in Mozambique [1]. However, the provision of care to cancer patients is conditioned by the country limitations on facilities and specialized oncologists [2]. Patients with advanced stages poses huge challenges in terms of adequate and effective treatment [3,4]. Cancer surgery, the oldest therapy modality remains the mainstay of treatment for solid tumors in countries with limited resources. In some less-developed regions of the world, surgery may be the only viable cancer treatment option [5]. Surgery is effective in the treatment of localized or locally advanced primary tumors and may prolong survival after surgical resection of distant metastases [6]. Thus, surgical oncology, as a subspecialty of general surgery, has emerged to play an increasingly important role in the multidisciplinary treatment of cancer. Effective cancer surgery is a combination of complex variables including the biology of the disease, patient health circumstances, and resources available, all intertwined with the surgeon's judgment and skill [7].
Unfortunately, more than three-quarters of cancer patients in lowincome and middle-income countries (LMICs) do not receive timely, safe, and affordable cancer surgery [5,8]. To address this impending problem of lack of adequate surgical care for cancer patients on the global stage, the European Society for Surgical Oncology (ESSO) and the Society of Surgical Oncology (SSO) outlined a framework of a global curriculum in surgical oncology education and training [9].
Such a framework is expected to enhance the quality of the specialists. However, the number of cancer surgeons that successfully accomplished this curriculum is insufficient. Therefore, this is an unmet need [10] [12]. In Mozambique, surgeons are proficient in general surgery, namely in the treatment of trauma and of surgical complications of infectious diseases. However, in what regards malignant neoplasm surgery, their knowledge and experience need to be enhanced. Therefore, is essential to train and certify surgical oncologist according to good oncological practices [13]. So, we must build our solution, taking into account the resources that we have, our cultural identity, the local nosology, the knowledge that future specialists have at the moment, the supports and partnerships that we already have and those we can involve, in order to quickly form the trainers who will ensure the future in this field. In Maputo, the training of the residents is carried out at Maputo's Central Hospital The item contexts were breast, esophagus, oral cancer and colorectal cancer. The test was made of 30 items, there were 12 single best answers multiple choice, 15 multiple true/false, 2 correspondence and 1 short answer item. We calculated individual participant scores, item percent correct scores and discrimination, we also test reliability using Cronbach´s alpha. For data analysis we used descriptive statistics.
The study was approved by the Mozambican National Bioethical Committee.

Results
Malignant tumors more prevalent treated at department of surgery: the most common cancers treated by surgery (general or thoracic), in the study period, were in order of frequency 156 (77%) breast, 25 (12%) esophagus and 22 (11%) colorectal (Table 1) When the study was performed, we had no access to radiotherapy and so, we did not perform conservative breast surgery. The exceptions were the cases that, to complete treatment radiotherapy was performed abroad. Advanced breast cancers sometimes develop complex wounds with associated pain, infection, massive discharge, malodor and bleeding, which distresses patients. Therefore, we performed Palliative surgery in these cases, allowing the patients to feel a more comfortable. Adriamycin-Cyclophosphamide (AC) followed by Paclitaxel (PC) was the most frequent options. Cisplatin is used in triple-negative or non-responder tumors and hormone therapy is prescribed when indicated.
Resident's knowledge: the reliability of the test was 0,728 (which indicates an acceptable internal consistency) and all but one item Page number not for citation purposes 4 showed positive discrimination indexes. Table 2 summarizes the participant overall and domain results percent correct scores. The mean percent correct score for the test was 37.3%. The dimension with the highest percent correct score were clinical management (46%) and surgical oncology (28%) showed the lowest correct score.

Discussion
In this study, we found that in Maputo, Mozambique esophageal, breast and colorectal cancer were the most prevalent malignancies breast and colorectal cancer, and the need to implement the notion that the therapeutic decision must be multidisciplinary [12]. This study stresses the need of a training program for residents and surgeons for delivery safe and effective cancer surgery.

Conclusion
According to this study, surgical oncology training is crucial, and we suggest it should be condensed and tailored to suit the local needs.
The oncology education program should be taught initially at the university level and improved during medical specialties. This specific training should take into account local cancer nosology, resources, their quality and the support of surgical oncology services with volume and experience. It is crucial to coordinate all training efforts efficiently so that results are relevant.

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What is known about this topic  There is a growing incidence of cancers in Mozambique and a concern that surgical oncology training may be insufficient.

Competing interests
The authors declare no competing interests.

Authors' contributions
This study was conceptualized, designed, performed and written by

Acknowledgments
We thank the residents who performed the oncology evaluation test and to Prof. Rita Ferreira of the University of Aveiro, Portugal, for having supported the accomplishment of the manuscript. Table 1: demographics characteristics and overall survival of the patients treated by the surgical department of the MCH