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In November 2020, The BMJ reported on a proposal to use UK aid to train doctors in developing countries,1 and thus help the ongoing global disparity in healthcare workers, particularly those with specialist training. It is well known that many foreign graduates of international medical schools come to the UK for postgraduate specialist training. Unfortunately, they seldom return home to serve the countries that raised and educated them, especially in the case of lower- and middle-income countries. The few doctors that do return to their native land, however, may find themselves facing a system plagued by inefficiencies, delays, and poor funding. There is often an inherent resistance to change, and a reluctance to alter the status quo to fall in line with international and evidence-based standards.
In Trinidad and Tobago, these are just a few of the challenges met by those doctors who return home. Four UK-trained specialists, (Figure 1) including a Royal College of Obstetricians and Gynaecologists (RCOG)-accredited subspecialist in gynecological oncology, an obstetrician and gynecologist, a histopathologist, and a radiologist returned to Trinidad and Tobago over the past few years following certification and completion of specialist training. They were all able to collaborate and perform the first reported radical trachelectomy in this country.
In Trinidad and Tobago, there is currently no existing national cervical cancer screening program, with the majority of cervical cytology performed being opportunistic. As a result, cervical cancer is the second most common cancer in women between the ages of 15 to 44 years and the most frequent cause of gynecological cancer death. Up until now, patients with early-stage disease underwent a radical hysterectomy with bilateral pelvic lymphadenectomy and were not assessed for suitability for fertility-preserving surgery, much less offered this alternative option. In addition, formal training in gynecological oncology is not available.
In 2020, a 31-year-old woman was referred to our center with a FIGO (2018) stage 1B1 cervical squamous cell cancer. She expressed a desire to conserve her fertility and was assessed accordingly. An MRI of the abdomen and pelvis was performed and reported by a radiologist experienced in evaluating the parameters necessary to determine eligibility for a radical trachelectomy. These include tumor size, distance from the internal os, involvement of the lower uterine segment, parametrial involvement, the presence of suspicious lymph nodes, and overall cervical length. Most radiologists in this country are unfamiliar with this procedure and it was beneficial that we had a specialist recently returned to Trinidad, who had experience in gynecologic oncology imaging.
The patient was deemed a suitable candidate for fertility-preserving surgery following discussion with all members of the specialist team and went on to have an uneventful radical trachelectomy and bilateral pelvic lymph node dissection. Intraoperative frozen section of the pelvic nodes was performed to ensure that there was no occult metastatic disease. This was done at the time of the trachelectomy as our system does not always allow for a two-step procedure due to pressure on operating lists, cost, and prolonged waiting times. Intraoperative consultations, in the form of frozen sections are quite a resource-intensive process in our system and having an experienced histopathologist who was instrumental in setting up this new service was essential. The patient had an uneventful recovery and 18 months after her surgery has remained well with no evidence of recurrent disease and is currently planning for a pregnancy.
The collaborative effort of trained specialists in this case highlights the importance of these individuals in low-resource settings. They used their skills and experience gained in the UK to the benefit of this young woman. It is therefore crucial we recognize that the training of specialists and subspecialists from the developing world is urgently needed if we are to alleviate current global health inequalities.
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Contributors All authors have contributed to the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.