The International Gynecologic Cancer Society (IGCS) Global Fellowship Program: Advancing Access to Gynecologic Oncology and Surgical Care Globally

Abstract

Objective

Gynecologic malignancies remain a leading cause of death among women in low- and middle-income countries. In 2017, the International Gynecologic Cancer Society (IGCS) started the Global Gynecologic Oncology Fellowship Program in countries without existing training. This two-year structured program allows fellows to train locally with support from international mentors through in-person visits, virtual mentorship, and didactic instruction. Fellows participate in monthly tumor boards, conduct research, complete international observerships, log surgical cases, and complete an oral exam upon graduation. Our objective was to characterize the growth of this program from 2017–2024 and to determine best practices and areas for improvement.

Methods

Between February and April 2024, 40 IGCS fellowship graduates were invited via email to complete a 38-question survey about their training and post-fellowship experiences. Data were analyzed using descriptive statistics and thematic analysis.

Results

Since 2017, the IGCS fellowship program has expanded from five pilot sites to 22 training sites in 18 countries. To date, 52 fellows have graduated and 38 are currently in training. There are 40 international mentors and 53 local supervisors, of whom 15 are prior graduates. Twenty fellows (50%) completed the survey. Nineteen respondents (95.0%) reported practicing as gynecologic oncologists, with an average of 70% of their clinical work focused on this area. However, most reported continuing to provide obstetric and benign gynecology care. Six respondents (30.0%) reported being the sole gynecologic oncologist at their hospital. Half of respondents never visited their international mentor’s site, though 70% reported consistent virtual support. All graduates expressed a need for post-fellowship support, including mentorship, meetings with other graduates, advanced surgical training, and subspecialty collaboration.

Conclusion

The IGCS fellowship program has significantly expanded gynecologic oncology capacity in low-resource settings. Graduates report valuable training experiences but desire ongoing post-fellowship support, a next step in growth for the IGCS fellowship program.

INTRODUCTION

Gynecologic malignancies remain a leading cause of death among women globally, with the highest incidence and mortality in low- and middle-income countries. Despite being a preventable disease, there are an estimated 600,000 new cases of cervical cancer and 350,000 related deaths each year, prompting the announcement of the World Health Organization cervical cancer elimination plan.^1,2 Beyond the need for management of cervical cancer, ovarian cancer patients continue to face challenges accessing treatment, and endometrial cancer rates are now rising significantly across the globe.³

The Lancet Commission on Cancer Surgery estimates that over 80% of all cancer cases will need surgery, yet modelling estimates show that less than 25% of patients with cancer will have access to surgery.⁴ This is in part due to difficulty accessing surgical equipment and supplies, but also due to lack of specialized providers who can perform complex surgeries appropriate for cancer patients.⁴ Many countries around the world have either very few or no gynecologic oncologists to address the large burden of gynecologic malignancies. In the U.S., there are over 1500 gynecologic oncologists.⁵ Conversely, in a study by Anakwenze et al., they found that only 31 African countries reported having a gynecologic oncologist and only 11 countries reported adequate staffing.⁶ Additionally, a study by Vanderpuye et al. found that an oncologist based in an African country sees 325 consults per year on average, often across multiple disease sites, compared to 175 per year in other countries.⁷ The clinical burden on oncologists in this region is more than two-fold greater than for those in high-resource settings.⁷

Currently, general obstetrician-gynecologists (OB/GYNs) are the mainstay providers of gynecologic oncology care in low- and middle-income countries, yet do not have the training for complex oncologic surgeries, provision of chemotherapy, and decision-making for various presentations of gynecologic cancers.^6,8 Various potential training models exist to fill the gap of gynecologic oncology subspecialists in low-resource settings, including training providers locally in-country or bringing individuals to high-income countries to train. While both models have challenges, as outlined in a commentary by Randall et al. in 2021, the need for subspecialist gynecologic oncologists remains critical.⁹

In 2017, in response to this significant need, the International Gynecologic Cancer Society (IGCS) started a Global Gynecologic Oncology Fellowship Program for regions of the world without existing formal training.¹⁰ This is a two-year structured training program that includes virtual didactics and tumor boards, hands-on training, consistent feedback and evaluations, as well as a formal oral exam for certification.¹⁰ Currently, the program is formally implemented through Memorandums of Understanding between IGCS, the low-resource setting institution, and the lead international mentor’s institution. Local mentors are teaching faculty at the low-resource setting institution with either formal training in gynecologic oncology or an informal focus on treating women with cancer. International mentors are formally-trained gynecologic oncologists based in high-income countries.¹⁰

Day-to-day fellowship training occurs through local mentors, who are often either senior OB/GYNs with extensive cancer care experience or gynecologic oncologists from nearby regions. Academic gynecologic oncologists from higher-resource settings serve as international mentors who visit several times per year to provide in-depth adjunctive training in operating rooms and clinics.¹⁰ Fellows may also do 1–3 month observerships at their international mentor’s home site(s).¹⁰ Beyond in-person opportunities, fellows engage in monthly virtual tumor boards through Project ECHO, where they present challenging cases, present evidence for decision-making, obtain feedback from local and international mentors, and receive formal didactic instruction on a topic in gynecologic oncology.^11,12 International mentors provide consistent virtual guidance and are available for feedback and support. Fellows also log all surgical cases into a REDCap (Research Electronic Data Capture) database to ensure that they are meeting expected proficiency numbers.^13,14 At the completion of their training, all fellows must undergo a formal objective structured clinical examination (OSCE) through an independent examiner outside of the fellowship.¹⁰ During these two years, fellows may also complete an academic research project and receive support from their international mentors to do so.¹⁰ The program outline is summarized in Figure 1.

Figure 1.

Outline of the IGCS Global Gynecologic Oncology Fellowship Program

The objective of this study was to characterize the growth of the IGCS Global Gynecologic Oncology Fellowship Program from 2017–2024 across various metrics, including number of graduates, number of mentors, and surgeries performed. In addition, we aimed to determine best practices and areas for improvement through a survey of recent graduates to support the program’s continued growth and expansion.

METHODS

From February to April 2024, the 40 most recent graduates of the IGCS Global Gynecologic Oncology Fellowship Program were invited via email with twice monthly reminders to participate in a comprehensive 38-question survey detailing their experiences during and after their fellowship training. The survey was administered in English with a combination of multiple choice, Likert scale, and free-response questions. These questions focused on feedback for various components of the IGCS fellowship program, experiences with local and international mentors, IGCS resources used during training, current experiences as practicing gynecologic oncologists in their countries, and recommendations for growth of the program. Descriptive statistics were performed on the quantitative data, and thematic analysis was performed on free-text responses.

The University of Texas MD Anderson Cancer Center Institutional Review Board (IRB) determined that this protocol met criteria for exemption from IRB review. All study participants provided informed consent as part of the survey. In accordance with the journal’s guidelines, we will provide our data for independent analysis by the Editorial Team for the purposes of additional data analysis or for the reproducibility of this study in other centers if such is requested.

RESULTS

The IGCS Global Fellowship Program started in 2017 with five sites, including Ethiopia, Kenya, Mozambique, Jamaica, and Vietnam. It has since expanded to 22 sites in 18 countries (Figure 2). Over the past seven years, 52 gynecologic oncology fellows have graduated from the IGCS program and 38 are currently in training. There are 40 international mentors and 53 local supervisors, of whom 15 are prior graduates. Since the program’s inception, fellows have performed 13,170 surgeries in their local hospitals, including 5,649 simple hysterectomies, 1,937 radical hysterectomies, and 4,469 lymph node dissections. Over 1,300 patient cases have been reviewed during 800+ virtual tumor boards.

Figure 2.

Map of IGCS Fellowship Sites and Mentor Locations

Of the 40 recent graduated fellows, 20 (50%) completed the survey. Respondents were from 11 countries, including Uganda, Zambia, Mozambique, Fiji, Kenya, Ethiopia, Nepal, Guatemala, the Bahamas, Jamaica, and Vietnam. Two countries (Qatar and China) had graduated fellows who did not respond – thus, 85% of eligible sites were represented in the study. The remaining five countries with newer fellowship programs did not yet have graduates.

Of the 20 respondents, 19 (95%) transitioned into independent gynecologic oncology practice. One fellow was unable to find a gynecologic oncology position. The graduated fellows describe their current clinical practice as 70% gynecologic oncology on average, but note they still spend significant time providing obstetric and benign gynecology care. Six graduates (30%) responded that they are the only gynecologic oncologist at their hospital.

During the IGCS fellowship program, 45% of survey respondents met with their local mentors every 1–2 months to review progress and receive feedback, while the remaining fellows had meetings quarterly or biannually. Most respondents (75%) described consistent support from their local mentors in the operating room and in preparing their ECHO tumor board presentations. Regarding formal meetings with international mentors: 25% responded that they were able to meet every 1–2 months, 30% were able to meet quarterly, while the remaining 45% reported meeting less frequently. Most respondents (70%) reported frequent support from their international mentors for patient care, and 45% reported support with their ECHO virtual tumor board presentations. International mentors were able to visit 80% of the fellows on a regular basis to provide hands-on training in-country, while the remaining mentors had difficulty visiting regularly, in part due to the COVID-19 pandemic.

Only 50% of the respondents travelled to their international mentors’ institution to participate in an observership program. Some of the challenges included inability to obtain travel visas, difficulty finding time away from local clinical duties, and also the COVID-19 pandemic. In addition to this structured gynecologic oncology fellowship program, 70% of fellows completed the IGCS Pre-Invasive Disease Program to learn cervical cancer prevention procedures including colposcopy, thermal ablation, and loop electrosurgical excision procedure. In addition, 30% completed the IGCS Palliative Care Program to improve knowledge and skills in the provision of symptom-management and end-of-life care for their patients.

All respondents felt ‘supported’ or ‘very supported’ by IGCS during their fellowship. The majority (70%) felt supported by their local institution, while the remaining 30% of fellows described little or no support. For 70% of respondents, their IGCS fellowship was recognized as a legitimate training program in their country; however, only eight (40%) respondents reported formal recognition from the Ministry of Health (MOH) specifically. All respondents expressed a desire for further support from IGCS after graduation, including one year of post-fellowship mentorship, quarterly meetings with other recent graduates, and more training in laparoscopic surgery and other advanced surgical skills.

When asked what they liked about the fellowship, common themes included direct mentorship and networking, opportunities to visit other gynecologic oncology programs abroad, and the virtual tumor boards and didactic sessions (Project ECHO). When asked what could be improved, themes included more in-person time with international mentors, more complex surgical skills training, regular evaluation of knowledge and skills, and formal support after graduation. Reported challenges included limited equipment, inadequate operating room availability, lack of staff, delays in diagnosis, limited chemotherapy and radiotherapy, lack of laparoscopic surgery skills, difficulty conducting research, challenges fitting into hospital structure, lack of formal support, and burn-out (Table 1).

Table 1.

Graduated Fellows’ Perspectives on the IGCS Global Gynecologic Oncology Fellowship Program

Questions	Responses
What did you like about the IGCS Fellowship Program?	Mentorship and Networking International Observership Opportunities ECHO Meetings (Tumor Board + Didactics) Complex Surgical Training
What needs to be improved about the IGCS Fellowship Program?	More in-person time with International Mentors More Surgical Skills Training and Exposure Regular Evaluation throughout Fellowship Continued Support after Graduation
Please let us know the challenges you are facing as a graduated fellow.	Limited Equipment Inadequate OR Availability Lack of Staff Delays in Diagnosis [for patients] Limited Chemotherapy and Radiation Therapy Desire for Laparoscopic Skills Difficulty Conducting Research Challenges Fitting into Hospital/Departmental Structure Lack of Support Burn-Out

DISCUSSION

Summary of Main Results

Over the course of seven years, the IGCS Global Gynecologic Oncology Fellowship has made significant strides in growing the gynecologic oncology workforce in low- and middle-income countries, now with over 50 graduates across 18 countries (Figure 2). Collectively, these new gynecologic oncologists have provided subspecialty surgical care to a significant number of patients, in addition to expanding access to gynecologic oncology clinical care in their regions. Fellows who graduate from this program feel well-trained, but desire further support beyond graduation.

Results in the Context of Published Literature

The IGCS fellowship program is a unique model for subspecialty training in low-resource settings, as the day-to-day education is occurring in-country led by local mentors, supplemented by visiting international mentors from high-resource settings.^9,10 This is contrary to programs that utilize an approach based exclusively on international mentors, which can be challenging to maintain and may not sustainably build local capacity.¹⁵ In addition, encouraging training in-country, as opposed to bringing trainees to high-resource settings for extended periods of time, may help reduce the effects of brain drain.^9,16 A report by Schluger et al. in 2018 detailed experiences building a pulmonary medicine subspecialist workforce in Ethiopia using U.S. and European volunteer faculty who travelled there consistently to provide training. While this approach was feasible for clinical training and allowed Ethiopian trainees to stay in-country, they found that it was challenging to build local capacity for subspecialist career pathways and to maintain a sustainable training model that did not only rely on volunteers.¹⁵ To facilitate a locally-centered approach, the IGCS program carries a robust virtual component with monthly tumor board discussions through Project ECHO, allowing for ongoing mentorship beyond in-person visits to supplement the training that fellows receive from their local mentors.^11,12 Additionally, many graduates of the program go on to serve as local mentors for future trainees, leading to sustainability of the program. This is further supplemented by coordination through IGCS as a large international professional organization, allowing for a unified and sustainable approach with a large workforce and more consistent funding.

While the IGCS fellowships are locally centered, another component of the program is the opportunity for bidirectional exchange, in which the fellows travel to their international mentors’ institution for 1–3 months to observe gynecologic oncology practice in a high-resource setting.¹⁷ In our study, 50% of the IGCS fellows who responded to the survey were not able to travel internationally to participate in these exchanges. This was in part due to the COVID-19 pandemic, which occurred during a large majority of the fellows’ training, but also due to challenges obtaining visas and travel approvals, as well as taking time away from in-country clinical responsibilities. In addition, international trainees who visit high-resource settings, such as the United States, were often unable to obtain adequate permissions to participate in care beyond shadowing. While continued efforts are being made to outline how to optimize bidirectional exchanges in global health collaborations and training, significant work is still needed.^18,19

Subspecialist training for gynecologic oncology in low-resource settings remains critical, particularly due to the high undue burden of cervical cancer in these regions.^1,2 Currently, management of cervical cancer and other gynecologic malignancies is often carried out by general OB/GYNs.⁸ A scoping review by Hill et al. found that task-shifting occurs frequently for the provision of radical hysterectomies in low-resource settings, yet there is consistent messaging that patients have worse outcomes when these surgeries are performed by OB/GYNs or general surgeons compared to subspecialty-trained gynecologic oncologists.⁸ This is often due to lack of understanding of the indications for radical hysterectomy, not performing appropriate lymph node assessment, and higher complication rates.⁸ While this task-shifting approach is currently necessary due to workforce limitations, some studies have found that patients who receive care from a subspecialty-trained gynecologic oncologist are more likely to receive guideline-concordant care and have better cancer outcomes.⁸ Thus, increasing the gynecologic oncology workforce in low-resource settings has important implications for oncology care in these regions.

While developing this new workforce has brought significant opportunities for addressing the burden of gynecologic malignancies in low- and middle-income countries, many of the graduated fellows are still required to practice general OB/GYN in order to support the high need in their countries. In our study, the average graduate of the IGCS fellowship program noted that 30% of their practice included taking call shifts on labor and delivery and providing benign gynecologic care, all while maintaining a busy gynecologic oncology clinical practice. This is exceptionally challenging as they transition from training to junior attending practice. Another theme throughout the survey was a need for additional support from IGCS beyond graduation. Six of the 20 respondents were serving as the only gynecologic oncologist at their hospital, likely resulting in a large clinical volume, minimal surgical mentorship, and limited support.

Significant effort is made to ensure that the IGCS fellowship program works with the local hospital’s academic leadership to ensure that the program is minimally disruptive to local medical needs and has concrete support for the trainees. While IGCS strives to engage national leadership in the implementation of these fellowship programs, this is sometimes limited due to other competing priorities and changes in government and leadership. A large proportion of the responding graduated fellows (60%) suggested that their programs are not officially recognized by their Ministry of Health. It is critical that further efforts be made to bolster formal support from Ministries of Health, which can not only help the program and its graduates succeed in a given setting, but also allow for leadership of IGCS fellowship graduates in national efforts to address the burden of gynecologic cancers. In particular, IGCS fellowship graduates have the potential to help build cervical cancer elimination plans unique to their setting. This is already ongoing at some of the current IGCS fellowship sites, including Kenya, where Mburu et al. conducted critical research on acceptability of cervical cancer prevention throughout the country.^20,21 This type of work can continue to be expanded.

Strengths and Weaknesses

The major strength of this study is that it captures data from gynecologic oncology fellowship graduates in 11 different countries across various continents. This provides a unique overview of the landscape of gynecologic oncology care in these settings and barriers that need to be addressed as we increase the subspecialty workforce. This study also highlights a highly successful capacity-building model that may be replicated by other professional organizations engaging in global health work, while highlighting areas for growth and improvement. The limitations of this study are that these results are based on survey data and not all fellowship graduates responded to the survey. While the survey response rate was 50% (20 of the 40 graduates), 85% of eligible fellowship sites (those with graduates) are represented in the study. It is possible that experiences of non-respondents in the two other countries (Qatar and China) is different than what is reflected here. However, the diverse sample from 11 countries does account for varied experiences to some extent.

Implications for Practice and Future Research

As the IGCS fellowship program continues to expand, a key next step is the development of a comprehensive model for post-graduate support. This includes ongoing mentorship, engagement in virtual tumor boards, involvement in research projects and academic support, and continued surgical development, including training in laparoscopy. Graduates also have the potential to serve as local mentors for new IGCS fellows in their own or neighboring regions, and to collaborate with Ministries of Health in creating strategies to address the high burden of cervical cancer in low-resource settings. Beyond its direct impact, this subspecialty training model offers a valuable blueprint for other medical and surgical disciplines engaged in global health – particularly those supported by large professional organizations. Looking ahead, the IGCS fellowship aims to expand to additional sites in underserved areas, with the overarching goal of improving access to gynecologic oncology care worldwide.

CONCLUSION

The IGCS Global Gynecologic Oncology Fellowship Program has made significant progress in training a skilled workforce to address the large gynecologic cancer burden in low- and middle-income countries. Graduates of the program have remained in their home countries and are actively engaged in clinical care, academic teaching, and leadership roles within their institutions. These findings demonstrate the program’s role in addressing workforce gaps and strengthening gynecologic cancer care capacity in low-resource settings. An important next step is supporting fellowship graduates through sustained mentorship, advanced surgical training, and research opportunities as they transition to independent practice within resource-limited healthcare systems. Continued investment in graduates’ post-fellowship development can not only strengthen individual career growth but also enhances the program’s broader impact by enabling graduates to become local leaders, mentors, and advocates for gynecologic cancer care. As the program continues to grow, it offers a model for sustainable, collaborative global health partnerships to advance equitable access to gynecologic oncology care worldwide.

KEY MESSAGES.

What is already known on this topic:

There is a shortage of trained gynecologic oncologists in low-resource settings, contributing to high mortality from gynecologic malignancies. The IGCS Global Gynecologic Oncology Fellowship was created to address this gap, but its outcomes have not been formally evaluated.

What this study adds:

This study shows that the IGCS fellowship has significantly expanded training capacity across low-resource settings, with most graduates practicing independently and contributing to clinical care, education, and leadership. It also identifies gaps in post-fellowship support, including a need for ongoing career mentorship, advanced surgical training, and research opportunities.

How this study might affect research, practice or policy:

Our findings highlight the importance of structured post-fellowship support and engagement to sustain and scale the impact of this gynecologic oncology training program. These insights can inform future models for subspecialist workforce development in various global health disciplines.