It has been more than two years since the start of the coronavirus disease 2019 (COVID-19) pandemic, and while staggering in terms of its global impact on both economy and human life, the number of deaths reported is still only a third of the estimated number of cancer-related deaths (19.8 million) in the same time period.^1,2 Cancer mortality rates may be even higher than these estimates because of the catastrophic impact of the pandemic. The World Health Organization (WHO) reports that cancer screening, diagnosis and treatment have suffered in an unprecedented way because of health systems’ requirement to respond to the influx of COVID-19 patients. The WHO Global Pulse Survey showed that, in the last quarter of 2021, there was disruption of 5% to 50% in screening and treatment of cancer in European countries. Although the situation has improved since then, 44% of countries have reported an increase in service backlogs with a long-term knock-on effect being predicted.³ Similar reports from Africa indicate that more than 75% of cancer care service providers report decreases in services offered between June and August 2020 and although relatively few COVID-19-related deaths were reported among cancer patients, severe disruptions to services occurred.⁴

Africa has always faced challenges in terms of cancer care, with lower numbers of oncology centres and treatment machines per person compared with other continents. There is no region in Africa with more than 3 megavoltage radiotherapy (RT) machines per million population and several countries have no access to RT at all. This is compared with North America with 11 machines/million population and Western Europe with a reported 7 machines/million population.⁵ Radiotherapy forms an essential part of cancer care, with approximately half of all cancer patients requiring RT at some point during their treatment and this number may be even greater in low- and middle-income countries (LMICs) where more patients present with advanced disease.⁶ Several international programmes have been launched over the last decade to address the need for additional RT machines in Africa, resulting in a steady increase in the number of megavoltage units being installed on the continent⁷ and this in turn, has resulted in increased pressure to teach and train RT professionals to safely plan and operate the modern units and create safe clinical treatment plans.⁸

The Access to Care (A2C) Cape Town radiotherapy training programme was launched in 2015 to address this training need on the continent. The focus of the programme was to allow teams of radiation therapy professionals (radiation oncologist [RO], medical physicist [MP] and radiation therapist [RTT] from the same department) to attend practical training in Cape Town over a 17-day period, to facilitate the transition from basic RT techniques utilising 2D planning and cobalt machines, to more modern techniques utilising CT-based 3D conformal radiotherapy (3D CRT).⁹ The increased conformity that is achievable with 3D CRT results in a more homogeneous dose delivery to the target volumes as well as a reduction in dose to critical organs at risk. The potential to improve local control as well as toxicity is directly beneficial to patients and is well described in the International Atomic Energy Agency’s (IAEA) Technical Document 1588.¹⁰ The IAEA TECDOC 1588 also highlights the need for safe implementation of the techniques to reduce risk of errors, making training essential.

Prior to the pandemic, A2C training was based on a hybrid e-learning and in-classroom teaching model. Pre-course learning and concept revision was performed through the LäraNära online training platform (https://online.laranara.se/), made available through Varian Education.¹¹ LäraNära is a Swedish-based RT distance learning platform that allowed participants access to online modules to review the principles of RT equipment, radiation beam characteristics, imaging, contouring, treatment planning, delivery techniques and radiation protection prior to the course. Participants were required to complete a test at the end of each module. The pre-course learning was followed by 17 days of in-person classroom-based training, with access to a virtual reality radiotherapy simulation system (VERT^TM; Vertual Ltd, United Kingdom [UK], https://www.vertual.co.uk/), a radiotherapy treatment planning (RTP) laboratory (Eclipse^TM, Varian Medical Systems, United States [US]), and demonstrations in the clinical department. The curriculum followed a modified version of the RT treatment chain with reference to specific clinical sites, including prostate, cervix and breast.¹² Teams were given the opportunity to attend didactic lectures, contouring and planning demonstrations and to attend up to 45 h of supervised practical planning and contouring, while developing clinical protocols to safely implement the 3D CRT techniques in their home departments. Details of the programme can be found in the previous article published in 2021.⁹

The identification of the first COVID-19 patient in South Africa on 05 March 2020, and the subsequent declaration of a National State of Disaster on 15 March 2020, resulted in a complete travel ban to and from South Africa.¹³ The team from Uganda that was in training in South Africa at the time had to be repatriated immediately and could not complete the last week of training.

With no in-person training possible for the foreseeable future, the decision was taken to immediately modify the platform to allow for emergency remote teaching to complete the training for the Ugandan team and allow future courses to take place. The restructuring process also offered the opportunity to reassess and modernise the programme itself in terms of the principles of modern medical education as described by Filetti et al.¹⁴:

Studies have shown that student comprehension and engagement increases when students are exposed to live-stream lectures, compared with more static pre-recorded lectures of the same format, identifying entertainment as the main factor conducive to academic achievement for the current generation of students. Special attention was therefore given to increasing the entertainment factor during training through live-streaming and creation of more entertaining video training material.¹⁵ Training would still be carried out in the team context, to support the critical need for multidisciplinary team learning.¹⁶

This study aims to retrospectively analyse and document all changes made to the Access to Care Cape Town training programme between March 2020 and January 2022, to deal with the teaching challenges resulting from the COVID-19 pandemic.

The status of the programme as previously described (2015–2019) was used as baseline, representing the in-person training model.⁹ An investigation was performed to determine the status in January 2022, considered to be representative of the emergency remote teaching model. This included an assessment of the computer equipment in both classrooms, comparison of the programmes of all courses offered between March 2020 and January 2022, and reviews of the training material changes and feedback from participants and faculty regarding challenges experienced. The investigation focused on five themes:

The virtualisation of the A2C programme allowed for continued teaching during the pandemic, with 18 teams attending remote teaching courses between April 2020 and January 2022 as well as completion of the outstanding modules for the team from Uganda who had to leave the last in-person course prematurely in March 2020.

Virtualisation of the A2C programme has provided many opportunities and insights into RT practical training and on-line educational teaching models generally.

Computer hardware and software changes are summarised in Table 1. Although careful planning was required, the number of modifications was achieved relatively easily and at a manageable cost, and the main concerns related to upskilling the home team in complicated information technology (IT) and technical troubleshooting.

An IT coordinator, although always necessary for A2C courses, has become an increasingly critical part of all the courses, to ensure that courses proceed smoothly. Pre-recording of lectures is an effective way of ensuring that absent lecturers (whether because of COVID-19 or for other reasons) can continue to deliver a high-quality product in a consistent way. The use of the VERT™ virtual simulation system was limited due to the fact that it is still on the Windows 7 operating system, which is considered a network security risk. A work around was found by using pre-recorded video material, which worked well.

The strategic thinking departmental design team exercise is one area where the on-line model may not work as well as the face-to-face version. This exercise was initially run as a competitive game, with teams learning from other team members and benefiting from the facilitator’s input. The on-line version of the exercise does not have the same impact, and going forward, consideration will be given to making this a separate stand-alone course, with more time available. It is considered a critical part of A2C.

The RT treatment planning computer access strategy has proven to be successful. However, a key concern for online training raised by both teaching faculty and course attendees was found to be stable internet connectivity. Connectivity issues during training can be very disruptive and needs to be addressed in the background while training continues. For this reason, it is essential to have one person dedicated to always managing the online platform, as this cannot be performed by the instructors while they are lecturing. Alternative methods of access must be tested in advance, to prevent one or multiple teams losing connectivity during training. Reserve training days should also be considered where all connectivity is lost because of international internet service provider failures.

Interestingly, the practical demonstrations from the live RT machine bunker were one of the biggest concerns regarding the virtual courses. However, the new combination of live streaming and pre-recorded videos works very well. The annual upgrade of all videos is necessary to ensure up to date material.

Increasing awareness of resources available, as well as familiarity with some of the on-line platforms has become a positive off shoot of the courses, accelerating adoption of new platforms. New skills are taken into the courses and into the home department.

One example of this is the increased use of the Vula™ platform. Although available for free for several years prior to the pandemic, it is only now routinely incorporated into training, making the courses more modern, and allowing access to the training material both before and after the modules were taught, according to preference. The active assessment of not only the training material but also the training methodology, also allowed for a much better alignment with the principles of modern medical education as detailed in Table 3.

The programming and curriculum changes are generally considered to have been an improvement on 17 continuous days of learning. The advantages to both the home teaching team and the visiting team from an LMIC relate to less workflow issues because of missing staff for long periods. However, there is a concern relating to team engagement when courses run over multiple weeks of training. As teams are still located in their home departments, there is a considerable risk of clinical pressures pulling them away from the training. This is particularly of concern for the RO in the team, and the concern needs to be addressed with each department’s managers in advance, to ensure maximum attendance of the courses by the full team.

Although the pandemic has brought many challenges to cancer care and cancer education, it has also opened new avenues to teaching and training. The immediate decision to virtualise the A2C training platform has allowed the programme to continue to function optimally and to reach further than ever before despite the COVID-19 pandemic. Keeping participants engaged on the online platform for extended periods of time remains a big challenge, especially when participants are also required to continue fulfilling clinical duties while courses are run. This was evident from the number of ROs who excused themselves from training sessions because of clinical obligation. Hospital management’s support during training is critical if participants are to make the most of the training opportunities. Despite these challenges, there are considerable advantages in terms of geographical reach as well as financial and time savings in terms of travelling for in-person attendance of courses. It is therefore very unlikely that the A2C training programme will revert to face-to-face teaching for all courses in the future. However, there are certain courses, such as the departmental design and procurement training, that will gain from in-person training. For this reason, some courses may in future be delivered in a hybrid format where a part of the training is performed remotely, with only a short training block performed in person.