Comparison of traditional vs. virtual simulation-enhanced training for scaling the cervical cancer surgery workforce in Zambia

Lead Research Organisation: King's College London
Department Name: Cancer Studies


Proposed work

We will use virtual reality simulation of a surgical procedure to pre-train surgical trainees by helping them acquire the psycho-motor skills, sensory acuity, and to a lesser extent, cognitive planning required to achieve the surgical dexterity necessary to perform cervical cancer surgery. After the have reached surgical proficiency we will use proctor them with a form of web-based tele mentoring technology that allows the surgical trainee who is performing surgery to wear a headset that transmits a live, real-time video feed of the surgical procedure to the monitor of an expert surgical mentor who is offsite. The mentor can provide real-time telestration feedback (drawings on the video feed) to the bedside monitor of the surgical trainee while the surgical procedure is being performed, i.e., the video feed from the trainee is transferred to the mentor and then back to the trainee from the mentor with the latter's telestration, much like commentators illustrating in a football game on a separate screen. We will measure the speed at which surgical trainees acquire and maintain the technical skills necessary to safely effectively perform cervical cancer surgery using the technology above with that when they are trained using traditional methods. We will also compare the economic and financial costs of traditional vs. technology-enhanced training for a surgeon to achieve proficiency in treating cervical cancer.


Cancer, the world's leading cause of death, is projected to increase at a staggering rate in the next two decades. Most of the new cases, and deaths, will occur in the world's poorest regions. Africa will be hardest hit, as it is estimated that by 2030 cancer will kill one million Africans each year. Within Africa, women will bear the heaviest burden, because cervical and breast cancers are its most common malignancies and causes of cancer-related death. In fact, one in every five of the world's annual cervical cancer deaths takes place in sub-Saharan Africa, making it the global killing field of cervical cancer.

A major bottle neck in the care of cancer patients in low and middle income countries is the shortage of surgeons, particularly those with specialized cancer training. A recent report (Lancet Oncology Commission on Global Cancer Surgery - 2105) revealed that only 20% of cancer patients living in middle income countries who need cancer surgery can access it, while in low income countries it's <5%.

Potential Applications and Benefits

1. Use in the training curriculum for surgeons in LMI countries, including

a. Major shift in the way surgeons are trained in LMI countries
b. Faster, safer and more effective training of surgeons to perform cervical cancer surgery
c. Standardized training for cervical cancer surgery with options to adapt training to individual needs

2. Rapid expansion of cancer surgery services in low income settings, leading to a

a. Decrease in waiting times for surgery, and associated pain and psychological effects
b. Decrease in fatalistic attitude towards cancer in the community
c. Decrease in the economic and societal consequences associated with deaths of young mothers in LMI countries, i.e., institutionalization of children in orphanages, failure of children to complete primary education, drop in economic status of the families etc.

3. Scientific proof-of-princple that technology-enhanced surgery training is effective, thus ensuring

a. Contribution towards policy changes on the local, national and international level
b. Shaping and enhancing the effectiveness and image of public health services
c. Attract investments from global businesses for purposes of selling the technology
d. Potential of spin out companies, and the creation of new processes, products and services
e. Increase in donor funding for research and implementation of technology-based surgical training in LMI countries

Technical Summary

Phase 1 Specific Aims:

1. Develop a virtual reality simulation training platform for the surgical treatment of invasive cervical cancer.
2. Compare effectiveness of traditional surgical training (TS) (control condition) to traditional surgical training enhanced with virtual reality simulation (VR)
(intervention condition) on the acquisition of surgical proficiency in treating cervical cancer.
3. Compare cost of achieving cervical cancer surgical proficiency using TS vs. VR training

Six (6) surgical trainees will be randomly assigned to TS or VR-enhanced training, after the completion of which they will be evaluated as they perform (six) 6 cancer surgeries under the guidance of an expert, blinded to their initial training. Economic costs of achieving cervical cancer proficiency using TS vs. VR training will be estimated using the C4P-ST tool.

Phase 2 Specific Aims:

1. Adapt remote real-time surgical supervision technology to resource-constrained surgical conditions
2. Evaluate the feasibility of virtual proctorship (real-time tele mentoring platform) to enhance and maintain the surgical proficiency of surgeons newly trained to perform cervical cancer surgery.

Trainees from each of the study arms, deemed to be surgically proficient, will perform an additional three (3) cancer surgeries, with mentoring provided by an expert using tele mentoring from a remote location. Experts will be different than those used in Phase 1 and will be blinded to Phase 1 training.

Potential Applications and Benefits:

1.Integration into surgical oncology education training curriculum in LMI countries
a. Paradigm shift in cancer surgery training

2.Rapid scale up of cervical cancer surgery services in low income settings
a. Decrease in cervical cancer morbidity and mortality

3. Evidence for effectiveness of technology-based surgery training
a. Evidence-based policy making at the national and international levels
b. Attract R&D investments from global fun

Planned Impact

We are investigating the use of recent technological advances in distance learning and real-time interaction to formulate a more efficient approach to surgical oncology training in resource-constrained settings. Our project addresses a critical problem confronting women in low and middle income countries (LMIC) - cancer of the cervix - a noncommunicable disease responsible for more years of loss life in LMICS than any other malignancy; it uses new technology to create cutting edge platforms for scaling up life saving surgical oncology services and in a manner that is appropriate for low income environments; it is also facilitating the formation of new partnerships that bring together individuals and organizations representative of a diversity of interests, talent and resources critical for delivering new technologies in low resource settings that are affordable, equitable and make a significant difference to patient outcomes.

In essence we are hypothesizing that modern computer and distance-learning technology can be successfully adapted to a resource-constrained African context, and when compared to the age-old method of training surgeons, will result in less time for surgical apprentices to master the skills required to perform cervical cancer surgery, and sustained levels of surgical proficiency, at a lower cost. Ultimately, the results may support a novel and rapid approach scaling up surgical services for a malignancy that kills more women in LMI countries than any other - cancer of the cervix. We know from numerous studies and, most recently, two major commissions - Lancet Global Surgery 2030 and Lancet Oncology Global Cancer Surgery that world-wide deficits in surgical provision are one of the most serious deficits in health systems. Cancer is now rapidly becoming a major burden in all emerging and low income countries.

Zambia has one of the heaviest cervical cancer burdens in the world. Because of the vast shortage of surgical oncologic manpower in Zambia the present waiting time for cervical cancer surgery at the University Teaching Hospital (UTH) - the country's only tertiary hospital - is 4-6 months, over which time we have witnessed progressions in disease stage, particularly in HIV-infected women who represent 40% of our cervical cancer population.

A bedrock of cervical cancer management, particular for early stage disease, is radical surgery. However, the reservoir of oncologic surgeons, formally trained to treat invasive cervical cancer, is extremely small throughout the African continent. Even in the very few countries where it is concentrated (South Africa), the disparity between demand and supply is grave, leading to missed opportunities to save lives and prevent unnecessary suffering. Traditional western models of surgical training have failed to provide the oncologic manpower that is needed to manage the cancer epidemic that is predicted to engulf low and middle income countries over the next two decades. The need for new approaches that facilitate rapid scale up of oncologic surgical platforms in high disease prevalence global regions is thus paramount. Our project will utilise the most innovative virtual simulation tools to rapidly train a cadre of surgeons in complex pelvic surgery for cancer of the cervix and compare this, in terms of process, outcomes and costs to traditional methods of surgical training. Thus the project will provide a major demonstrator for the possible utility of advanced training methods to more rapidly deliver surgical capacity and capability for women's cancer, and as a springboard for investigating this approach in the surgical management of other types of cancers in low and middle income countries.
Description We have now developed a full VR environment for pelvic surgery for cancer of the cervix. This is now ready to be put into the field over the next 10 months, which will take us to the end of the 2 year feasibility study. Please see
Exploitation Route Yes. This provides the first highly affordable VR training and QA environment for cancer surgery. We are already in discussion with National Cancer Grid of India for further clinical trials there.
This has been used as a springboard to develop a major multi-centre clinical trial and new Welcome Trust funded programme
Sectors Healthcare

Description This research is one of the first in the XR category that has produced cost-effective simulation that can be utilized in resource-poor settings. The work that this funded was then supported by Welcome Trust through which we have been able to complete a major first in man educational trial
First Year Of Impact 2020
Sector Healthcare
Impact Types Economic

Description Lebanon - the failed state: how politics and policy shapes population health and wellbeing
Geographic Reach Multiple continents/international 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
Title Pelvic and operating theatre VR simulation 
Description VR software. The visuals of this project consist of everything seen by the user. These consist of three-dimensional objects, modeled and designed for accuracy and specific training purposes. This project's visuals are to ensure the proper training of surgical modules through VR using 1:1 scale matching of real world elements. Maintaining a high frame rate no less than 60fps per eye without sacrificing visual fidelity and thereby suspending disbelief. 
Type Of Technology Software 
Year Produced 2018 
Impact Now been beta tested in laboratory conditions and is being moved to field testing in Zambia 
Description Livesaving VR 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Video interview posted on University website regarding innovation to improve surgical training for physicians in LMICs. Graduate students and external researchers have expressed interest in collaboration.
Year(s) Of Engagement Activity 2019
Description Surgical faculty beta test 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Workshop event at SMU bringing together key gynae oncologists and experts to review software VR build
Year(s) Of Engagement Activity 2018
Description Video interview by eCancer 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Video interview with eCancer posted one internet to inform global community about importance of low cost innovations to train surgeons in LMICs. Interest in the research for its application to other areas was generated.
Year(s) Of Engagement Activity 2018
Description World Cancer Congress, Kuala Lumpur, Malaysia, October 2018 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Panel discussion on improving health system efficiency for breast and cervical cancer screening and early detection in Africa at World Cancer Congress, Kuala Lumpur, Malaysia. Interchange with international group of cancer professionals and health policy makers focused on low and middle income countries.
Year(s) Of Engagement Activity 2018