A world first: Global Oral Cancer Diploma program brings together gold-standard educational content, online access, and interaction with experts

Active in the deployment of the Surgery module during the Global Oral Cancer Diploma program’s 2023 pilot and now editor of the program’s Module 6: Treatment Planning, Prof Brett A Miles, DDS, MD, has keen insight into this collaborative initiative of AO CMF and the International Association of Oral Oncology (IAOO)—and he has a big vision for those who complete the 10-month, self-directed online program. Miles, a globally renowned New York, United States, otolaryngologist and head and neck surgeon believes participants will be transformed by the end of the program and ultimately carry it forward.

Please tell us a bit about yourself. What inspired you to pursue a career in otolaryngology and head and neck surgery, and what ignited your interest in oncology?

I was completing my training in oral and maxillofacial surgery, and as part of that, I got really interested in taking care of head and neck cancer patients because of the nature of the disease. It involves structures related to your speech, swallowing, and facial appearance, and patients can really be devastated by the treatments. I really got passionate about taking care of these patients and I sort of retooled my career to become a head neck surgical oncologist. So, I did a lot of otolaryngology training, including fellowship, and a lot of research in that area, and it became my passion.

How does oral cancer change everything for a patient?

Patients affected by oral cavity cancer frequently lose their ability to swallow and lose their ability to talk because of the tongue and jaw involvement. So oral cavity cancer has a great effect on nearly everything that they do. We use our face as part of our socialization and how we recognize each other; it’s part of our identity, and if that's altered, it has a large impact. If you can't talk in public because you're embarrassed due to speech impairment resulting from previous treatment, or if you just don't have the ability to talk in some cases, it's very devastating. And, certainly, eating is such a huge element of human socialization worldwide. If there's one thing all we have in common, it’s that we love to eat and socialize while we're eating—and if that gets taken away from the patient, it's really impactful. Doing our best to get them treated and cured from these cancers, but also do the reconstructive work that restores them to function so that they can get back to those activities, is the goal for us as a field. Seeing what these patients go through gives you an appreciation of the human spirit. At the same time, I see how they can overcome some of these challenges and that provides a valuable perspective on my own life and how lucky most of us are that we are not facial oral cancer patients.

Was there a particular case or something that inspired you?

I think it was just the experience of seeing the same patterns over and over again. When you see a new, recently diagnosed oral cancer patient, there's a lot of fear and anxiety and focus on the cure: Can I be cured? Is there a cure for this? After they get through treatment, many of them are cured and then their focus shifts to, for example, “Well, now that I'm doing okay, what about everything else? I've had radiation. My mouth is very dry, I can't swallow. My speech is impaired. I look deformed.” And those things don't go away as easily as that initial shock because once they're on a treatment plan, they kind of get over that initial shock and on the path to recovery. They feel more in control of their lives. But once they realize that they're left with some of these deficits—some of which may not be reversible—that's really hard for them, and that tends to last for many years and sometimes forever. Seeing the impact on those patients just made me personally feel like this was a really meaningful career and I decided to put all my professional effort into this specialty because I wanted to do something that was impactful.

Many people take care of their health in general but don’t give oral cavity cancer a second thought. Why is that?

There are a couple of reasons for that. One is that it's a lower incident disease. There is a much higher incidence of breast cancer, for example, so you hear more about breast cancer. But the other thing is the population involved: Breast cancer tends to affect younger women in the prime of their lives. Or, as another example, there’s pediatric cancer: Everyone can understand the impact on the family and young child. Neck cancer often affects older patients and because it doesn't get the same press so to speak, you don't really hear about it that much. But I think people don't realize that if you happen to be one of those people that gets it, it’s a formidable disease. With oral cavity and tongue cancer, the survival rate is often very poor, and even if you do survive, the functional deficits that you live with for the rest of your life can really be a challenge.

The experiences you’re describing really underscore the AO mission of promoting excellence in patient care and outcomes. How did you become involved with the AO?

If you count my first AO experience, which was when I was surgical trainee presenting a research project at an AO meeting, I’ve been involved with the AO for over 20 years. Some of my surgical mentors had encouraged me to look into the AO for educational opportunities first as a resident and later as faculty, because of the AO’s very unique nature in terms of AO CMF. I think one of the very special things about AO CMF is that it brings together all of the craniomaxillofacial (CMF) subspecialties—oral and maxillofacial surgery; plastic surgery; ear, nose and throat; head and neck surgery; ophthalmology; and neurosurgery—to share knowledge and work together toward the AO mission. I personally got a lot out of the AO CMF courses that I participated in and ultimately became a faculty member—something I still enjoy after many years. The AO is a global community and the premier education, innovation and research organization in the treatment of trauma and musculoskeletal disorders. It’s an outstanding collaborative culture where surgeons get together without a lot of ego or posturing and get down to nitty-gritty of clinical problems and really address our challenges.

Why did you get involved with the Global Oral Cancer Diploma program?

The first reason is that in North America, where I practice, you don't hear a lot about oral cancer and the use of tobacco is decreasing over time in this country, which is excellent progress, but representative of the situation worldwide. The burden of oral cancer, for example, in Southeast Asia and India, Pakistan and other countries with higher tobacco use rates and different social factors is extraordinarily burdensome. Many of these areas are challenged by advanced malignancies that are life-threatening and incurable because of the aggressive nature of the disease. Along the same lines, many countries with the highest burden have some of the least resources, including the least educational opportunities. This is why the ten-month, self-directed, online Global Oral Cancer Diploma program was attractive to me: It provides high-quality education to surgeons in even the most remote and economically disadvantaged regions in a cost-effective way—and they learn from and have the opportunity to interact with global leaders in oral cavity oncology.

Another reason I joined this collaborative initiative of AO CMF and IAOO is that I feel it's really important for us to create a legacy of education that allows people to understand how important it is to participate in these types of activities. I remember taking my first AO course: It was only a weekend long, but the resident I was when I went into the course on Friday afternoon and the resident who came out Monday morning were very different people in terms of their understanding of some of surgical techniques. I think the same will be true for Global Oral Cancer Diploma program. The surgeons who sign up for this program and go through this process will come out different on the other end, and they'll appreciate it. And I hope that eventually they will become the contributors to this program and keep it going.

In addition to being the editor of Module 6: Treatment planning, you were involved in the development of four module pilot last year. What was that experience like?

It was very interesting because it combined some elements of traditional teaching. For example, we would record lectures and deliver those lectures electronically, leveraging technology to deliver lectures, but it was kind of a traditional lecture format. But we also had other activities such as asynchronous forums and chats where the participants could ask us questions and we could send pictures. I really enjoyed hearing the opinions from people all over the world about how they would tackle a problem. That interaction was really fun, almost like a surgeon's live chat about what’s the right thing to do in a variety of situations. We also had events where we would all get together in a meeting online and talk about cases. It was great to see the faces of all the participants around the world who really want to improve their skills in oral cavity oncology. It was a rewarding experience. And, certainly when the final program is fully fleshed out in terms of all the content, which we're finalizing now, that will be even more rewarding because I'll be able to see the progress throughout the program, from beginning to completion.

How did the pilot enhance your understanding of surgeons’ educational needs in the field of oral cancer?

When you're working at a major medical center in North America or Europe, for example, you have resources available to you and you really lack understanding of the heterogeneity of what can be delivered around the world. So, from a global perspective even if everyone in the room knows what the correct plan is, not everybody in the room has the resources to deliver that plan. For example, I can remember one of the pilot participants was from a very under-resourced country, and we as a group were discussing which reconstruction plate to use, and surgeon person said, “What if you don't have reconstruction plates? I don't have them where I work.” Reconstruction plates have been around for many, many years and I would never have thought of that question because I've had access to them and have been using them my whole career. But that's not true everywhere in the world, so getting that perspective was pretty valuable because it demonstrates that not everybody is on the same page in terms of resources, and that's the value of the program.

Would you say that was key lesson that will be critical to the ongoing success of the program?

I think understanding the need for the program is absolutely essential, and you can't understand how needed a program is until you run it and actually get feedback from the participants. Running the pilot reinforced what I believed was a need for access to the high-quality educational content we’re offering. Now, the size and scope of the program are expanding, but I think the more important thing is that we are adapting and learning as we run the project. The AO really pays attention to participant feedback and that’s important because participants’ feedback can make the program better. The AO has a track record of collecting and analysing participant feedback and making data-driven adaptations to its educational content in order to best meet to surgeons’ and patients’ real-world needs.

Who is the Global Oral Cancer Diploma program aimed at?

The program’s content is aimed at anyone who is at a senior level in their training and has decided to pursue oral cancer as a major part of their practice or anyone currently in practice. In the pilot, we had a variety of ages and participants and at all levels; whether they were just getting out of their training or had been out of their training for many years, the content is designed to help them improve. One of the gaps in surgeons’ professional education is that once you've graduated, often the goal is to present the cutting-edge research at national or international meetings. These meetings often have world-famous experts as keynote speakers, but they're not focused on getting the basics right sometimes because that's not the charge of that meeting structure. But many surgeons, even if they've been practicing for many years, need a refocus and they haven't had access to appropriate educational programs. The Global Oral Cancer Diploma program allows them to really consolidate and refocus on what the current best practice is in oral cavity cancer. To my knowledge, there is no other oral cancer diploma program that is online and offers access to and interaction with world-leading experts in the field. The most innovative thing about this is putting together a structure of content and the interaction with the faculty in live and asynchronous settings and delivering that worldwide. That's where I think this program is really different than anything else I've seen—and it’s built on the AO legacy of gold-standard education in collaboration with the IAOO and with support from the AO Education institute.

What do you hope will be Module 6: Treatment planning participants’ key takeaways?

If you asked anyone who treats cancer patients, they would probably admit that one of the most important elements is treatment planning. Without a good treatment plan, you're really setting yourself up for failure. Treatment planning is not only one of the more important modules, but I also think it will give participants an in-depth understanding of what a real treatment plan means. What elements does every patient need? That's where this module really will allow clinicians—when they see a new oral cavity cancer patient—to know exactly what to do in terms of surgery, preop optimization, postoperative rehabilitation, molecular testing, pathology, radiation, chemotherapy, genetics, all of the other things that are involved in a treatment plan. That’s what they're going to get out of this module.

What are your biggest challenges as a module editor?

There’s always a time challenge for my own schedule but the other challenge is asking other busy individuals who have very busy schedules to contribute, because this work is something of a labor of love. You really have to want to do it to contribute. But I believe that people who treat patients with cancer tend to be very generous
with their time in general.

What are your two or three biggest ongoing priorities as editor of Module 4: Treatment planning?

My biggest priority is to ensure that this module is high quality, to ensure that it's very clear in terms of its delivery and that it is not overly complicated because the basic elements really need to be effectively communicated. It’s also important to ensure that we really are listening to the participants’ feedback in the forums and chats that, because that real live loop feedback allows us to actually adapt the program on the fly. If someone writes in the chat, “Hey, I'd like to hear about this,” we can add something to the forum on that topic in real time.