There is a growing gap between developing and developed countries in the availability of treatment for pediatric subspecialties. Twinning and telemedicine are effective ways to improve the quality of healthcare in developing countries. We evaluated the impact of e-mail exchanges on the development of a neuro-oncology twinning program between the King Hussein Cancer Center (KHCC), Amman, Jordan, and the Hospital for Sick Children, Toronto, Canada. We conducted a retrospective review of all e-mail communications between KHCC and the Hospital for Sick Children from August 2003 to December 2005 for subject, attachments, and responses. Over a period of 29 months, 356 e-mail exchanges (average, 12.3/month) occurred. Subjects discussed were specific consults (88), videoconferencing (65), general neuro-oncological questions (54), personal (45), exchange visits related (44), research projects related (28), articles or treatment guidelines (21), and Web site translation (11). Our study suggests that e-mails promote effective communication between twinning partners and enable discussion of complex cases, organization of teleconferences and workshops, aid other research activities, and further personal relationships between partners. Use of e-mail in telemedicine can be especially useful to improve the quality of care for children with cancer in developing countries.