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Program Objectives

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Program Objectives

  1. 1. MEDICAL ONCOLOGY RESIDENCY TRAINING PROGRAM of BC OBJECTIVES (revised 1 June 2009)
  2. 2. TABLE OF CONTENTS PAGE 1. General Overview……………………………………………3 2. Can MEDS Competencies…………………………………..4 3. Team Based Rotations and Schedules……………………..9 4. Basic Scientific Principles………………………………......12 5. Basic Principles in Management and Treatment………….13 6. Management and Treatment of Individual Cancers………14 7. Other Rotations………………………………………………19 8. Useful Resources……………………………………………..22 9. Administrative Structure……………………………………..23 10. Appendix……………………………………………………...23 Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 2
  3. 3. 1. GENERAL OVERVIEW: The University of British Columbia Medical Oncology Training Program based at the British Columbia Cancer Agency (BCCA)-Vancouver Cancer Center (VCC) and Vancouver General Hospital (VGH), is an accredited subspecialty of Internal Medicine recognized by the Royal College of Physicians and Surgeons of Canada. The BCCA, a provincial organization whose mandate is cancer care and research, is comprised of four regional cancer centers: VCC in Vancouver, Vancouver Island Cancer Center (VICC) in Victoria, Fraser Valley Cancer Center (FVCC) in Surrey and Cancer Center for the Southern Interior (CCSI) in Kelowna. The overall objective is to enable trainees to function as competent independent medical oncologists in a general hospital setting with continuing self-education and self-evaluation. The trainee needs to develop internal medicine skills and knowledge in preparation for the written and oral fellowship examinations and be expected to acquire the skills and knowledge outlined in the Royal College Specialty Training Requirements in Medical Oncology to a level at least sufficient to satisfy the examination requirements. Eligible trainees are also encouraged to obtain certification from the Medical Oncology Subspecialty Board of the American Board of Internal Medicine. The trainee will spend two years in the basic clinical program and will be encouraged to consider an additional one or two years of training as a fellow in clinical or basic research especially if they are interested in an academic career. The basic 24 month program is as follows: • Fifteen months of general medical oncology including: -Three months on Team I = lymphoproliferative disorders, endocrine and melanoma -Four months on Team II = lung cancer, genitourinary cancer and sarcoma -Four months on Team III = breast cancer and CNS tumors -Four months on Team IV = gastrointestinal cancer and head and neck malignancy • Two months of radiation oncology • One month of hematology/stem cell transplantation • One month of gynecologic oncology • One month of Palliative Care • Four months of electives The structure of the program is depicted below: Note that the order of rotations in an academic year may vary but the rotation content of each year is fixed. YEAR 1 Block A (2 Month) Block B (2 Month) Block C (2 Month) Block D (2 Month) Block E (2 Month) Block F (1 Month) Block G (1 Month) (PGY-4) Team I Team II Team III Team IV Radiation Oncology Gynecological Oncology Palliative Care YEAR Block A Block B Block C Block D Block E Block F - Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 3
  4. 4. 2 (1 Month) (2 Month) (2 Month) (2 Month) (4 Month) (1 Month) (PGY-5) Team I Team II Team III Team IV Elective Stem Cell Transplant - In Year 1 (PGY-4) the trainee will: Be expected to learn the fundamental principles of the basic and clinical science of oncology including etiology, molecular biology, diagnosis, staging, natural history, treatment goals, evaluation of response and practical aspects of systemic therapy. Be expected to interpret laboratory and imaging studies and demonstrate an ability to manage common neoplasms and complications. Develop experience in routine procedures including marrow biopsy, lumbar puncture with intrathecal therapy, thoracentesis, paracentesis and the use of needle aspiration. Develop experience with common examination techniques during the radiation and gynecology rotations, particularly ENT and pelvic exams. Critically appraise and interpret medical oncology literature. Identify a clinical research project. Learn practical aspects of radiation oncology as it relates to medical oncology, including modality interaction. Be able to outline the roles of curative, adjuvant and palliative radiotherapy and radiotherapy planning. In Year 2 (PGY-5) the trainee will: Develop a more in depth understanding of the basic and clinical science underlying medical oncology and the principles involved in the management and treatment of malignant diseases. Develop of consultative skills and long-range management planning. Take a peer leadership role in the training program with supervision of junior trainees. Learn the basics of stem cell transplantation, hematologic supportive care and infectious complications. Learn basic principles of clinical research and literature interpretation and complete and submit a research project for presentation and publication (see section 7.IV.below) Structure electives to focus on career path (e.g. community or academic) The above is a very general overview of the structure and content of the training program. The remainder of this document will focus on the CanMEDS roles and competencies, the detailed structure of the program, and the basic science and clinical curriculum. In addition the specific goals for the radiation oncology, hematology, gynecology, community and research electives will be outlined. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 4
  5. 5. 2. CanMEDS ROLES AND COMPETENCIES: STANDARD ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA REQUIREMENTS FOR TRAINING IN MEDICAL ONCOLOGY: Specialists possess a defined body of knowledge and procedural skills, which are used to collect and interpret data, make appropriate clinical decisions, and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date, ethical, and cost- effective clinical practice and effective communication in partnership with patients, other health care providers, and the community. The following seven roles are considered integral to the training of a specialist in the discipline of medical oncology. Each role contains key competencies. At the end of the two-year training program in medical oncology at the BC Cancer Agency, a medical oncologist should be experienced in the following roles: 2.1 MEDICAL EXPERT Demonstrate the diagnostic and therapeutic skills necessary for the effective care of patients with a wide spectrum of malignant neoplasms: • Elicit a history that is relevant, concise, accurate and appropriate to the patient’s problem(s) • Perform a physical examination that is relevant, sufficiently elaborate, appropriate and meets and if necessary exceeds the standards expected of a medical oncologist • Select medically appropriate investigative tools in a cost-effective and useful manner. • Demonstrate the cognitive and process skills towards solving the individual patient’s problem(s). Anticipate, diagnose and manage complications of cancer and its treatment in both an in-patient and ambulatory setting. • Perform and document patient assessments and recommendations in both written and verbal form as is expected of a subspecialty consultant. • Apply knowledge and expertise to performance of technical skills relevant to medical oncology. • Be able to structure the patient centered problem to perform a systematic search of the recent medical oncology literature, critically evaluate this literature and make evidence-based decisions regarding patient care. • Develop the attitudes and skills necessary to stay up to date. • Access, retrieve, assist and apply relevant information of all kinds to problem solving and introduce new therapeutic options to clinical practice. • Demonstrate medical expertise in situations other than those involving direct patient care (e.g. formal presentations, medico-legal cases etc.) • Demonstrate insight into own limitations by self-assessment. These goals will be obtained through: Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 5
  6. 6. • Tumor sites specific rotations in which an adequate of volume of patients are seen and evaluated in the setting of a multidisciplinary approach to the treatment of cancer. • A graded responsibility over the two years of training with senior trainees performing as junior consultants. • Demonstration of effective skills as a consultant with well documented consultation notes that outline the diagnosis, plan for staging and ultimate treatment of the patient with cancer. • Demonstration of critical thinking in the review of current literature used in therapeutic decision making. • Attending subspecialty-orientated conferences. • Learning the core procedures that are relevant to the practice of medical oncology which will include thoracentesis, abdominal paracentesis, lumbar puncture and bone marrow aspiration and biopsy. • Demonstrating knowledge of basic science as applied to the clinical situations faced in the ambulatory care clinic and the inpatient ward. • Understanding the epidemiology of the common cancers and its application to patient and community care. These skills will be taught in the follow ways: • Assignment to tumor site specific rotations with both outpatient and inpatient responsibilities in a graded format. • Watch, do and teach procedures in Medical Day Care • Attendance at clinical and research rounds, Wednesday academic lectures, Journal Club and tumor site specific teaching sessions. • Development of critical thinking skills in reviewing clinical situations in the light of current literature at tumor site specific disposition conferences and at the weekly Journal Club. These skills will be evaluated by: • Monitoring attendance at formal teaching sessions. • Review of consultation notes and plans of investigation and treatment with staff consultants. • In-training evaluations as per the ITERs. • Discussions at the end of each rotation with the head of that service regarding the ITER • Formal examinations after completion of training by the Royal College of Physicians and Surgeons in the subspecialty examination in medical oncology. • Bi-annual MKSAP written multiple choice test for self assessment 2.2 COMMUNICATOR • Establish effective relationships with patients who have a malignancy and with their family and caregivers. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 6
  7. 7. • Effectively explain prognosis, risks and benefits and management plans to patients and their caregivers. Be able to break bad news with sensitivity. • Interact with primary care physicians and other health professionals within the community in order to obtain relevant information regarding the patient as well as to bring about appropriate ongoing community-based care. • Learn to effectively utilize written consultations and discharge summaries as well as verbal interactions with medical colleagues. • Effectively communicate with the members of an interdisciplinary team in the resolution of conflicts, provision of feedback, and where appropriate, be able to assume a leadership role. These skills will be taught and evaluated by: • Daily observation of trainee performance in the presence of the clinical supervisors with ongoing dialogue to give appropriate feedback on approach and performance. • Review of written records, including daily chart notes, consultation notes and discharge summaries by the attending consultant with feedback to the trainee. • Direct observation of the interaction between the trainee and the staff medical oncologists during the rotations. • Lecture on communication skills as part of Wednesday seminar series. 2.3 COLLABORATOR • Know when it is appropriate to consult other physicians and health care professionals. • Identify and describe the role, expertise and limitations of all members of an interdisciplinary team required to optimally achieve a goal related to patient care, a research problem, an educational task, or an administrative responsibility. • Develop a care plan for patients including investigation, treatment and continuing care, in collaboration with the members of the interdisciplinary team. Implement appropriate discharge planning and ongoing community-based care. • Participate in an interdisciplinary team meeting, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing specialty-specific expertise him/herself. These skills will be taught by: • Observation of the practice patterns of the attending staff medical oncologists during the rotations. • Active participation at the tumor group specific multidisciplinary weekly or twice weekly conferences. • Participation in discharge planning conferences and family meetings. These skills will be evaluated by: Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 7
  8. 8. • Observation of trainee performance by the attending medical oncology staff. • Feedback through in-training evaluations. 2.4 MANAGER • Demonstrate the ability to utilize the available resources effectively and to balance the needs of patient care with the realities of health care economics. • Understand the interaction between government funding and health care institutions in making decisions regarding resource allocation. • Develop effective and efficient strategies for managing patients that stress obtaining all relevant patient information from other health care sources where available, avoiding duplication of services and accessioning of this information by use of sophisticated information technology. • Learn to effectively delegate responsibility to junior house staff and to supervise their activities. • Learn to manage the competing demands of clinical, academic and personal demands during individual rotations and over the two year training period. These skills will be taught by: • Observation of and guidance by medical oncology staff consultants in their interactions with other caregivers. • Graded responsibilities that allow supervision of more junior house staff. • Provision of a computer and instruction in accessing information through the systems in place at BCCA • Attendance at presentations and rounds that discuss therapeutic priorities and resource utilization. • Taking responsibility for team related activities • Quarterly “fireside chats” at the home of attending physicians These skills will be evaluated by: • Observation of the trainees in their tumor-specific rotations by the attending medical oncology staff with direct feedback. • Formal evaluations as per the ITERS. 2.5 HEALTH ADVOCATE • Identify those factors that are important in the development of malignancies, their treatments and outcome. • Be able to discuss preventative strategies relevant to patients or to their families or community. • Intercede on behalf of patients where accessing services from other components of the health care institutions is required. • Recognize and respond to those issues where advocacy on the patient’s behalf is appropriate. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 8
  9. 9. • Describe how health care governance influences patient care, research and educational activities at a local, regional, provincial and national level. These skills will be taught by: • Formal lectures that address the epidemiology of various malignancies. • Formal lectures that address the roles of various institutions in our health care system. • Observation of the attitudes and practices of attending staff medical oncologists and other members of the interdisciplinary care team. • Quarterly “fireside chats” at staff homes These skills will be evaluated by: • Provision of feedback through the ITERS 2.6 SCHOLAR • Develop, implement and be able to document a long-term personal continuing education strategy. • Acquire the learning skills involved in the practice of evidence-based medicine. • Develop effective techniques for teaching more junior house staff and other health professionals. • Develop a desire to contribute new knowledge to the field through participation in research projects supervised by a faculty mentor. These skills with be taught by: • Learning how to critically review the literature at Journal Club and during discussions of specific patient treatment plans. • Attendance at Wednesday Seminar Series and rounds that didactically address relevant topics. • Opportunities to take faculty wide teaching courses • Participation in research projects through the two years of residency, which is mandatory in the training program. These skills will be evaluated by: • Regular feedback from the attending medical oncologists. • Formal review and feedback through ITERS. • Presentation of research projects at national and international conferences. • Submission of manuscripts for publication. • Presentations at the Medical Oncology Tuesday Noon Rounds. 2.7 PROFESSIONAL • Develop those skills that will allow the trainee to deliver the highest quality care to the patient with cancer with integrity, honesty and genuine compassion. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 9
  10. 10. • Understand their professional obligations to both patients as well as to colleagues. • Exhibit the appropriate personal and interpersonal professional behaviors. • Practice medicine ethically • Demonstrate insight into own limitations of expertise by self-assessment. These skills will be taught by: • Observation of the daily practice and behavior patterns of attending physicians and other health care workers at BCCA. • Quarterly “fireside chats” at the home of attending physicians • Lectures on ethics as part of Wednesday seminar series • Web based ethics courses available through the Royal College of Physicians and Surgeons of Canada These skills will be evaluated by: • Daily observations of trainees by attending medial oncologists. • Formal evaluation through ITERS. • Reviews with the program director and other members of the postgraduate training committee. 3. TEAM-BASED ROTATIONS AND SCHEDULES In order to develop the roles and key competencies of a medical oncologist, residents will learn the specific problems associated with cancers of each anatomic site. These sites are grouped into four medical oncology teams. Each year the trainee will spend two months on each team. In the PGY-4 year the resident is expected to acquire basic knowledge of the scientific principles, management and treatment of the individual cancers. In the PGY-5 year a more sophisticated understanding of the biologic underpinnings, management and treatment of the individual tumor sites is expected. Each team consists of staff medical oncologists with overlapping interests in oncologic disease sites, General Practitioners in Oncology (GPO) and one or two medical oncology trainees. Residents from other specialties and subspecialties (e.g. internal medicine, radiation oncology, hematology etc.) and medical students may also be training in any given month. The other health care professionals associated with team activities are: ambulatory care nurses, ward nurses, chemotherapy nurses, pharmacists, nutritionists, patient and family counselors and physiotherapists. The staff team leader is responsible for the overall clinical and teaching schedule and smooth running of the team. He or she is also responsible for ensuring the in- training evaluation report (ITER) is completed and delivered to the trainee at the end of the rotation. The most senior resident on the team is responsible for Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 10
  11. 11. coordinating the daily assignments (in patient admissions, consultations, follow up clinics, procedures) of the team. The following pre-scheduled activities are part of each team: Referred new patient consultations (REMO slots), active treatment and follow-up out-patient clinics, teaching rounds, scheduled admissions and weekly or twice weekly multidisciplinary conferences (2nd floor conference room). These conferences include radiation, medical and surgical oncologists, pathologists and radiologists with special expertise in the particular tumor sites. Teams also have the following divisional and academic activities on their schedules: weekly medical oncology Tuesday noon rounds, weekly Friday morning journal club, weekly British Columbia Cancer Research Center Monday noon scientific rounds and Wednesday 5 pm seminar series The following activities are also part of each team: In-patient consultations at VGH or from radiation oncology at VCC, urgent admissions, rounding on in-patients, procedures scheduled in Medical Day Care (often done by the GPO). A trainee in medical oncology should be proficient at: thoracentesis, paracentesis, bone marrow aspiration and biopsy, lumbar puncture, intrathecal (via LP or Ommaya reservoir) administration of chemotherapy. Given the number of specialists on each team there are frequently overlapping activities. The staff team leader should clarify which activities in any given week are the priorities. The trainee should attempt to get exposure to all tumor sites represented in a given rotation. Since the bulk of patients in medical oncology are seen in the out patient clinics, the trainee should try to complete rounds on the in-patients expeditiously each morning. In the out patient setting the trainee will learn patient management in a longitudinal fashion. They will have the opportunity to see new patients with a wide variety of cancers, develop consulting skills, become familiar with the indications, delivery and side effects of systemic therapy (chemotherapy, hormonal therapy, immunotherapy, investigational new drugs) and familiarize themselves with long term toxicities and patterns of recurrence. To maintain smooth running of the team the most senior resident should send an e-mail to all staff regarding trainee assignments for clinics and admissions the next day. They should also remind the staff of scheduled teaching sessions. Team I: Tumor Sites: Lymphoma, Endocrine, Melanoma • Staff Members: Lymphoma: Dr J Connors, Dr R Klasa, Dr L Sehn, Dr K Savage, Dr P Hoskins, Dr T Shenkier Endocrine: Dr J Connors, Dr M Knowling Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 11
  12. 12. Melanoma: Dr K Savage, Dr R Klasa, Dr A Shah Team Coordinator: Dr Joseph Connors Team II: Tumor Sites: Lung, GU, Sarcoma • Staff Members: Lung: Dr N Murray, Dr J Laskin, Dr B Melosky, Dr S Sun, Dr C Ho GU: Dr K Chi, Dr C Kollmannsberger, Dr N Murray Sarcoma: Dr M Knowling, Dr L Sehn Team Coordinator: Dr Nevin Murray Team III: Tumor Sites: Breast, CNS, Pain & Symptom Management • Staff members: Breast: Dr K Gelmon, Dr S Chia, Dr T Shenkier, Dr M Knowling, Dr S Sun, Dr H Lim, Dr C Lohrisch, Dr S O’Reilly, Dr J Laskin, Dr H Kennecke CNS: Dr B Thiessen, Dr M Knowling Pain & Symptom Management: Dr P Hawley, Dr R Gallagher, Dr M Lymburner Team Coordinator: Dr Stephen Chia Team IV: Tumor Sites: GI, Head & Neck • Staff members: GI: Dr A Shah, Dr S Gill, Dr K Savage, Dr C Lohrisch, Dr B Melosky, Dr C Kollmannsberger, Dr H Kennecke, Dr H Lim, Dr A Weiss Head and Neck: Dr S Chia, Dr J Laskin, Dr H Kennecke Team Coordinator: Dr Barb Melosky GPO’s may be associated with a particular team or a particular staff member. Dr. Shirley Howdle is the overall GPO liaison and coordinator. At the beginning of each rotation the trainee should clarify the role of the GPO on that particular team. The weekly schedules for each of the four teams (including clinical and academic events) are attached in the Appendix. There are basic skills and procedures which a trainee in medical oncology should be proficient at: 1. Fine Needle Aspiration and Punch Biopsy 2. Thoracentesis 3. Paracentesis 4. Bone Marrow Aspiration and Biopsy 5. Lumbar Puncture 6. Chemotherapy Administration • Care and access of indwelling venous catheters • Knowledge of the acute toxicities of chemotherapy related to the administration of drugs Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 12
  13. 13. • Administration of chemotherapy and biologics by all therapeutic routes: intrathecal, intraventricular (Ommaya Reservoir), intraperitoneal, etc. • Knowledge of the handling and disposal of chemotherapeutic and biologic agents. Proficiency at the above will be obtained and evaluated through the team-based rotations. Most of the procedures are performed in Medical Day Care except FNA. The trainee is expected to keep a log of procedures done throughout the two-year training period. Special sessions will be arranged via the Cancer Centre Pharmacy and Nursing to address issues of Chemotherapy Administration. 4. BASIC SCIENTIFIC PRINCIPLES As a foundation for treating malignant disease the trainee should understand the biology of cancer, principles of therapy and proper conduct and interpretation of clinical research These principles include: 4.1 Cancer Biology: Trainees should know the biology of normal cells and the basic processes of carcinogenesis. They should have an understanding of gene structure, organization, expression and regulation. They should have a fundamental understanding of the cell cycle and its control and general concepts of signal transduction. They should have an understanding of tumor cell kinetics including proliferation, apoptosis and the balance between these two. Trainees should understand the concepts of tumor suppressor genes and oncogenes. They should know various means of carcinogenesis including ionizing radiation, chemical and viral. Trainees should understand the components of the metastatic cascade and the concept of angiogenesis. Trainees should also be familiar with the common techniques of molecular biology including PCR, blotting, cloning and chromosomal analysis. 4.2 Pharmacology and Pharmacokinetics: The trainee should be familiar with the basic principles of pharmacology and be able to interpret basic pharmacokinetic information. They should be familiar with the mechanism of new drug development and how these agents are tested. They should also be familiar with the mechanisms of action and metabolism of antineoplastic agents. They should also be familiar with the dosages, routes of administration, toxicities and drug interactions of common antineoplastic drugs. 4.3 Tumor Immunology: Trainees should have a basic knowledge of the cellular and humoral components of the immune system and regulatory role of cytokines. They should understand the inter-relationship between tumor and host immune systems including tumor antigenicity, immune mediated anti-tumor cytotoxicity and the direct effect of cytokines on tumors. 4.4 Etiology, epidemiology, screening and prevention: The trainee should understand the genetic and environmental factors in oncogenesis and have basic Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 13
  14. 14. knowledge of epidemiologic factors including sex, age, heredity, occupation and geography. They should understand principles and roles of screening and risk assessment. They should understand the principles and indications for genetic testing and counseling. They should know the value of prevention (primary, secondary and tertiary) in cancer development. 4.5 Clinical Research including statistics: Design and conduct of clinical trials, phase I-II-III studies, review of the ethical and regulatory issues involved in study design and conduct, criteria for defining response to therapy, basic statistics including statistical methods, requirements for patient numbers in designing studies and proper interpretation of data. How to critically evaluate publishes articles. Instruction in preparing abstracts presentations and articles. These issues will be covered in multiple formats including: 1. Wednesday Medical Oncology Seminar 2. BC Cancer Research Monday Noon Rounds 3. Journal Club 4. Self learning: Tannock, Hill, Bristow and Harrington, The Basic Science of Oncology 4th Edition 5. Attendance at oncology conferences including Annual BCCA Cancer Care Conference 6. Tuesday Medical Oncology Noon Rounds 7. Participating in a research project with the guidance of a mentor 5. BASIC PRINCIPLES IN THE MANAGEMENT AND TREATMENT OF MALIGNANT DISEASES The management of malignant disease requires interdisciplinary expertise. The trainee should recognize the contributions of each of these subspecialties in making the diagnosis, assessing the stage, and treating the underlying disease and its complications. The trainee should be capable of assessing the patient’s comorbid medical conditions that affect the toxicity and efficacy of treatment, including geriatric issues. 5.1 Pathologic Classification: Relative incidence of each type and treatment response relative to histology. The trainee should have the opportunity to review biopsy material and surgical specimens with a pathologist. They should appreciate the role of the pathologist in confirming the diagnosis of cancer and in determining the severity and extent of disease. Trainees should be familiar with newer pathologic techniques (e.g. immunostaining, cytology, flow cytometry, fine needle aspiration). They should appreciate the utility of tumor markers and recognize their limitations. 5.2 Extent of Disease: Clinical staging and systems of staging, pathological staging, studies available to aid clinical staging (history and physical exam). Trainees should also know the indications for imaging procedures including functional imaging techniques. They should understand the anatomy and incidence of spread to various sites and how to evaluate metastases. They should be familiar Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 14
  15. 15. with the presentation and management of metastases to particular sites (e.g. brain, leptomeninges, pleura etc.) 5.3 Treatment of Primary Disease: Surgery: role in staging, cure and palliation; contraindications (oncology specific), risks and benefits, post op complications. Radiation: principles of radiation biology; indications as a curative or palliative modality; familiarity with planning and dosimetry; sequencing and combined modality therapy; acute and late toxicities. Systemic anticancer agents: indications and goals of treatment in primary and recurrent malignant disorders; risk/benefit and indications for adjuvant, neoadjuvant or metastatic treatment; knowledge of the pharmacology and the toxicity profile of the various agents, including long-term hazards; how to adapt the dose and treatment schedule according to comorbidities and toxicities; knowledge of the different categories of systemic agents including, hormonal, classic antineoplastic, monoclonal antibodies, targeted molecular therapy and other biologic agents. Use of Growth Factors: The trainee should know the indications, proper use and side effects of cytokines including filgrastim and erythropoietin. 5.4 Supportive Care: Pain: The resident should be able to assess location, severity and nature of pain and understand the basic principles of pain physiology. The resident should be able to implement the World Health Organization pain ladder and understand the pharmacology and toxicities of common analgesics including non-steroidal anti-inflammatory drugs, opioids etc. They must be able to anticipate and manage these side effects. The resident should be able to manage pain crises. The resident should understand and implement the use of co- analgesics and be able to recognize indications for palliative radiotherapy or surgery and the indications for anesthetic intervention a. Infections and Neutropenia: The trainees should know the principles of diagnosis and management seen in all types of cancer patients. b. Nausea and vomiting: Trainees should understand the physiology of nausea/emesis and understand the means by which drugs can modulate these states. c. Mucositis: The trainee should be able to distinguish mucositis resulting from infection from that resulting from chemotherapy. They should be aware of the need for pain medications, topical anesthetics and antibiotics. They must recognize when mucositis can result in a medical oncology emergency. d. Diarrhea: The diagnosis and management of treatment induced diarrhea. e. Constipation and bowel obstruction: Treatment and disease related, including management. f. Transfusion: The trainee should know the indications for and complications of red cell and platelet transfusions. They should be aware of the options regarding preparation and administration of these products. g. Marrow and Peripheral-Blood Progenitor Cells. Trainees should be aware of methods for their procurement and storage. h. Malignant Effusion: Trainees should have a working knowledge of the indications for paracentesis, thoracentesis and pleurodesis. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 15
  16. 16. i. Indications: for and complications of enteral and parenteral support j. Oncologic Emergencies: pain crisis, spinal cord compression, superior vena cava syndrome, febrile neutropenia, metabolic emergencies, bowel obstruction, obstructive uropathy, pericardial tamponade, extravasation of vesicants and irritants k. Paraneoplastic syndromes: Diagnosis and management l. Palliative and end of life care: Pain (see above), palliation of other symptoms ( eg respiratory, GIT obstruction, neurologic, etc) 6. MANAGEMENT AND TREATMENT OF INDIVIDUAL CANCERS: Having understood the general principles of treatment, the trainee should be instructed in the care of individual cancer types and the unique considerations for each malignant disease. For each specific disease, the trainee should know the epidemiology, pathophysiology, genetics, signs and symptoms, diagnostic work-up, treatment, and follow-up. The trainee should be able to communicate and discuss these topics with the patients. For each tumor, specific items may be more important. They are stated below. * next to the site indicates that a more detailed outline is available in the appendix 6.1 BREAST:* Trainees should be familiar with the interpretation of mammograms and breast ultrasounds. They should understand which women are appropriate candidates for breast conservation surgery. They should recognize the pathologic and prognostic features that define the indications for adjuvant and neoadjuvant therapy. They should understand the rationale for the choices of therapy for advanced disease, including the appropriate use of cytotoxic chemotherapy, hormonal therapy, biologic therapy (e.g. trastuzumab) and supportive treatments such as bisphosphonates. They should understand the risk factors for the development of breast cancer including the role of heredity. 6.2. CARCINOMA OF UNKNOWN PRIMARY SITE: The trainee should learn the importance of tumor histopathology, pathologic analysis and tumor markers in directing the work up. They should recognize setting in which treatment may affect survival versus when it is palliative. 6.3 CENTRAL NERVOUS SYSTEM MALIGNANCIES: The trainee should be aware of the roles of surgery, radiation therapy and chemotherapy in the management of both primary brain tumors as well as other tumors that metastasize to the central nervous system. 6.4 ENDOCRINE CANCERS: Trainees should know the specific diagnostic work-up and treatment of endocrine cancers. They should know that endocrine cancer may be part of a cancer syndrome due to specific genetic defects. They should know the role of anti-cancer drugs in the different endocrine cancers. 6.5 GASTROINTESTINAL CANCERS:* Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 16
  17. 17. a. Esophageal Cancer: Trainees should understand the risk factors for this malignancy and understand the role of endoscopy in both diagnosis and staging. They should understand the need for parenteral nutritional support. They should understand the role of combined modality therapy as well as palliative chemotherapy and radiation. b. Gastric Cancer: Trainees should understand the risk factors for this disease. They should understand the potential curative role of surgery and the role of combined modality therapy. c. Colorectal Cancer: Trainees should know the risk factors and heritable risk associated with this malignancy. They should understand the controversies in screening for this cancer. Trainees should know the role of surgical staging and the indications of both adjuvant chemotherapy and radiation therapy. They should also understand the roles of palliative chemotherapy, surgery and radiation in advanced disease. d. Anal Carcinoma: This site provides a model of viral carcinogenesis. Combined modality therapy with the goal of organ preservation should be appreciated. e. Hepatobiliary Cancers: Trainees should understand the epidemiology and risk factors associated with these malignancies. The role of alpha-fetoprotein in screening, diagnosis and response to treatment should be understood. The potential curative role of surgery for localized disease and the role of chemotherapy in palliation should be addressed. f. Pancreatic Cancer: Trainees should understand the genetic aspects of pancreatic cancer as well as the role of endoscopy and molecular biology in diagnosis. The potential curative role of surgery in rare patients and its palliative role in others should be known. The palliative role of chemotherapy and combined modality therapy in locally advanced disease should be understood. 6.6 GENITOURINARY CANCER: a. Renal Cell Carcinoma: Trainees should understand the diagnostic dilemmas of this disease as well as its paraneoplastic aspects. They should understand the potentially curative role of surgery in localized disease and the potential for biologic therapy as palliation in advanced disease. b. Urothelial Cancers: Trainees should know the risk factors of this disease, the differences between localized and invasive disease and the propensity for local recurrence of transitional cell carcinomas. Trainees should understand the role of urine cytology and cystoscopy in the staging and follow-up of patients. The roles of intravesical therapy and surgery in early-stage cancers should be understood. They should also appreciate the role of combined modality therapy in locally advanced disease, the indications for adjuvant or neo-adjuvant therapy, and the management of metastatic disease. c. Prostate Cancer: Trainees should understand the epidemiology and controversy over the screening of prostate cancer. They should know the role and controversy of PSA in screening and follow-up. They should also understand the role of grade and stage in planning therapy. They should also recognize the Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 17
  18. 18. roles of surgery, radiation therapy in the management of early stage disease and the role of hormonal therapy and chemotherapy in advanced disease. d. Germ Cell tumors: The trainees should be able to classify patients according to the International Germ Cell Collaborative Group classification. Trainees should know the utility of tumor markers in the diagnosis, prognosis, and follow-up of patients. They should know the roles of surgery, radiotherapy, and chemotherapy. They should know that combination chemotherapy is curative in advanced disease. 6.7 GYNECOLOGICAL CANCERS: a. Ovarian Cancer: Trainees should recognize the genetic aspects of this disease and its implications for cancer screening. The role of surgery for initial treatment and staging of the disease and the role of chemotherapy in both localized and advanced disease will be appreciated. b. Uterine Cancer: Trainees should recognize the roles of hormones and hormonal therapies in the etiology of endometrial cancers. The curative role of surgery in early stage disease and the value of radiation in the multidisciplinary approach to advanced disease should be understood. Trainees should also appreciate the use of chemotherapy and hormonal therapy in the palliation of metastatic disease. c. Cervical Cancer: Trainees should understand the role of HPV in the pathogenesis of cervical carcinoma. The role of screening, surgery and radiation for the treatment of localized disease should be recognized. Trainees should also understand treatment options for patients with advanced disease. d. Vulva and Vaginal Cancers: Trainees should recognize the role of DES in the induction of clear-cell carcinoma of the vagina. They should understand proper surveillance and management of these patients. They should also recognize the role of surgery in early stage disease and combination therapy in advanced disease. The resident should have an organized approach to the vulval and pelvic examination. They should be comfortable with the normal pelvic exam, the pelvic exam after hysterectomy, and to be able to determine what's normal versus pathologic. This would include speculum as well as bimanual examination. The resident should know what's appropriate for the follow-up of patients (what is pertinent in history, physical exam, and laboratory and imaging) after treatment for gynecologic malignancies. 6.8 HEAD AND NECK CANCER: Trainees should be able to perform a proper head and neck examination. They should understand the risk factors for head and neck cancers and the natural histories of the individual primary tumor sites. The importance of panendoscopy in staging must be emphasized. Trainees should understand the roles of surgery, radiation, neoadjuvant chemotherapy and options for organ preservation. They should also be aware of the long-term management issues particularly surveillance for second malignancies. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 18
  19. 19. 6.9 HEMATOLOGIC MALIGNANCIES: a. Chronic leukemias: Trainees should be able to distinguish the chronic leukemias on peripheral-blood smear. Trainees should understand the current therapeutic approaches in the treatment of the chronic leukemias in addition to understanding the expectations of treatment. They should be aware of the indications for marrow transplantation. b. Lymphomas: Trainees should be familiar with the Ann Arbor Staging and World Health Organization classification as well as its strength, limitations, and current initiatives to improve upon the staging classification. They should understand the role of PET scanning in the diagnosis and restaging of patients with lymphoma. c. Hodgkin’s disease: Trainees should be experienced with the staging of Hodgkin’s disease and the indications for surgical staging. They should be familiar with the curative role of radiation therapy in early-stage disease. They should know the indications for chemotherapy in stages II, III, and IV. Trainees should be aware of the long-term complications of treatment and know what is entailed in the follow-up of patients. They should appreciate the indications for marrow transplantation in patients with relapsed or refractory disease. d. Non-Hodgkin’s lymphoma: Trainees should be aware of the association of lymphomas with HIV and immunosuppression. They should be familiar with the Revised European-American Lymphoma classification and the International Prognostic Factors. They should be familiar with the different molecular subtypes of lymphomas. They should recognize the curative role of chemotherapy and the value of marrow transplantation in relapsed or refractory disease. They should understand different types of low-grade lymphomas and appreciate when treatment is indicated and when observation is appropriate. They should appreciate the roles of radiation therapy, surgery, and chemotherapy, including monoclonal antibodies in staging and treatment of intermediate grade non-Hodgkin’s lymphomas. They should know the challenge and unique clinical properties of high-grade lymphomas and the role for intensive treatment of this subgroup. e. Cutaneous T-cell lymphoma: Trainees should recognize the clinical appearance of patients at different stages of the disease. They should be aware of the value of immunophenotyping in the diagnosis. They should appreciate the roles of psoralen and ultraviolet A, radiation therapy, and topical chemotherapy in the initial management of patients. They should be aware of the palliative roles of chemotherapy, biologic agents, and radiation therapy in advanced or refractory disease. f. Plasma cell dyscrasias: Trainees should know how to distinguish the plasma cell dyscrasias: monoclonal gammopathy of unknown significance, Waldenstrom’s, macroglobulinemia, plasmacytoma, multiple myeloma, POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes), and plasma cell leukemia. They should know the indications for treatment in each instance. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 19
  20. 20. g. AIDS-associated malignancies: The trainee should be familiar with association of central nervous system tumors with immunosuppression and AIDS. The trainee should recognize the increased incidence of malignancy in the HIV- positive population. They should know the indications for treatment of those cancers and be aware of the potential of increased toxicities attributable to concurrent medical problems. Trainees should know the appropriate prophylaxis and treatment for common opportunistic infections. 6.10 LUNG CANCER: The trainee should be aware of the risk factors for the development of lung cancer. a. Small Cell Lung Cancer: The trainee should be familiar with the definitions of limited and extensive stage of SCLC. The trainee should know and define appropriate staging investigations for patients with SCLC. They should understand the importance of staging in selecting treatment modalities (chemotherapy, radiotherapy) for patients with SCLC. The trainee must have an understanding of factors influencing prognosis in SCLC. They must also be familiar with the indications for prophylactic cranial radiotherapy as well as understand issues surrounding treatment of SCLC in elderly populations. b. Non-Small Cell Lung Cancer: The trainee should become familiar with staging system for NSCLC including indications for surgical staging. The trainee should develop an understanding of the role of surgery, radiation and chemotherapy for patients with NSCLC as well as develop an understanding of the current approaches and controversies in combined modality treatment (chemoradiation) of NSCLC. The trainee should understand the importance of prognostic factors in selection of treatment. They should understand the indications for adjuvant systemic therapy in early stage lung cancer. They should develop an understanding of the role of combination chemotherapy versus single agent chemotherapy in patients with advanced NSCLC and develop an approach to symptom management of patients with advanced NSCLC. c. Mesothelioma: The trainee should be familiar with the risk factors, criteria for operability and the value of chemotherapy. 6.11 SARCOMAS:* a. Bone Sarcomas: The trainee should recognize the predisposing factors for the development of primary bone sarcomas. They should understand the indications and considerations for limb preservation and the role of adjuvant chemotherapy and combined modality therapy for specific tumors. b. Soft Tissue Sarcomas: The trainee should understand the genetics involved in some of these tumors. They should understand the appropriate surgery for initial diagnosis, indications for limb preservation and the roles of chemotherapy, surgery and radiation therapy. They should know the specific biology and targeted treatment available for GI stromal tumors. 6.12 SKIN CANCER: a. Melanoma: Trainees should understand the risk factors for melanoma and the varied clinical presentations of melanoma and precursor lesions (dysplastic Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 20
  21. 21. nevus). They should be able to distinguish benign from potentially malignant lesions. They should understand the use of depth and nodal involvement as prognostic factors and the type of surgery required for diagnosis, staging and curative resection including the rationale for sentinel node biopsy. They should be familiar with adjuvant therapies offered to patients with moderate to high- risk melanoma as well as the value and limitations of chemotherapy and biologic therapy (interferon, interleukin-2, and tumor vaccines) in patients with metastatic melanoma. They should also use this as a model system to explore tumor-immune system interactions. Trainees should also understand primary prevention in this disease b. Basal Cell and Squamous Cell Cancers: Trainees should be able to recognize their appearance and associate them not only with sun exposure, but also as a long-term complication of cancer therapy. 7. OTHER ROTATIONS 7.I RADIATION ONCOLOGY: Radiation therapy is an important tool in the treatment of cancer. Trainees will engage in a three-month rotation assigned to two or three radiation oncologists per month. Trainees will attend their new patient, follow-up and review clinics. They will also attend simulations and planning and participate in in-patient care. They are also expected to attend Radiation Oncology Noon Rounds and the Radiation Oncology Academic Half-Day if there is a topic of interest. During this rotation they should also attend the weekly academic Medical Oncology activities (Tuesday noon rounds, Wednesday lecture series, Friday journal club). Medical oncology trainees should be familiar with principles of radiation biology (radiation interaction with biologic materials; the 4 R’s of reoxygenation, repopulation, repair, and redistribution; radiosensitivity and radioresistance); mechanisms of cell death and normal tissue tolerance and toxicity and interactions with chemotherapy. They should read the appropriate chapters in the 4th edition of Tannock, Hill, Bristow and Harrington as preparation for this rotation. They should have a basic understanding of physics and technology including properties of therapeutic photons; radiation techniques including external beam radiation, brachytherapy, radionuclides; treatment planning including conventional simulation and CT-SIM treatment planning process. With respect to clinical considerations, they should also be able to: a. Evaluate patients referred to radiation oncology assessing diagnosis, prior management and need for additional staging b. Develop an treatment plan in collaboration with other disciplines and understand issues including: - Simulation - Computer dosimetry - Choice of appropriate fractionation schedule - Sequencing of radiation with chemotherapy and/or surgery Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 21
  22. 22. c. Account for the possible interactions and complications of multi-modality treatment (surgery, radiation and chemotherapy). d. Understand the short- and long-term effects of treatment and how to recognize and manage these complications, e. Understand palliative versus radical radiotherapy; commonly used doses and rationale for fractionation f. Recognize radiotherapy emergencies (airway obstruction, spinal cord compression, superior vena cava obstruction). 7.2 COMMUNITY ONCOLOGY ELECTIVE: The resident may also participate in a community hospital cancer clinic(s) with a view to contrasting the referral pattern; management approach and relationship with referring physicians with the tertiary care centre. In addition, the resident will learn the operating relationship between the community clinic and the tertiary care centre. For centers outside the Lower Mainland, commuting and accommodation expenses will be reimbursed by the program. Trainees may choose to spend time at one of the other three BC Cancer Agency Regional Cancer Centers (Vancouver Island Cancer Centre- in Victoria, Cancer Centre for the Southern Interior- in Kelowna, Fraser Valley Cancer Centre – in Surrey) or in a private community oncologist’s practice. The structure of the rotation and patient exposure during this month will vary depending on the location of choice, but trainees should aim to fulfill the following objectives by the end of the month. a. To perform as an independent medical oncology consultant in a general community hospital setting (medical expert and professional) b. To work effectively with the various support services (medical and surgical specialties, palliative care, nursing, pharmacy, social worker) available to provide optimal patient care in the community (collaborator and communicator) c. To recognize the limitations in resources in the community setting, and recognize the proper indications for patient referral to a tertiary cancer centre (manager and health advocate) d. To become a valuable resource for community physicians and general public in the education of other aspects of cancer management such as prevention, screening and long-term follow-up of cancer survivors ( health advocate) e. To develop learning skills and become familiar with available resources for ongoing education and practice of evidence-based medicine (scholar) f. To become proficient as a general oncology consultant for addressing other aspects of cancer management less commonly encountered by the resident at BCCA-VCC i.e. work-up of solitary lung nodule, lymphadenopathy not yet diagnosed ( medical expert) g. If applicable, to learn the fundamentals of setting up a private community practice affiliated with a community hospital (manager) Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 22
  23. 23. The resident will learn these skills by seeing patients with the community oncologist and reviewing these cases under their supervision. If the elective is within the Lower Mainland the resident is expected to attend the Wednesday seminar series lectures. 7.3 HEMATOLOGY/STEM CELL TRANSPLANT ROTATION: a. Understand the classification scheme, the molecular and standard pathologic diagnosis, the epidemiology (including therapy induced leukemia) and the current therapeutic approach to the broad classes of myeloid malignancies in adults, including the elderly. They should understand the differences between the chronic and acute leukemias with respect to prognosis and treatment. b. Understand the indications for high dose chemotherapy and stem cell transplantation in myeloid and lymphoid malignancies. Understand the relative merits and risks of autologous versus allogeneic procedures. Be able to describe the types of donor sources and the range of conditioning options. c. Recognize the multiple acute and long term side effects of autologous and allogeneic stem cell procedures (including infection, GVHD, VOD etc.). Be able to manage the acute and long term consequences of autologous stem cell procedures. d. Understand the indications for and risk of transfusion products, including RBCs, platelets and immunoglobulin products In one month the resident will get a superficial introduction to each of these issues. They will also learn about the available resources specifically the www.leukemiabmtprogram.org website and the Medical Practice Handbook (a.k.a. the blue book). The trainee will participate in direct patient care on Tower 15 of VGH or 6W at BCCA and round daily with the attending physician. The academic component of this rotation is held in Room 3326 at VGH and includes: new patient conference on Monday afternoon 4-7 PM, Wednesday noon lectures organized by Dr Tom Nevill and Friday noon journal club. On Fridays 1-2 PM there are in-patient sign out rounds and from 2-3PM there is a review of practice guidelines or tough cases. The trainees are also welcome to attend the "Pizza sessions”, 2-hour presentations by fellows given every 2-3 months on BMT/Leukemia topics (organized by Dr Kevin Song). 7.4 ELECTIVE ROTATIONS: During the PGY-5 (second year) three months of elective time are available. The trainee should discuss ideas with the program director and should structure this time to suit his or her career goals. The following is only a partial list of possibilities. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 23
  24. 24. 1. Clinical Research Project: Completion of basic or clinical research project under the supervision of a research mentor. a. Objectives: • To understand principles of research design, ethics, scientific method, conduct and analysis b. Participation in research activity should include: • Preparation of a research proposal • Collection and Analysis of Data • Presentation of Results c. Presentation at a national or international meeting is encouraged and will be supported. d. Preparation of a manuscript for submission to a peer-reviewed journal is strongly encouraged. 2. Community elective (see section 7.2 above). 3. Palliative Care elective. 4. Surgical Oncology elective. 5. Elective at another national or international cancer center. Typically this is set up in conjunction with plans to do a fellowship with a specific mentor at that center the next year. 8. USEFUL RESOURCES 1. The BCCA website www.bccancer.bc.ca contains the Cancer Management Guidelines, Chemotherapy Protocols, the Cancer Drug Manual, Cancer Statistics and information on the Research Ethics Board. In the first week you should familiar with the policy for drug reactions and chemotherapy induced emesis (www.bccancer.bc.ca/HPI/ChemotherapyProtocols/SupportiveCare/ and http://www.bccancer.bc.ca/HPI/DrugDatabase/Appendices/) and diarrhea. and management of febrile neutropenia (www.bccancer.bc.ca/HPI/CancerManagementGuidelines/SupportiveCare/) 2. The h://drive on the BCCA intranet contains numerous shared files. One example is at h:lym_docs/Teaching which has teaching files on various lymphoma topics. Another is h:everyonemed onc for up-to-date oncall schedules and rotations etc. 3. The website of the Royal College of Physicians and Surgeons of Canada www.rcpsc.medical.org contains the requirements for all the sub-specialties and information about examinations and accreditation. It also has self contained learning modules, regarding various topics such as ethics, for example. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 24
  25. 25. 4. Guidelines on Conference Leaves: h:EveryoneMedOncResidencyTrainingProgramDocumentsConferenceResiden tCfrLeaveGuidelines28May05.doc 5. These Objectives are also available at this link: h:EveryoneMedOncResidencyTrainingProgramDocumentsObjectivesMedical Oncology Objectives rev 22 January 2008 cg.doc 6. The website for the UBC Faculty of Medicine Dean’s Office of Postgraduate Medicine www.med.ubc.ca/postgrad 7. The Department of Medicine maintains a password secure on-line evaluation and scheduling system for all the residents is www.one45.com/webeval/ubc/admin/index.php 8. Information on fellowship opportunities and funding is available at the Canadian Oncology Societies website. This society includes the Canadian Association of Medical Oncology or CAMO. Dr Chris Lee a medical oncologist at the FVCC has maintained a website of fellowships: www.telus.net/cwlee/medonc/index.htm 9. VII. Recommendations of a joint ESMO/ASCO task force for a Global Core Curriculum in Medical Oncology were published in Volume 22. Number 22 November 15 2000 in the Journal of Clinical Oncology www.jco.org. They closely mirror the objectives outlined in this document. 10.Rx&D Guidelines: www.canadapharma.org/Industry_Publications/Code 11.Textbooks and Journals: • Essential reading for all trainees is The 4th Edition of The Basic Science of Oncology by Tannock, Hill, Bristow and Harrington. This contains all the basic science information outlined in the objectives above in a comprehensive and readable format • Cancer: Principles and Practice of Oncology 6th Edition edited by DeVita, Hellman and Rosenberg is recommended. • There are other site specific texts which are excellent. One example is the latest edition of Diseases of the Breast by Harris, Lippman, Morrow and Osborne. • The Educational Books issued at the ASCO and ASH meetings are also valuable resources for topic reviews and cutting edge information. • In 2005 the Journal of Clinical Oncology www.jco.org created a new series, review topics and molecular oncology. A monthly issue covers these themes in an up to date and comprehensive fashion. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 25
  26. 26. 12. This website contains guidelines (albeit Americocentric) for 97% of tumour sites. It is also updated annually. I recommend it as a good starting point for thinking about treatments in a flow chart type of pattern. • http://www.nccn.org/professionals/physician_gls/default.asp 9. ADMINSTRATIVE STRUCTURE The program director is Dr Tamara Shenkier. The assistant program director is Dr Sharlene Gill. The program administrator is Carol Gascoyne. The site members from the other centers are Dr Gary Pansegrau from the Fraser Valley Cancer Centre (FVC), Dr Sheila Souliere from the Victoria Cancer Center (VIC) and Dr Sanjay Rao from the Cancer Centre for the Southern Interior (CSI). The postgraduate training committee consists of all the above named staff members and all ten trainees including the chief residents as well as Dr Shirley Howdle for the General Practitioners of Oncology (GPOs). The committee meets four times per year to review program design, goals and objectives, evaluation of the clinical and academic content of the program, research topics and social events. Minutes are kept and issues that arise from this committee are relayed to Dr Susan O’Reilly and the Division of Medical Oncology via the monthly staff meetings. The residents are welcome to meet with Drs Shenkier and Gill informally at any time. Extraordinary meetings may be held at the request of residents or the staff. There are two separate faculty only subcommittees of the RTC: one for interviews and resident selection for each academic year comprising additional staff members and another that meets every 6 months to discuss evaluations and promotions. These committees feed back information to the RTC. 10. APPENDIX I. BREAST: Breast Imaging/Diagnosis Screening mammography – mortality reduction, controversies Diagnostic mammography Use and interpretation of other diagnostic imaging modalities Biopsy techniques FNA, Core, Open Biopsy Genetic Factors/tumor Suppressor Genes BRCA1 BRCA2 Others Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 26 Family history Lifetime risk of which cancers
  27. 27. Breast Cancer: Molecular Biology Hormone Receptor Her2neu oncogene Main signal transduction pathways Non-genetic Risk factors Gynecologic history Environmental Prior XRT Non-malignant breast disease (eg ADH, fibroadenoma) Premalignant/LCIS DCIS Definition Main subtypes Paget’s disease Local management Systemic Pathology Histology Understanding the elements of the BCCA synoptic report Prognostic/predictive markers: definition Techniques to assess her2neu over expression Working Knowledge of TNM staging 2002 Including definition of locally advanced Natural history and risk of recurrence for various stages Local management of Invasive Breast Cancer Indications/Contraindication for Breast Conservation Surgery Modified Radical or Total Mastectomy Reconstruction (autologous vs implant) Indications/Contraindications for Radiation Systemic Treatment of Invasive Breast Cancer: hormonal indications aromatase inhibitors chemotherapy benefit (risk reduction; absolute and relative) tamoxifen Adjuvant targeted therapies side effects cyclophosphamide role of primary systemic treatment mechanism of action & of resistance doxorubicin ongoing clinical trials epirubicin 5FU paclitaxel docetaxel Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 27
  28. 28. Treatment of Locally Advanced and Inflammatory Breast Cancer Natural history Follow-up issues following Completion of Adjuvant Treatment Treatment related Menopause (managing symptoms) Psychologic/spiritual Lymphedema (workup and management) Risk of ipsilateral or contralateral recurrence Review Family History Locoregional Recurrence Risk factors Work-up Management Management of Metastatic Breast Cancer Prognostic factors for survival Indications for Hormone vs Chemotherapy: Choice of hormonal therapy: Premenopausal response rate postmenopausal mechanism of action side effects Choice of Chemotherapy: single agent response rate Multiagent mechanism of action monoclonal abx (eg Trastuzumab) action – side effects Site specific therapy of M.B.C a. Bone mets • Medical treatment (Mechanism of action/side effects) • Local treatment b. Brain mets c. Malignant effusions d. Solitary nodules (eg pulmonary, liver) e. Leptomeningeal f. Brachial plexopathy Special Male Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 28
  29. 29. Pregnant/post partum Primary unknown axillary adenocarcinoma Palliative Issues Community Services/Support available Palliative Care Drug Benefit Program Pain Control Issues - Mechanism of action and side effects of opioid and non- opioid analgesics. 2. GASTROINTESTINAL First Year: Understand the types of cancers of the GI system, their frequency, risk factors, modes of presentation, diagnostic and staging procedures, the general principles underlying therapy, and outcome for the different cancers. Second Year: Understand the evidence behind recommendations for therapy, including the basis for multi-modality therapy, screening procedures available and follow-up tests. 2.1 Sites: The GI system comprises several organs. An understanding is required of the malignancies arising in them with emphasis on those that are common. Common cancers Less common cancers Esophagus Anus Stomach Liver Colon Gallbladder Rectum Biliary tract Pancreas Small bowel (particularly carcinoid tumors) 2.2 Natural History and Diagnosis: a. Changing incidence of certain cancer types and possible reasons (esophagus/GE junction, anal, colorectal and hepatocellular cancers) b. Presenting features c. Diagnostic tests d. Role of tumor markers (CEA in colorectal carcinoma, AFP in hepatocellular cancer) e. Precautions re: biopsies of pancreatic cancer and hepatocellular cancer 2.3 Molecular Biology: a. Adenoma-carcinoma sequence for colorectal cancer b. Genetic syndromes • Hereditary Polyposis Coli or HPC • HNPCC Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 29
  30. 30. 2.4 Risk factors: a. Environment/lifestyle • Role of diet (fat and fiber) • Potential role of chemopreventive agents (NSAIDS, calcium) b. Infectious agents • Viral - Hepatitis B & C (hepatocellular carcinoma); HPV (anal carcinoma) • Bacterial - H. pylori (stomach carcinoma) 2.5 Screening: a. Colorectal cancer • Knowledge of randomized screening trials with fecal occult blood • Knowledge of current BCCA recommendations • Familiarity with guidelines for surveillance of high risk groups and those with cancer susceptibility genetic syndromes b. Controversy about screening for hepatocellular carcinoma 2.6 Pathology: a. Histological subtypes of gastrointestinal cancers and the implications for therapy and patient outcome b. Prognostic/ predictive markers 2.7 Working Knowledge of the TNM Staging for all sites: a. Natural history, risk of recurrence for various stages of all sites 2.8 Management of GI cancers: a. Understand the role of surgery for the different GI cancers and where potential cure or useful palliation can be achieved by surgery. b. Understand the scientific basis for multi-modality treatment for different GI cancers. c. Understand the systemic management of GI cancers 2.9 Systemic Treatment of GI Cancers: a. Adjuvant therapy: colorectal cancer Chemotherapy - indications - benefit (risk reduction; absolute & relative) rectal cancer timing and schedule of pelvic radiation stomach cancer knowledge of SWOG trial 1999 Pancreas knowledge of controversies in adjuvant therapy Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 30
  31. 31. Esophagus knowledge of controversies in adjuvant/ neoadjuvant treatment b. Follow-up issues following completion of adjuvant treatment • Treatment related toxicity • Colonoscopy follow-up in colon cancer • CEA follow-up in colorectal cancer c. Recurrence after adjuvant therapy • Risk factors • Work-up and management 2. Management of Advanced/Metastatic Cancer: a. Prognostic factors for survival b. Indications for chemotherapy c. Choice of chemotherapy: • Single agent vs. multi-agent regimens • Use of biological agents (monoclonal antibodies) • Response rates to chemotherapy/biological agents • Mechanisms of action of drugs d. Side effects of the common agents: • 5-FU • irinotecan • cisplatin • oxaliplatin • gemcitabine • cetuximab • bevacizumab e. Role of liver resection in metastatic colorectal cancer f. Role of radiofrequency ablative therapy for liver metastasis g. Role of palliative radiation or surgery in management of obstructive symptoms. h. Role of stents in management of biliary obstruction, colorectal obstruction, esophageal obstruction. i. Indications for laser therapy in management of esophageal or rectal cancer 3. Palliative issues: a. Pain management • mechanism of action and side effects of opioid and non-opioid analgesics • role of palliative radiation for pain control b. Management of chemotherapy-induced diarrhea • recognition of potential severity • role of antibiotics • role of octreotide c. Community services/support available d. Palliative Care Drug Benefit Program Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 31
  32. 32. 3. SARCOMA: Sarcoma service will offer exposure to a wide variety of soft tissue neoplasms both benign and malignant. At conference, most new patients are reviewed by multidisciplinary group for primary management decision. Clinics are generally follow-up with new patient/consult exposure outside clinic time. Major Disease Group: Residents will be exposed to patients with both benign and malignant soft tissue neoplasms as well as bony tumors - mainly osteosarcoma, Ewings sarcoma and variants. The trainees will be expected to acquaint themselves with the basic aspects of epidemiology, etiology, and pathogenesis of the individual disorders. The following clinical aspects will be covered: Staging and its implications for therapy and prognosis, radiologic and other specialized diagnostic tools; use and implication of chromosomal translocations to diagnose and prognosticate as well as; therapy: basis, benefits and potential complications acute and chronic; post-therapy management and treatment of failures and relapses. Specific Learning Goals: Residents will be expected to review epidemiologic features, presentations, staging and management - including principles of biopsy, surgery, radiation therapy and chemotherapy that are important to management of sarcomas, treatment results, genetic abnormalities, special immuno-histologic stains and management of recurrence. Most important disease groupings include: a. Osteosarcomas b. Ewing’s Family tumors (PNET, Askins) c. Adult soft tissue sarcoma – approach to management this multitude of diseases that at this time are treated in a similar fashion including the locally advanced group d. Gastrointestinal Stromal tumors e. Desmoids – both musculoskeletal and FAP related f. Rhabdomyosarcoma g. Intraabdominal small round blue cell tumor Attachment: Palliative Care Curriculum in Oncology Residency/Fellowship Objectives are based on principles common to palliative care and oncology. They can be grouped under the broad headings of the 4 “C”s: Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 32
  33. 33. Competence, Communication, Co-ordination and Compassion. A reading resource list is attached for residents/fellows to pursue the curriculum objectives. Dr Hawley is available to assist residents/fellows with any of the curriculum components, pager 05081. A Palliative Care elective can be arranged if the resident/fellow wishes, and the Pain and Symptom Management/Palliative Care Clinic held on Tuesday afternoons welcome residents/fellows by arrangement through Dr Hawley. Understanding Palliative Care and Death in Our Society 1) Define Palliative Care. 2) Describe its basic principles (as developed by the CPCA). 3) Describe current North American Attitudes towards death and dying. 4) Identify different issues in death and dying among different cultures. 5) Describe current blocks to providing better care to the dying including misinformation, attitudes, organizational, cultural and financial. 6) Understand ethical principles relating to palliative care. 7) Define euthanasia and understand the different between the withdrawal and withholding of treatment and euthanasia. The Oncologist is an Effective Clinician 1) Have an understanding of the natural history of diseases and be aware of treatment accomplishments and limitations in advanced and progressive disease. 2) Have a systematic method of pain assessment and management leading to effective pain management. 3) Be knowledgeable and comfortable with the use of commonly available opioid medications. 4) Manage common physical symptoms especially dyspnea, nausea and vomiting, constipation, delirium and mouth care. 5) Identify psychological issues and differentiate them from psychiatric illnesses (depression) in patients with life-threatening illnesses. 6) Describe normal grief and be able to identify complicated grief. 7) Identify the principles of grief counseling and ensure access to services for families of your patients. The Doctor-Patient Relationship is Central to Oncology and Caring for the Whole Person is Central to Palliative Care 1) Describe the physical, psychological, social and spiritual issues of dying patients and their families. 2) Demonstrate effective communication skills in delivering bad news. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 33
  34. 34. 3) Demonstrate effective communication skills in discussing death and dying with the patient and their family and be able to discuss advanced directives and treatment options. 4) Demonstrate an ongoing commitment to a patient from the time of diagnosis of cancer and be able to guide the patient and family through the disease as it progresses. This includes working with other health care agencies (eg family doctor, home care nursing). 5) Demonstrate a systematic approach to working with families of dying patients 6) Describe your own concerns about dealing with dying patients and their families 7) Demonstrate an awareness of how your own personal experiences of pain, death and dying have influenced your attitudes towards these issues. Oncology and Palliative Care is Community-Based 1) Provide or arrange for palliative care for patients in your hospital. 2) Describe the community resources available to support patients in their home and know how to access them. 3) Be able to work as a team member with the interdisciplinary team of community service providers. 4) Advocate for the needs of home care patients. The Oncologist is an Effective Member of an Interdisciplinary Team 1) Describe the roles of other disciplines in providing palliative care in oncology. 2) Identify the limits of your own role and know when to involve other disciplines in the care of the patient. 3) Participate in interdisciplinary team meetings. 4) Communicate effectively with other team members. 5) Be able to educate other members of the interdisciplinary team. 6) Recognize and describe areas where there are deficiencies in evidence-based care in palliative care. Resources Books Palliative Care: Towards a Consensus in Standardized Principles of Practice Canadian Palliative Care Association, 1995. This is the booklet that contains the standard definitions and principles of palliative care in Canada. Oxford Textbook of Palliative Medicine, Second Edition, 1998. Doyle, Hanks, MacDonald eds. Oxford Medical Publications. This is the gold standard reference book for palliative care. Useful as a reference or if palliative care is your field of interest. Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 34
  35. 35. Medical Care of the Dying. Third Edition. 1998. Victoria Hospice Society. This is an affordable manual that provides an excellent guide to palliative care. It is written with our medical system in mind. Victoria Hospice Society 1900 Fort St. Victoria, BC V8R 1J8 Fax: 250-370-8625 $95 Pocket Booklet Companion to Medical Care of the Dying. A pocket book summary of the useful tables and information from the above manual. Victoria Hospice Society $10 Shorter books Palliative Medicine: a case-based manual. Edited by Neil MacDonald. Oxford Medical Publications, 1998 This is an excellent Canadian book that deals with palliation on a case-based approach. It is designed for medical students and residents. The Pain Manual. Principles and Issues in Cancer Pain Management. S. Lawrence Librach, Bruce P. Squires. 1997. Brief, useful manual on cancer pain management. Available from Purdue Frederick pharmaceutical company ABC of Palliative Care. Eds. Marie Fallon, Bill O’Neill. 1998 British Medical Journal Books. UBC Health Sciences Centre Bookstore has it. This is a compilation of the ABC series in palliative care that the BMJ ran in 1998. Well written, but very brief and may not give enough details. BMJ originals are in BCCA library. How to Break Bad News. A guide for Health Care Professionals. Robert Buckman 1992 UBC Health Sciences Bookstore has it. A detailed guide on how to break bad news. Well worth reading. “I Don`t Know What To Say” by Rob Buckman. A book for families, valuable resource for health care professionals to help families cope with cancer and dying. Available through Dr Hawley or most public libraries. Books of Psychosocial Interest Final Gifts. M. Callanan An excellent book about psychosocial issues around dying. Dying Well. Ira Byock MD. A book about personal growth at the end of life. Internet Sites of Interest Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 35
  36. 36. 1) http://homebrew.cs.ubc.ca:8900/public/RNP/index.html The UBC Department of Family Practice has a site for the rural network program that has a site on palliative care. There is information about the philosophy of palliative care as well as links to a good series of articles called the ABCs of palliative care in the British Medical Journal. Will need access code but you can sign up for it at the site. 2) www.palliative.org The Edmonton Palliative Care site has information for both the physician and patient and is well worth visiting. There is also access to the many symptom assessment scales used by the Edmonton group. 3) www.pallcare.org The Ottawa Institute of Palliative Care has information for both the physician and patient. There is also information on the philosophy of palliative care. Both this site and the Edmonton site have good links to other palliative care sites. 4) www.dyingwell.org Dr. Ira Byock’s website has information on psychosocial and spiritual issues around death and dying. It looks at the issues beyond symptom management. 5) www.aahpm.org American Academy of Hospice Palliative Medicine website has information on policies and curriculum. There are also learning modules for palliative care. 6) http//:pain.roxane.com/slideshow/ The Roxane Laboratories has a site and one part of it is a tutorial on cancer pain management. Useful information and review. 7) www.growthhouse.org Information for patient and physician from US organization. Has monthly newsletter that you can receive via e-mail. 8) www.halcyon.com/iasp The International Association for the Study of Pain. Many articles on pain and pain management available at this site. 9) www.pain.com Useful CME with monthly learning modules that address a wide range of current topics in pain and pain management. 10) www.patientsafetyinstitute.ca/education/safetycompetencies.html Enhancing patient safety across the health professions Palliative Care Journals Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 36
  37. 37. Website for Palliative Care: Revised Palliative Website: 15 April 2008 http://www.fraserhealth.ca/Services/HomeandCommunityCare/HospicePalliative Care/Pages/SymptomGuidelines.aspx The Journal of Palliative Care: Quarterly Canadian journal has mostly articles on psychosocial aspects of palliative care in the BCCA library. The Journal of Pain & Symptom Management: Monthly American journal. Good for learning about new symptom management methods (in the BCCA library). Also can see topics on the web: www.elsevier.nl/inca/publications Journal of Palliative Medicine: A new US journal which has good articles on palliative care education and policies. Can access information from the web: www.liebertpub.com and is in the BCCA library. Palliative Medicine: English journal with articles on symptom management and palliative care policies (in the BCCA library). European Journal of Palliative Care: European journal. Summaries of current articles are available on the web: www.ejpc.co.uk Videos On The Edge of Being. Five doctors talk about facing their own life-threatening illness and how it has affected their life and practice of medicine (in the BCCA library). Wit. Award-winning movie with Emma Thompson playing patient with ovarian cancer. Available from Jack Critchley (Communities Oncology) or your local video rental store. Revised: 1 June 2009 Medical Oncology Objectives Dr Tamara Shenkier, BCCA, VCC 37

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