Oncology Curriculum.doc

Competency Based Curriculum in Hematology/Oncology

PageCurriculum Structure and Core Competencies 2

Required Rotations

Hematology Consultation Service and 7Benign Hematology Clinic

Stem Cell Transplantation 11

Leukemia/Lymphoma Inpatient Service 17

Solid Tumors 21Gastrointestinal Malignancies

Breast CancerGenitourinary MalignanciesGynecologic OncologyHead and Neck CancerThoracic Malignancies

Lymphoma/Benign Hematology 34

Medical Oncology Consultation Service 39

Laboratory Medicine/Hematopathology 42

Radiation Oncology 46

Continuity Medical Oncology/Hematology Clinic 48

Required Supplemental Modules

Basic Scientific Principles 50

Clinical Research: Design, Implementation and Analysis 51

Key Procedures 52

Radiation Oncology 53

Palliative Care 54

Electives 55

Research

Palliative Care Consult Service

Pediatric Hematology-Oncology

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Curriculum Structure and Core Competencies

The fellowship curriculum consists of required inpatient- and outpatient-centered rotations, elective rotations and required modules. The information contained in the modules will be transmitted/acquired over the course of multiple rotations. The fellowship is structured to facilitate knowledge acquisition and skills based on the following six core competencies:

1. Patient Care

Competency: Gathers essential and accurate information about the patientPerforms a complete history and detailed and accurate physical examinationDemonstrates knowledge of how to access adjunctive sources of information (family, outside records, caretaker)

Competency: Makes informed diagnostic and therapeutic decisions based on patient information, current scientific evidence, clinical judgment, and patient preference

Utilizes the appropriate laboratory tests and imaging studies to evaluate medical problems and interprets the resultsReviews imaging studies with a radiologist’s guidance for accurate interpretation when appropriateUtilizes subspecialty consultation appropriatelyIdentifies and accesses available resources to gather information from the medical literatureAssesses the utility and appropriateness of a clinical trial in the care of the individual patientFormulates and prioritizes a differential diagnosis based on information from the patient, current scientific information and sound clinical judgmentRecognizes limitations of his/her level of training and seeks help appropriatelyDemonstrates sensitivity to the preferences of patients and their families when arriving at a management plan

Competency: Carries out patient management plansDefines the need for appropriate follow-up based on diagnosis, performance status, anticipated complications from therapeutic interventions and psychosocial issuesCounsels and educates patients and families regarding diagnosis and management plansPlans for appropriate measures to gauge the effectiveness of treatment

Competency: Performs competently all medical procedures essential for the practice of hematology/oncology

Demonstrates knowledge of the indications for the proceduresAccurately describes procedures to patients and caretakers in language that is appropriate to their educational, developmental, and emotional statusDemonstrates proficiency in performing procedures and maximizes patient comfort

Competency: Sensitively and accurately counsels patients and familiesProvides accurate and up-to-date information to guide patients and their families in making informed decisionsProvides good and bad news in a sensitive and professional mannerHandles patient and family emotional response or calls in help as needed

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Competency: Provides effective health maintenance and anticipatory guidanceProvides appropriate health maintenance and anticipatory guidance based on age, gender, and risk factors Identifies appropriate community resources to address patient needs

Competency: Uses information technology to optimize patient careUses information technology to practice evidence-based medicine and enhance patient care

2. Medical Knowledge

Specific details concerning the medical knowledge to be acquired can be found in the description of the rotations. However, the following competencies apply to all the rotations.

Competency: Demonstrates an investigatory and analytic approach to clinical problem solving and knowledge acquisition

Demonstrates an open-minded and analytical approach to the acquisition and application of knowledge by utilizing evidence-based medicine skills to answer clinical questions, analyze the answers and apply the relevant aspects to the care of patientsSeeks and locates resources useful to secure information Initiates a discussion with faculty preceptor at the beginning of the rotation to address learning objectivesIdentifies areas for improvement by seeking feedback from facultyImplements strategies to improve knowledge, based on feedback and self-assessment

Competency: Acquires, applies and teaches the body of knowledge that comprises clinical hematology and oncology, the basic science that has led to our current understanding, and the ongoing research that will underlie future developments in the field

Accesses all available information to support clinical decision-makingInterprets the principles of evidence-based medicine and statistics as they apply to clinical situationsApplies knowledge with attention to performance status, clinical outcome, cost-effectiveness, risk-benefit and patient preferenceDevelops and maintains a willingness to be a life-long learner by querying the literature and texts on a regular basis, attending conferences, and pursuing answers to clinical questionsTeaches other fellows, residents and students in an organized, enthusiastic, and effective manner on a regular basis

3. Practice-Based Learning and Improvement

Competency: Analyzes practice experience and performs practice-based improvement activities using a systematic methodology

Develops and maintains a willingness to learn from errorsDescribes the process of practice assessment: identification of issues, implementation of change, analysis of the results of the changeUtilizes the necessary resources to complete the processImplements strategies to improve patient care practice

Competency: Locates, appraises, and assimilates evidence from scientific studies related the patients’ health problems

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Interprets the principles of evidence-based medicine and statistics by knowing the principles and statistical techniques necessary for these analysesLocates search engines to effectively search the literatureDistills information to enhance patient and self-education

Competency: Obtains and uses information about the patients and the larger population from which they are drawn

Describes the epidemiology of disease in one’s patient population including risk factors and public health issuesApplies epidemiologic information to assess risk/prognosis and to assist in health maintenance and disease management

Competency: Participates in the advancement of knowledge by appropriately enrolling and following patients on clinical trials

Understands the clinical trials process and appropriately applies the results of studies to patient careParticipates in enrolling patients in clinical trials when appropriate, and documenting the necessary clinical information Understands and complies with the regulatory requirements for reporting adverse eventsNotifies the appropriate personnel in a timely manner of any study deviations

Competency: Facilitates the learning of students and other health care professionalsAssesses educational needs of learnersAssists learners in accessing informationDemonstrates responsibility and leadership in engaging learners in the educational process

4. Interpersonal Skills and Communication

Competency: Communicates effectively to create and sustain a therapeutic relationship with patients and families

Identifies the primary provider(s) of informationIdentifies self and other members of the health care team and explains role appropriately to patient and/or family membersCommunicates with patient effectively, and in the appropriate settingDemonstrates the ability to maintain a therapeutic relationship with patients over timeUses appropriate language at the proper developmental/educational level Elicits histories from patients using effective verbal and non-verbal techniques, using effective listening skillsUses correct English in written and verbal communicationMaintains comprehensive, timely, and legible medical records and correspondenceFacilitates, reflects, clarifies, confronts and/or interprets at the appropriate time in the patient encounterProvides effective patient education in verbal and written form

Competency: Works effectively with others as a member or leader of a health care team or other professional group

Identifies and learns the names of health care team membersAssumes the appropriate role on the teamCommunicates effectively and respectfully with other members of the health care teamFacilitates team communication when in the role of team leader

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Assumes the role of consultant where appropriateProvides constructive verbal and written feedback to other members of the health care team

5. Professionalism

Competency: Demonstrates respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

Acts with honesty and integrityShows reliability and responsibilityShows respect for others in all spheres of contact and regard for others’ worth and dignityProvides compassionate and empathetic careListens attentively and responds humanely to concerns of patients and their familiesStrives for self-improvement so as to provide the highest quality of health care through life-long learning and educationIndicates self-awareness and a knowledge of one’s own limits by recognizing the need for guidance and supervision and through use of self-evaluation toolsPractices altruism and advocacy by displaying an unselfish regard for and devotion to the welfare of patient and their familiesIdentifies the important roles physicians play in societyDiscusses the role of peer review as it relates to professional accountabilityInteracts with patients, staff, colleagues and other health professionals in a respectful manner to include appropriate dress, verbal and non-verbal behaviorStrives to facilitate effective communication with other physicians and health care teams, respecting the expertise of others and avoiding/minimizing conflicts to enhance the delivery of good patient careResponds positively to constructive criticism by improving behavior and/or skills

Competency: Demonstrates a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practice

Recognizes ethical dilemmas and utilizes consultation from the hospital’s ethics committee appropriatelyAdheres to the laws and rules governing the confidentiality of patient informationObtains proper informed consent from patient or family members/legal guardian, recognizing the situational need for determining competenceEngages in ethical business practices

Competency: Demonstrates sensitivity and responsiveness to a diverse population, including but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation

Recognizes the impact that characteristics such as culture, age, gender, and disability has on patient preferences and perceptions, and how these factors influence the effective delivery of health careConsiders the impact of disability on a patient’s life and that of the family

6. Systems-Based Practice

Competency: Knows how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

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Becomes familiar with documentation criteria for different levels of care Differentiates between various medical practices, including hospital- and community-based models, PPO, and HMO health care delivery systemsDescribes the methods by which individuals or hospitals can be reimbursed, including fee-for-service, capitation, hospital DRGs, etc

Competency: Practices cost-effective health care and resource allocation that does not compromise quality of care

Considers cost/benefit analysis in providing clinical careIdentifies factors that contribute to rising health care costs and strives to lessen where appropriateRecognizes resource limitation within the health care system

Competency: Advocates for quality patient care and assists patients in dealing with the system complexities

Recognized potential conflicts of interest between the individual patients and their health care organizationsAnticipates problems patients/caregivers may face in negotiating the health care system and advocates on the patient’s behalf

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Hematology Consultation Service

Mission StatementTo provide the opportunity for fellows to learn the art and science of clinical care in a tertiary teaching hospital in the subspecialty discipline of hematology, to include the approach to the patient diagnosed with a hematologic disease, either primary or secondary, and the various treatment modalities available for these disorders

Program ObjectivesPatient Care: To improve basic clinical skills as applied to patients with hematologic diseasesTo become familiar with the indications for and procedures involved in apheresisMedical Knowledge: To learn diagnostic algorithms used in the evaluation of the various hematologic diseases encountered in hospitalized patients (see below)Practice-Based Learning and Improvement: see Core CompetenciesInterpersonal Skills and Communication: To improve skills in communicating with referring physicians and housestaff Professionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program ComponentsServices provided by the Hematology Consultation team include:Consultations at the University of Maryland Medical Center on the:

Medical inpatient unitsSurgical inpatient unitsIntensive care units (medical, surgical, neurosurgical)Shock-Trauma Transplantation serviceNeurology servicePsychiatric inpatient service

Follow-up visits after the patient’s discharge from the hospital, if indicatedBone marrow aspiration/biopsy procedures on inpatients (excluding those on the Cancer Center or Stem Cell Transplantation services)Supervision of the therapeutic apheresis proceduresSupervision of the use of hematologic “controlled” drugs (argatroban, lepirudin, recombinant activated factor VII)Consultations on the medical and surgical inpatient services (including the various intensive care units) at the Baltimore Veterans Administration Medical CenterOutpatient consultations for patients with benign hematological conditions, with appropriate follow-up visits

Focused Areas for StudyInpatient component:Evaluation of the causes and treatment of thrombocytopenia, to include bone marrow suppression, disseminated intravascular coagulation, heparin-induced thrombocytopenia, other drug-induced thrombocytopenias, hypersplenism, consumption Granulocytopenia (not chemotherapy-associated): causes and treatment, appropriate use of cytokines Causes of pancytopenia in hospitalized patientsGranulocytosis, monocytosis, eosinophilia: differential diagnosisThrombocytosis: causes, differentiation between primary and secondary, complications

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Thrombotic thrombocytopenic purpura and other causes of microangiopathic hemolytic anemiaApheresis: indications, procedures, complications Antiphospholipid syndromesManagement of complications of sickle cell anemia and other hemoglobinopathies, indications for exchange transfusion, role of red cell transfusion regimensNormal mechanisms of hemostasisRational approach to the bleeding patientCoagulopathies: inherited (factor deficiencies, von Willebrand’s disease)Coagulopathies: acquired (vitamin K, hepatic failure, iatrogenic, inhibitors)Effects of systemic diseases on hemostasis Acquired platelet function disordersUse of the various factor replacement products, complications of therapy Venous thrombosis, pulmonary embolusAnticoagulation, appropriate use of the various available agentsHypercoaguability: genetic, acquired factorsAnti-platelet agents: phamacokinetics, toxicities, indications, and interactionsHematologic issues in HIV-positive patientsHematologic issues in pregnancyHematologic complications of organ transplantEvaluation and treatment of lymphoproliferative disorders in the organ transplant patient (PTLD)

Outpatient component: Rational diagnostic approach to patients with anemiaProduction disorders: nutritional deficiencies, anemia of chronic disease, red cell aplasia, sideroblastic anemiaHemoglobinopathies: thalassemias, sickle cell, other congenital hemoglobinopathiesIdiopathic thrombocytopenic purpura

Educator RoleThe medical oncology fellow supervises the medical residents and medical students who participate in this elective rotation. The fellow evaluates the patient, has a preliminary discussion with the junior team member with regard to the diagnostic approach and the differential diagnosis, and makes suggestions for guidance to the appropriate resources. The fellow is also the person often responsible for communicating recommendations of the Hematology consult team and the rationale for them back to the housestaff of the referring service during the follow-up period.

Evaluation and FeedbackThe supervising attending physician will provide direct and written feedback to the fellow based upon direct observation and according to the following six competencies:

Patient Care1) Gathers essential and accurate information about the patient through interviews, examination, and complete history; appropriately accesses additional sources of information, such as other health care facilities, non-UMMC or BVAMC physicians, family members.2) Interacts with other health-care professionals to facilitate the process of diagnosis and treatment planning3) Carries out patient management plans based on age, other co-morbid conditions, psychosocial issues, including arranging appropriate follow-up of diagnostic tests

Medical Knowledge

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1) Understands the approach to the patient with primary or secondary hematologic disease2) Understands the theory and practice of the plasmapheresis and red cell exchange procedures3) Understands concepts regarding hematologic disorders which affect hospitalized patients4) Can identify abnormalities on peripheral blood smears, and make clinical inferences

Practice-Based Learning and Improvement1) Uses feedback to identify areas for improvement2) Seeks opportunities to strengthen deficits in knowledge/skills3) Demonstrates initiative in researching current scientific evidence using modern information technology and applying it to problems encountered in daily practice

Interpersonal and Communication Skills1) Communicates effectively with other members of a multi-disciplinary team2) Maintains a comprehensive, timely and legible medical record3) Communicates comprehensibly and compassionately with patients and their family members4) Provides accurate and timely feedback to the referring physicians

Professionalism1) Recognizes ethical dilemmas and utilizes appropriate consultation where needed2) Adheres to laws and rules governing the confidentiality of patient information3) Adheres to the institution’s Code of Conduct

Systems-Based Practice1) Demonstrates a commitment to the practice of cost-effective medical care and resource allocation2) Partners with other members of the health-care team to manage complex patient issues3) Advocates and facilitates patient advancement through the health care system

In the interest of improving the quality of the learning environment in the fellowship, the fellows must confidentially provide a written evaluation of each teaching attending at the end of the rotation. We also require that the fellows complete a questionnaire critically assessing the completeness of their acquisition of the knowledge expected for the rotation, and, if their knowledge acquisition is not adequate, their plans to “fill in the gaps”.

Reading ListTextbooks: Blood: Principles and Practice of Hematology, 2nd edition, ed. Handin, 2003.Hematology: Basic Principles and Practice, 4th edition, ed. Hoffman, et al., Elsevier, 2005.Williams Hematology, 6th edition, ed. Beutler, et al, McGraw-Hill, 2001. Wintrobe’s Clinical Hematology, 11th edition, ed. Greer, Lippincott, Williams & Wilkins, 2003.Consultative Hemostasis and Thrombosis, ed. Kitchens, et al, Elsevier Science, 2002.Blood Cells: A Practical Guide, 3rd edition, Bain, Blackwell Science, 2002.ASH Self-Assessment Program, 2nd edition

Journal articles: Madore F: Plasmapheresis: Technical aspects and indications. Crit Care Clin 2002;18:375-92.Smith JW, et al: Therapeutic apheresis: a summary of current indication categories endorsed by the AABB and the American Society for Apheresis. Transfusion 2003;43:820-822.Moake JL: Thrombotic Microangiopathies. N Engl J Med 2002;347:589-600.Rock GA, et al: Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. NEJM 1991;325:393-7.

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Bandarenko N, et al: United States Thrombotic Thrombocytopenic Purpura Apheresis Study Group: multicenter survey and retrospective analysis of current efficacy of therapeutic plasma exchange. J Clin Apheresis 1998;13:133-141.Coppo P, et al: High-dose plasma infusion versus plasma exchange as early treatment of thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome. Medicine 2003;82:27-38.McCrae K, Cines DB: Thrombotic microangiopathy during pregnancy. Semin Hematol 1997;34:148-158.Cines DB, Blanchette: Immune thrombocytopenic purpura. N Engl J Med 2002;346:995-1008.Cines DB, Bussel JB: How I treat idiopathic thrombocytopenic purpura (ITP). Blood 2005; 106:2244-2251.Kojouri et al: Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systemic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood 2004;104:2623-2634.George et al: Drug-induced thrombocytopenia: a systematic review of published case reports. Ann Intern Med 1998;129:886-890.Kelton JG: The pathophysiology of heparin-induced thrombocytopenia. Chest 2005;127:9S-20S.Warkentin TE: New approaches to the diagnosis of heparin-induced thrombocytopenia. Chest 2005;127:35S-45S.Gruel et al: Biological and clinical features of low-molecular-weight heparin-induced thrombocytopenia. Br J Haem 2003;121:786-792.Warkentin TE and Kelton JG: Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med 2001;344:1286-1292.Hassell K: The management of patients with heparin-induced thrombocytopenia who require anticoagulant therapy. Chest 2005;127:1S-8S.Di Nisio M, et al: Direct thrombin inhibitors. NEJM 2005; 353:1028-1040.Bartholomew JR: Transition to an oral anticoagulant in patients with heparin-induced thrombocytopenia. Chest 2005;127:27S-34S.Crowther et al: Thrombocytopenia in pregnancy: diagnosis, pathogenesis and management. Blood Reviews 1996;10:8-16.Bates SM and Ginsberg JS: How we manage venous thromboembolism during pregnancy. Bleed 2002;100:3470-3478.Greer IA and Nelson-Piercy C: Low-molecular weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005;106:401-407.Kearon C, Hirsch J: Management of anticoagulation before and after elective surgery. NEJM 1997;336:1506-1511.Prandoni P: How I treat venous thromboembolism in patients with cancer. Blood 2005;106:4027-33.Varki A. Trousseau's syndrome: multiple definitions and multiple mechanisms. Blood 2007;110:1723-9.Lyman G, Khorana AA, Falanga A, et al: ASCO Guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Onc 2007;34:5490-505.Roberts HR, et al: The use of recombinant factor VIIa in the treatment of bleeding disorders. Blood 2004;104:3858-3864Giannakopoulos B, Passam F, Rahgozar S, et al: Current concept on the pathogenesis of the antiphopholipid syndrome. Blood 2007;109:422-30.

Platt OS: The acute chest syndrome of sickle cell disease. N Engl J Med 2000;342:1904-47.

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Stem Cell Transplantation (SCT)

Mission StatementTo provide the opportunity for fellows develop the clinical skills and understanding necessary to become an outstanding provider of care for patients with diseases requiring high-dose chemotherapy and hematopoietic stem cell transplantation.

Program Objectives Patient Care: To actively participate in the management of patients undergoing allogeneic and autologous transplantation for diverse hematologic disorders (malignant and non-malignant) and high-risk solid tumors Medical Knowledge: To develop competence in the pre-transplant outpatient evaluation of patients, including clinical staging and HLA typing, synthesis of an appropriate clinical plan, and discussion of risks and benefits of treatment alternatives including informed consent for chemotherapy and clinical trials.To acquire and understanding of the disorders for which stem cell transplantation offers potential cure, and the general requirements, which a patient must meet in order to undergo transplant.Practice-Based Learning: see Core CompetenciesInterpersonal Skills and Communication: To understand the importance of the "Team" approach to clinical BMT, and to facilitate its implementation, by interacting well with peers, coordinators, nurses, pharmacists, data managers, etc.Professionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program ComponentsThe Stem Cell Transplantation unit is a state-of-the-art, self-contained 16-bed inpatient unit plus a separately designated outpatient clinic area. Each room is supplied with only HEPA filtered air under positive pressure. The entire unit is totally separate from the rest of the cancer center with its own air lock double door entrance. Highly specialized resources facilitate the clinical and basic research efforts of the Stem Cell Transplant Program. The stem cell collection and storage facilities are located on the same floor, and the fellow is exposed to them and the procedures performed in them.

Fellows are required to examine all patients, elicit the histories of the patients, and in the case of new patients review all outside records. Fellows are required to make rounds daily on all inpatients with the attending physician, and write a daily progress note on all inpatients. Under supervision of the attending physician, the fellow performs procedures such as bone marrow aspirations and biopsies, as well as other procedures required on patients.

Teaching functions include daily attending rounds with the transplant team (attending physician, nurses, dental hygienist, social worker, and pharmacist), scheduled weekly lectures on topics related to stem cell transplantation, discussions of patient problems on a one to one basis with the attending and/or other consultants. A selected reading list of topics related to transplant and review of blood smears, bone marrows, pathology slides and radiology materials are part of the teaching agenda. The fellow is expected to attend and participate actively in the weekly bone marrow transplant patient conference in which all patients (potential transplants, patients in the process of evaluation, patients undergoing transplant and long term follow ups) are discussed with specialists in multiple fields including the HLA laboratory, pathology, radiology, pediatric transplantation, oral surgery, pharmacy, and nursing. Once a month, the fellow selects and

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prepares a topic for discussion, including literature review, analysis of current clinical and laboratory data, and correlations with patient material. In addition, the fellow is exposed to the stem cell laboratory where stem cell products are collected, and learns some of the basic concepts of graft engineering and stem cell manipulation for transplant. As time and interest permit, they are encouraged to identify a problem in clinical transplantation or basic science relevant to transplantation, allowing them in subsequent elective months to execute a transplant-related research project.

Focused Areas for StudyLearn recent advances in basic and clinical aspects of transplant immunobiologyIdentify appropriateness of stem cell product therapy, growth factor therapy, and transfusion medicine as is relevant to transplantationIdentify, stage and manage acute and chronic GVHDIdentify and manage infectious complications of transplantation including suspected and documented bacterial, viral and/or fungal infectionsManage thrombotic and hemorrhagic complications of transplantation including bleeding, DIC, TTP, and deep venous thrombosesDiagnose and manage other complications of transplantation, including hemorrhagic cystitis, diffuse alveolar hemorrhage, veno-occlusive disease, and graft failureDiscuss prognosis and options for supportive care of terminally ill patientsFormulate a follow-up plan and educate patients at dischargeUnderstand principles of apheresis and photopheresis as relevant to stem cell collection and for the treatment of TTP and GVHD Understand contraindications to and complications of apheresisManage autologous and allogeneic transplant patients in the outpatient setting and assist in the transition of care to referring physicians when appropriateIdentify indications and contraindications for marrow harvest, evaluate patient for marrow harvest, and learn to perform and manage complications of harvest

Educator RoleThe fellow works on the bone marrow transplant unit along with nurse practitioners, who have achieved considerable expertise in the area of transplant mechanics and complications, but are somewhat less knowledgeable in related areas of internal medicine. The fellow’s internal medicine experience allows him/her to serve as a resource for the team, while gaining skills as a teacher for professionals with a different educational background.



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Medical Knowledge1) Understands the biology underlying the stem cell transplant procedure2) Understands the evaluation and indications for the procedure3) Understands the diagnosis and management of the many complications that can befall the patient who has undergone a stem cell transplant.





In the interest of improving the quality of the learning environment in the fellowship, the fellows must confidentially provide a written evaluation of each teaching attending at the end of the rotation. We also require that the fellows complete a questionnaire critically assessing the completeness of their acquisition of the knowledge expected for the rotation, and, if their knowledge acquisition

Reading ListJournal Articles: Choi S-J, et al: Post-transplant complications: Peri-engraftment clinical abnormalities following allogeneic hematopoietic cell transplantation: a retrospective review of 216 patients. Bone Marrow Transplantation 2003;32, 809–813.Marsh, JCW, et al: Guidelines for the diagnosis and management of acquired aplastic anemia. Br J Haemat 2003;123:782–801.Brodsky R, Jones RJ: Aplastic anaemia. Lancet 2005;365:1647-1656.Prospective Trial of Chemotherapy and Donor LeukocyteLevine JE: Infusions for relapse of advanced myeloid malignancies after allogeneic stem-cell transplantation. J Clin Oncol 2002;20:405-412.Schots R, et al: Proinflammatory cytokines and their role in the development of major transplant-related complications in the early phase after allogeneic bone marrow transplantation. Leukemia 2003;17:1150–1156.Akpek G, et al: Hepatitic variant of graft-versus-host disease after donor lymphocyte infusion. Blood 2002;100:3903-3907.

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Dispenzieri A, et al: Superior survival in primary systemic amyloidosis patients undergoing peripheral blood stem cell transplantation: a case-control study. Blood. 2004;103:3960-3963.Bensinger WB, et al: Transplantation of bone marrow as compared with peripheral blood cell from HLA-identical relatives in patients with hematologic cancers. N Engl J Med 2001;344:175-81.Reddy P, Ferrara JLM: Immunobiology of acute graft-versus-host disease. Blood Reviews 2003; 17,187–194.De Lima M, et al: Once-daily intravenous busulfan and fludarabine: clinical and pharmacokineticresults of a myeloablative, reduced-toxicity conditioning regimen for allogeneic stem cell transplantation in AML and MDS. Blood 2004;104:857-864.Bertz H, et al: Allogeneic stem-cell transplantation from related and unrelated donors in older patients with myeloid leukemia. J Clin Oncol 2003;21:1480-1484. Wong R, et al: Prognostic factors for outcomes of patients with refractory or relapsed acute myelogenous leukemia or myelodysplastic syndromes undergoing allogeneic progenitor cell transplantation. Biol Blood Bone Marrow Transplant 2005;11:108-114.Acute Myeloid Leukemia NCCN Clinical Guidelines in Oncology, Version 2.2005. www.nccn.org/professionals/physician_gls/default.aspCraddock C, et al: Biology and management of relapsed acute myeloid leukaemia. Br J Haematol 2005;129:18-34.Chang JC, El-Sayed MA: Acute respiratory distress syndrome as a major clinical manifestation of thrombotic thrombocytopenic purpura. Am J Med Sci 2001;321:124-128.Hahn T, et al: The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of diffuse large cell B-cell non-Hodgkin’s lymphoma: an evidence-based review. Biol Blood Bone Marrow Transplant 2001;7:308-331.Lee, et al: Chronic graft-versus-host disease. Biol Bone Marrow Transplant 2003;9:215-233.Vogelsang G: How I treat chronic graft-versus-host disease. Blood 2001;97:1196-1201.Lee SJ: New approaches for preventing and treating chronic graft-versus-host disease. Blood 2005;105:4200-4206.Mohty M, et al: Chronic graft-versus-host disease after allogeneic blood stem cell transplantation: long-term results of randomized study. Blood 2002;100:3128-3134.Sorror ML, et al: Hematopoietic cell transplantation after nonmyeloablative conditioning for advanced chronic lymphocytic leukemia. J Clin Oncol 2005;23:1-11.Goldman JM, Melo JV: Chronic myeloid leukemia – advances in biology and new approaches to treatment. N Engl J Med 2003;349:1451-1464.De Maar EF, et al: Pulmonary involvement during cytomegalovirus infection in immunosuppressed patients. Transpl Infect Dis 2003;5:112-120.Mylonakis E, et al: Combination antiviral therapy for ganciclovir-resistant cytomegalovirus infection in solid-organ transplant recipients. CID 2002;34:1337-1341.Riddell SR, et al: The graft versus leukemia response after allogeneic hematopoietic stem cell transplantation. Blood Rev 2003;17:153-162.Antin JH: Long-term care after hematopoietic-cell transplantation in adults. N Engl J Med 2002;347:36-42.Busca A, et al: Infectious complications following nonmyeloablative allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2003;5:132-139.Sullivan KM, et al: Preventing opportunistic infections after hematopoietic stem cell transplantation: the CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation practice guidelines and beyond. ASH Education Book 2001, 392-421.Hosing C, et al: Long-term results favor allogenic over autologous hematopoietic stem cell transplantation in patients with refractory or recurrent indolent non-Hodgkin’s lymphoma. Ann Oncol 2003;14:737-744.

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http://www.nccn.org/professionals/physician_gls/default.asp

Van Besien, et al: Comparison of autologous and allogeneic hematopoietic stem cell transplantation for follicular lymphoma. Blood 2003;102:3521-3529.Schouten HC, et al: High-dose therapy improves progression-free survival and survival in relapsed follicular non-Hodgkin’s lymphoma: results from the randomized European CUP trial. J Clin Oncol 2003;21:3918-3927.Hunault-Berger M, et al: Intensive therapies in follicular non-Hodgkin’s lymphomas. Blood 2002;100:1141-1152.Afessa B, et al: Bronchiolitis obliterans and other late onset non-infectious pulmonary complications in hematopoietic stem cell transplantation. Bone Marrow Transplantation 2001;28:425-434.Ganti AK, et al: Hematopoietic stem cell transplantation in mantle cell lymphoma. Ann Oncol 2005:618-624.Vandenberghe E, et al: Outcome of autologous transplantation for mantle cell lymphoma: a study by the European Blood and Bone Marrow Transplant and Autologous Blood and Marrow Transplant Registries. Br J Haematol 2003;120:793-800.Rifkind J, et al: Allogenic stem cell transplantation for mantle cell lymphoma – does it deserve a better look? Leuk Lymph 2005;46”217-223.Scott BL, et al: Pretransplantation induction chemotherapy and posttransplantation relapse in patients with advanced myelodysplastic syndrome. Biol Blood Marrow Transplant 2005;11:65-73.Cutler CS, et al: A decision analysis of allogeneic bone marrow transplantation for the myelodysplastic syndromes: delayed transplantation for low-risk myelodysplasia is associated with improved outcome. Blood 2004;104:579-585.Gibson J, et al: Evolving transplant ooptions for multiple myeloma: autologous and nonmyeloablative allogeneic. Transplant Proc 2004;36:2501-2503.Morris C, et al: Benefit and timing of second transplantations in multiple myeloma: clinical findings and methodological limitations in a European Group for Blood and marrow Transplantation Registry Study. J Clin Oncol 2004;9:1674-1681.Rondelli E, et al: Allogeneic hematopoietic stem-cell transplantation with reduced-intensity conditioning in intermediate- or high-risk patients with myelofibrosis with myeloid metaplasia. Blood 2005;105:4115-4119.Sorror ML, et al: Comparing morbidity and mortality of HLA-matched unrelated donor hematopoietic cell transplantation after nonmyleoablative and myeloablative conditioning: influence of pretransplantation comorbidities. Blood 2004;104:961-968.Peggs KS, et al: The role of allogeneic transplantation in non-Hodgkin’s lymphoma. Br J Haematol 2004;128:153-168.Non-Hodgkin;s Lymphoma, NCCN Guidelines in Clinical Oncology, version 1.2005. www.nccn.org/professionals/physician_gls/default.aspHamlin PA, et al: Age-adjusted International Prognostic Index predicts autologous stem cell transplantation outcome for patients with relapsed or primary refractory diffuse large B-cell lymphoma. Blood 2003;102:1989-1996.Alyea EP, et al: Comparative outcome of nonmyeloablative and myeloablative allogeneic hematopoietic cell transplantation for patients older than 50 years of age. Blood 2005;105:1810-1814.Dreger P, et al: Reduced-intensity conditioning lowers treatment-related mortality of allogeneic stem cell transplantation for chronic lymphocytic leukemia: a population-matched analysis. Leukemia 2005;19:1029-1033.Kerbauy FR, et al: Hematopoietic cell transplantation from HLA-identical sibling donors after low-dose radiation-based conditioning for treatment of CML. Leukemia 2005;19:990-997.

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http://www.nccn.org/professionals/physician_gls/default.asp

Shimoni A, et al: Hematopoietic stem-cell transplantation from unrelated donors in elderly patients with hematologic malignancies: older age is no longer a contraindication when using reduced intensity conditioning. Leukemia 2005;19:7-12.Gorak E, et al: Engraftment syndrome after nonmyeloablative allogeneic hematopoietic stem cell transplantation: incidence and effects on survival. Biol Blood Marrow Transplant 2005;11:542-550.Khouri IF, et al: Nonablative allogeneic stem-cell transplantation for advanced/recurrent mantle cell lymphoma. J Clin Oncol 2003;21:4407-4412.Sarwani P, et al: Reduced-intensity allogeneic stem cell transplantation in adults and children with malignant and nonmalignant diseases: end of the beginning and future challenges. Biol Blood Marrow Transplant 2005;11:403-422.Shimoni A, et al: Thrombotic microangiopathy after allogeneic stem cell transplantation in the era of reduced-intensity conditioning: the incidence is not reduced. Biol Blood Marrow Transplant 2004;10:484-493.Loren AW, et al: Post-transplant lymphoproliferative disorder: a review. Bone Marrow Transplant 2003;31:145-155.SakaidaE, et al: Late-onset noninfectious pulmonary complications after allogeneic stme cell transplantation are significantly associated with chronic graft-versus-host disease and with the graft-versus-leukemia effect. Blood 2003;102:4236-4242.Silliman CC, et al: Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood 2003;101:454-462.Elliott MA, et al: Posttransplantation thrombotic thrombocytopenic purpura: a single-center experience and a contemporary review. Mayo Clin Proc 2003;78:421-430.Cutler C, et al: Sirolimus and thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2005;11:551-557.Ballen KK: New trends in umbilical cord blood transplantation. Blood 2005;105:3786-3792.Narimatsu H, et al: Bloodstream infection after umbilical cord blood transplantation using reduced-intensity stem cell transplantation for adult patients. Biol Blood Marrow Transplant 2005;11:429-436.Wadleigh M, et al: Prior gemtuzumab ozogamicin exposure significantly increases the risk of veno-occlusive disease in patients who undergo myeloablative allogeneic stem cell transplantation. Blood 2003;102:1578-1582.Coppell JA, et al: Veno-occlusive disease: cytokines, genetics, and haemostasis. Blood Rev 2003;17:63-70.Lowsky r, et al: Protective conditioning for acute graft-versus-host disease. NEJM 2005;353:1321-32.

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Malignant Hematologic DisordersLeukemia/Lymphoma Inpatient Service

Mission StatementTo provide the opportunity for fellows to learn the art and science of clinical care in a tertiary teaching hospital in the subspecialty discipline hematology/oncology-hematologic malignancies. As a result of clinical rotation on the Leukemia/Lymphoma Inpatient Service, fellows will become familiar with specific diagnostic and treatment modalities, as well as the complex medical management of complications (e.g., infectious diseases, bleeding diastheses, tumor lysis syndromes) arising from both the disease and the treatment.

Program ObjectivesPatient Care: To improve basic clinical skills as applied to patients with hematologic malignancies, in particular acute leukemias and aggressive lymphomasTo learn to manage acute clinical situations associated with the treatment of leukemias and lymphomas, such as tumor-lysis syndrome, bleeding diathesis, disseminated intravascular coagulation (DIC), febrile neutropeniaTo become familiar with the indications for and procedures such as bone marrow aspirate/biopsy, spinal tap with administration of intrathecal chemotherapy, and to develop competency in the performance of the procedures Medical Knowledge: To learn diagnostic and prognostic algorithms used in the evaluation and therapeutic-decision making for various hematologic malignancies (see below for details)To become familiar with the chemotherapeutic approaches used in the treatment of leukemias and lymphoma, their side effects and the management of the side effectsPractice-Based Learning: see Core CompetenciesInterpersonal Skills and Communication: To improve skills in communicating with referring and consulting physicians and housestaffProfessionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program ComponentsThe inpatient Leukemia/Lymphoma service consists of 15 inpatient beds located on 9 West for the intensive induction and consolidation chemotherapies of newly diagnosed and relapsed leukemias, lymphomas and myelomas, including the complex lymphoproliferative disorders arising in immunocompromised patients post-solid organ transplantation or in the setting of HIV/AIDS.

Hematology/Oncology fellows participate actively in all aspects of the UMGCC inpatient and outpatient effort in hematologic malignancies, and are exposed to the entire spectrum of these diseases with respect to clinical presentation, molecular and histologic features, experimental therapeutics, and management of emergency syndromes such as leukostasis, disseminated intravascular coagulation, tumor lysis syndrome and hyperviscosity. Fellows also perform procedures such as bone marrow aspirate/biopsy, spinal tap with administration of intrathecal chemotherapy. All procedures are supervised. All fundamental diagnostic studies (e.g., marrow interpretation, histopathology, immunohistochemistry, flow cytometry/immunophenotyping, cytogenetics, radiology) are reviewed with the fellow. Teaching rounds are made both at the bedside and at the multi-headed microscope in order to review bone marrow, peripheral blood, biopsy tissue and body fluid morphology and histopathology.

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Focused Areas for Study1. Develop expertise in the clinical, histologic and molecular diagnosis and management of

the broad spectrum of hematologic malignancies (leukemias, lymphomas, myeloma). It includes the knowledge of FAB and WHO classification for acute and chronic leukemias, myelodysplasias, and lymphomas.

2. Recognize and manage the emergency syndromes that can accompany the acute presentation of certain leukemias and lymphomas (e.g., leukostasis, DIC, tumor lysis syndromes).

3. Understand and actively participate in the therapeutic decision-making and multifaceted treatment of hematologic malignancies. It includes the knowledge of prognostic factors, need for evaluation and treatment of extramedullary sites of disease (e.g. CNS prophylaxis in ALL) and making therapeutic decision based on prognostic factors. It also includes an understanding the standard treatment for each type of disease (e.g. AML: induction, consolidation, need for further treatment such as stem cell transplant, treatment options for relapse or refractory disease; ALL: induction, consolidation, stem cell transplant; myelodysplasia: treatment dependent on type and symptoms, immunomodulatory agents, differentiation agents). Recognition of the specific factors guiding treatment in the elderly, with their different tolerance of the treatment and different prognosis. Introduction to novel therapeutic concepts through clinical trials.

4. Learn to interpret and integrate the information derived from peripheral blood smears, bone marrow aspirates and biopsies, cytogenetic analyses, biochemical and immunohistochemical staining patterns, and flow cytometric immunophenotypic patterns in order to make a specific diagnosis and implement targeted therapy for the broad diversity of hematologic malignancies.

5. Become competent in the performance of bone marrow biopsy and aspiration, and in the intrathecal administration of chemotherapy for central nervous system leukemia and lymphoma.

6. Develop expertise in transfusion medicine as it applies to the myelosuppressed patient with leukemia and lymphoma.

7. Develop an in-depth understanding of the pathogenesis, pathophysiology and clinical management of the infectious complications that commonly accompany the hematologic malignancies and the intensive myelosuppressive therapies.

8. Acquire theoretical and working knowledge regarding the potential applications and complications of hematopoietic cytokines (colony stimulating factors, thrombopoietin) in managing disease- and treatment-related marrow suppression.

Educator RoleThe medical oncology fellow supervises the medical residents and medical students who participate in this rotation. The fellow evaluates the patient, has a preliminary discussion with the junior team member with regard to the diagnostic approach and the differential diagnosis, the therapeutic approach, and makes suggestions for guidance to the appropriate resources. During this rotation, the fellow is also responsible for the selection of patients for the Leukemia/Lymphoma Conference, and leads the discussion of the diagnosis, prognosis and therapeutic options available for the patients presented.


Patient Care

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1) Gathers essential and accurate information about the patient through interviews, examination, and complete history; appropriately accesses additional sources of information, such as other health care facilities, non-UMMC or BVAMC physicians, family members.2) Interacts with other health-care professionals to facilitate the process of diagnosis and treatment planning3) Carries out patient management plans based on age, other co-morbid conditions, psychosocial issues, including arranging appropriate follow-up of diagnostic tests

Medical Knowledge1) Understands the approach to the patient with known or suspected hematologic malignancy such as leukemia, lymphoma, etc.2) Understands the principles of chemotherapeutic drugs and their administration3) Understands concepts regarding central nervous system involvement with hematologic malignancies, prophylactic central nervous system treatment, oncologic emergencies such as spinal cord compression, cranial nerve palsies, tumor lysis syndrome etc.






Reading List

Journal Articles: Yates J, et al: Cytosine arabinoside with daunorubicin or adriamycin for therapy of AML: a CALGB study. Blood 1982;60:454-462.Bishop JF, et al: A randomized trial of high-dose cytarabine in induction in AML. Blood 1996;87:1710-1717.

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Berman E, et al: Results of a randomized trial comparing idarubicin and cytosine arabinoside with daunorubicin and cytosine arabinoside in adult patients with newly diagnosed AML. Blood 1991;77:1666-74.Vogler WR, et al: Phase III trial comparing idarubicin and daunorubicin in combination with cytarabine in AML: a Southeastern Cancer Study Group Study. J Clin Oncol 1992;10:1103-11.Wiernik PH, et al: Cytarabine plus idarubicin or daunorubicin as induction and consolidation therapy for previously untreated adult patients with AML. Blood 1992;79:313.Cassileth PA, et al: Maintenance chemotherapy prolongs remission duration in adult ANLL. J Clin Oncol 1988;6:583-7.Mayer RJ, et al: Intensive postremission chemotherapy in adults with AML. CALGB. N Engl J Med1994;331:896-903.Zittoun RA, et al: Autologous or allogeneic bone marrow transplantation compared with intensive chemotherapy in AML. EORTC and GIMEMA. N Engl J Med 1995;332:217-23.Burnett AK, et al: Randomized comparison of addition of autologous bone marrow transplantation to intensive chemotherapy for AML in first remission: results of MRC AML 10 trial. Lancet 1998;351:700-8.Cassileth PA, et al: Chemotherapy compared with autologous or allogeneic bone marrow transplantation in the management of AMLin first remission. N Engl J Med 1998;339:1649-56.Harousseau JL, et al: Comparison of autologous bone marrow transplantation and intensive chemotherapy as post remission therapy in adult AML. Goelam. Blood 1997;90;2978-86.Giles F, et al: Gemtuzumab ozogamicin in the treatment of AML. Cancer 2003;989:2095-2104.Goldman JM: How I treat chronic myeloid leukemia in the imatinib era. Blood 2007;110:2828-37.Evans WE, Pui C-H: Treatment of acute lymphoblastic leukemia. NEJM 2006;354:166-78.Larson RA, et al: A five-drug regimen with intensive consolidation for adults with ALL: CALGB study 8811, Blood 1995;84:2025-37.Annino L, et al: Treatment of adults with ALL: long-term follow-up of the GIMEMA ALL 0288 randomized study. Blood 2002;99:863-71.Kantarjian HM, et al: results of treatment with hyper-CVAD, a dose-intensivc regimen, in adult ALL. J Clin Oncol 2000;18:547-61.Thomas DA, et al: Hyper-CVAD program in Burkitt’s type adult ALL. J Clin Oncol 1999;17:2461-70.Magrath K, et al: Adults and children with small on-cleaved-cell lymphoma have a similar excellent outcome when treated with the same chemotherapy regimen. J Clin Oncol 1996;14:925-34.Schlichter SJ: Optimizing platelet transfusions in chronically thrombocytopenic patients, Semin Hematol 1998;35:269-78.

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Solid Tumors

Mission StatementTo provide the opportunity for fellows to learn the art and science of clinical care of patients with the full spectrum of solid malignancies as they undergo multi-faceted diagnostic evaluation, and to select among the many available therapeutic choices the most appropriate for each patient, considering the many facets of both the disease and the patient

Program ObjectivesPatient Care: Understand and actively participate in the therapeutic decision-making and multimodality treatment of solid malignanciesLearn to interpret and integrate the information derived from tissue biopsy specimens, molecular analyses (including biochemical and immunohistochemical staining patterns), and imaging studies in order to make a specific diagnosis and implement targeted therapy for the broad diversity of solid malignanciesRecognize and manage the emergency syndromes that can accompany the acute presentation of diverse cancers (e.g. cord compression, hypercalcemia, tumor lysis, superior vena cava syndrome)Become competent in the performance of invasive diagnostic and therapeutic thoracenteses, paracenteses, and lumbar punctures, including installation of chemotherapeutic and biologic agents through these routesMedical Knowledge: Develop expertise in the clinical, histologic and molecular diagnosis and management of the broad spectrum of solid malignancies (see below for details)Acquire theoretical and working knowledge regarding applications and complications of biologic response modifiers (interferons, interleukins, colony stimulating factors) as direct antitumor agents or as adjuncts to therapyAcquire a knowledge of the molecular and cellular biologic principles that underlie the new “targeted” agents, and an understanding of the ongoing studies that will clarify their role as anti-cancer agents Develop knowledge and fluency in the areas of pain management, nutrition, and social issues (including hospice) related to patients with cancerPractice-Based Learning: Develop skills necessary to design, conduct and analyze clinical trials, with the aim of becoming an independent clinical investigatorInterpersonal Skills and Communication: see Core CompetenciesProfessionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program ComponentsOutpatient consultations and outpatient follow-up visits in the Rosalyn and Leonard Stoler Pavilion at UMMSInpatient consultations at UMMS on patients in the medical and surgical servicesConsultations in conjunction with multiple specialists, including surgical oncologists, radiation oncologists, internal medicine subspecialists, radiologists at weekly multi-disciplinary clinicsCase presentations and discussions at the subspecialty multidisciplinary conferencesPatient enrollment in some of the many local and national phase I, II, and III clinical trials ongoing at UMMS in all subspecialty areas

Subspecialty-specific Program ComponentsGastrointestinal Malignancies

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• Collaborative effort among medical oncology, medical gastroenterologists, GI surgery, interventional radiology and radiation oncology, pathology and molecular genetics

• Multidisciplinary GI Malignancy Case Conference (bimonthly) for case presentation, discussion and on-site patient evaluation by multiple specialists provide integrated consultation and multimodality therapeutic planning in one coordinated clinic visit

• UMMS and BVAMC have parallel programs, with shared protocols and participation of the same medical, surgical and radiation oncologists

• Emphasis on multimodality experimental therapeutics for gastric, pancreatic, hepatic, and colorectal cancers; focus on innovative clinical trials of vaccines, high-dose brachytherapy combined with chemotherapy for hepatic and pancreatic cancers, arterial infusional therapies, phase I studies of novel antitumor agents

Breast Cancer• Active clinical investigation focusing on both chemotherapy and hormonal therapy in all

stages of breast cancer (both CALGB and institutional clinical trials)• Multidisciplinary Breast Evaluation Program: medical and surgical oncology, plastic surgery,

and radiology provide integrated consultation and therapeutic planning at a single encounter for a single fee (weekly clinic)

• Multimodality Breast Pathology Conference: medical and radiation oncologists, pathologists, surgeons, and mammographers review biopsy tissue histology and correlate histopathology with mammographic pattern and formulate a multidisciplinary treatment approach

Genitourinary Malignancies• Development of clinical trials of chemotherapy, hormonal, and vaccine strategies in all stages

of prostate cancer (institutional and CALGB trials)• UMMS and BVAMC have parallel programs with shared protocols and participation of the

same team of medical, surgical (urologic) and radiation oncologists• Multidisciplinary GU conference for prostate, renal and bladder cancers: medical oncologists,

urologists, radiation oncologists, radiologists and pathologists meet twice weekly for case presentation, discussion and multimodality therapeutic planning

Gynecologic Oncology • Interdisciplinary approach among gynecologic surgery, surgical oncology and radiation

oncology• Multimodality clinic meeting every other week• Active involvement in national cooperative group trials

Head and Neck Cancer• Integrated approach among medical oncology radiation oncology pathology, otolaryngology,

oral/maxillofacial surgery, dentistry, speech rehabilitation, plastic and general surgery, and nutrition

• Cooperative training for residents training in medical hematology/oncology, surgical otolaryngology and oral/maxillofacial, and radiation therapy

• UMMS and BVMAC have parallel programs, with participation of the same radiation oncologists and a conjoint medical-surgical clinic at BVMAC

• Highly active translation research program for all stages of disease, including institutional and cooperative group trials in advanced locoregional disease; experimental radiation therapy; therapeutic vaccine trials

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Thoracic Malignancies• Interdisciplinary approach among medical, surgical and radiation oncology, radiology,

pathology and pulmonary medicine• Multimodality clinic at UMMS and BVMAC, twice-weekly case management conferences

with on-site radiology review by computerized tomographic radiologist• Active involvement in design and conduct of CALGB and novel institutional multimodality

protocols for esophageal and lung cancers• Program in molecular epidemiology of pre-malignant and malignant esophageal lesions, with

collaboration among thoracic surgery, medical oncology and gastroenterology: focus on rapid molecular diagnosis, novel therapy and prevention

Focused Areas for Study

Gastrointestinal MalignanciesAnal Cancer: epidemiology, pathogenesis, pathology, tumor biology, risk factors, prevention, screening, diagnosis, biopsy, imaging, staging and prognostic factors, treatment by stage (stage I, local disease, positive inguinal nodes, recurrent of residual disease, metastatic disease), follow-upBiliary Tree Cancer: epidemiology, pathogenesis, pathology, tumor biology, risk factors, diagnosis, imaging, staging, prognostic factors, treatment by stage (resectable, unresectable, advanced or recurrent), supportive careColorectal cancer: epidemiology, pathology, genetic syndromes, pathogenesis, assessment of risk, prevention, screening, diagnosis, staging and prognostic factors, treatment by stage (adjuvant therapy for stage II or III disease, metastatic and recurrent disease, regional metastases), follow-up after curative resection, supportive careGallbladder Cancer: epidemiology, pathogenesis, pathology, tumor biology, diagnosis, imaging, staging and prognostic factors, treatment by stage (T1/T2, T3/T4, evaluation after laparoscopic cholecystectomy, recurrent or metastatic disease), supportive careGastric Cancer: epidemiology, pathogenesis, pathology, tumor biology, screening, diagnosis, imaging, staging, treatment by stage (resectable, unresectable and metastatic)Hepatocellular Cancer: epidemiology, pathogenesis, pathology, tumor biology, genetics and molecular markers, viral factors, chemical exposure, prevention, screening, diagnosis, imaging, tumor markers, staging and prognostic factors, treatment (resectable, unresectable liver-only, metastatic)Neuroendocrine (carcinoid) Tumors: epidemiology, hereditary syndromes pathogenesis, pathology, tumor biology, histochemistry and products, genetic syndromes, diagnosis, screening, prognostic factors, treatment (surgery, somatostatin analog therapy, chemotherapy, palliative therapy, liver-directed therapy)Pancreatic Cancer: epidemiology, pathology, genetic and molecular factors, risk factors, genetic factors, prevention, diagnosis, biopsy, imaging, staging, prognostic factors, treatment by stage (resectable, unresectable, metastatic and recurrent), follow-up after curative resection, supportive careGastrointestinal Stromal Tumors: epidemiology, pathology, pathogenesis, diagnosis, imaging, staging, treatment by stage

Breast CancerEpidemiology, pathogenesis, pathology, tumor biologyGenetic factors, assessment of risk, preventionScreening, diagnosis, biopsy, staging, prognostic factors

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Treatment by stage: premalignant, carcinoma-in-situ, early-stage invasive, locally advanced, locally recurrent, metastaticHormonal therapy, trastuzumab and other biologic therapySupportive care: psychosocial issues, lymphedema, bisphosphonate therapy, menopausal symptoms, sexuality and fertility, cognitive dysfunction, surgical reconstructionMale breast cancer

Genitourinary MalignanciesBladder (ureter, renal pelvis) Cancer: epidemiology, pathology, chemical and infectious causes, genetic factors, prevention, screening, diagnosis, imaging, staging, prognostic factors, treatment by stage (superficial, early-stage and locally advanced, recurrent and metastatic) follow-up after curative resection, supportive careGerm Cell Tumors: epidemiology, pathology, genetic factors, diagnosis, imaging, molecular markers, serum markers, staging, prognostic factors, treatment by histology (seminoma vs non-seminoma) and stage (I, II, III, metastatic or recurrent), residual disease, follow-up, supportive care, fertility and sexuality issuesPenile Cancer: epidemiology, pathology, pathogenesis (HPV, premalignant lesions), prevention, diagnosis, staging, treatment by stage (treatment of primary lesion, management of regional nodes, metastatic or recurrent disease), supportive careProstate Cancer: epidemiology, genetic factors, risk factors, prevention, screening, diagnosis, imaging, staging, prognostic factors, treatment by stage (organ confined, rising PSA, locally recurrent, metastatic), follow-up, supportive care (sexuality, incontinence, proctitis, osteoporosis, hot flashes), small-cell carcinomaRenal Cell Cancer: epidemiology, pathology, genetic factors, risk factors, prevention, diagnosis, imaging, staging, prognostic factors, treatment by stage (localized disease, metastatic disease), follow-up, supportive care, bilateral tumors, Wilms’ tumor, oncocytoma, collecting system tumor

Gynecologic OncologyCervical Cancer: epidemiology, pathogenesis (HPV, immunosuppression/HIV, lifestyle factors), pathology, tumor biology, prevention, screening, diagnosis, staging and prognostic factors (clinical staging, prognostic factors), treatment by stage (microinvasive and other IA, IB-IIA, locally advanced, recurrent and metastatic), supportive care (treatment-related complications, ureteral obstruction)Ovarian Cancer: epidemiology, pathogenesis, pathology, tumor biology, genetics (BRCA1 and 2, hereditary non-polyposis colorectal cancer syndromes), prevention and genetic counseling, screening, diagnosis (clinical presentation, imaging, diagnostic laparoscopy, serum markers), prognostic factors, staging, treatment by stage (stage I vs all others, secondary surgical procedures, recurrent or metastatic disease), follow-up, supportive care, non-epithelial cancer (stromal, germ cell tumors), low-malignant potential cancersUterine Cancer: epidemiology, pathogenesis, genetic syndromes, assessment of risk, tumor biology, diagnosis, imaging, biopsy, staging, treatment by stage, sarcomas and mixed mesodermal tumors, gestational trophoblastic diseaseVulvar and Vaginal Cancers: epidemiology, pathology, pathogenesis (HPV, immunosuppression, tobacco use), diagnosis, staging, treatment by stage (microinvasive, early, locally advanced), supportive care

Head and Neck CancersHead and Neck Squamous Cell Cancers: epidemiology, pathology, genetic and molecular factors, lifestyle and viral factors, prevention, screening, diagnosis, imaging, staging, prognostic factors, treatment – site (hypopharynx, larynx, nasal, nasopharynx, oral cavity, oropharynx) and stage specific, follow-up, supportive care

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Salivary Gland Tumors: epidemiology, pathology, diagnosis, imaging, staging, treatment by stage (resectable, unresectable/locally advanced, metastatic)Thyroid Cancer: epidemiology, pathology, genetic syndromes, risk factors, diagnosis, screening, staging, treatment (well-differentiated, anaplastic, medullary), follow-up, supportive care

Thoracic MalignanciesLung Cancer: epidemiology, pathology, risk factors, prevention, screening, diagnosis, imaging, staging, prognostic factors, treatment by histology (non-small cell vs small cell) and stage (pre-op evaluation, carcinoma-in-situ, early-stage, locally advanced, metastatic or limited/extensive), follow-up, supportive care, bronchoalveolar, Pancoast tumors, treatment of isolated metastasesEsophageal cancer: epidemiology, pathogenesis, pathology, tumor biology, prevention, diagnosis, imaging, staging and prognostic factors, treatment by stage (local-regional, recurrent and metastatic), supportive careMesothelioma: epidemiology, pathology, prevention, diagnosis, staging, prognostic factors, treatment by stage (stage I, unresectable, recurrent and metastatic), management of effusions, peritoneal mesothelioma, benign mesotheliomasThymomas and Thymic Cancer: epidemiology, pathology, risk factors, diagnosis, associated systemic syndromes, staging, prognostic factors, treatment by stage (localized, recurrent or metastatic)



Medical Knowledge1) Understands the approach to the patient with known or suspected malignant disease2) Understands the principles of chemotherapeutic drugs and their administration3) Understands concepts regarding diagnostic procedures, imaging studies, pathologic interpretation, multimodality therapy of solid tumors, including chemotherapeutic regimens, their efficacy and toxicity, and novel treatment modalities



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Reading ListA list of general medical oncology textbooks can be found in the reading list of the Medical Oncology Consult rotation description.

BreastJournal Articles: Arpino G, et al: Premalignant and in situ breast disease: biology and clinical implications. Ann Intern Med 2005;143:446-457. Yager JD, Dvidson NE: Estrogen carcinogenesis in breast cancer. NEJM 2006;354:270-82.

Fisher B, Brown AM, Dimitrov NV, et al: Two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with 6 months of cyclophosphamide, methotrexate, and fluorouracil in positive-node breast cancer patients with tamoxifen-nonresponsive tumors: results from the National Surgical Adjuvant Breast and Bowel Project B-15. J Clin Oncol. 1990 Sep;8(9):1483-96.The French Adjuvant Study Group: Benefit of a high-dose epirubicin regimen in adjuvant chemotherapy for node-positive breast cancer patients with poor prognostic factors: 5-year follow-up results of French Adjuvant Study Group 05 randomized trial. J Clin Oncol.2001;19:602Coombes RC, et al: Adding exemestane therapy after 2 to 3 years of tamoxifen therapy improved disease-free survival more than 5 years of tamoxifen therapy alone. N Engl J Med 2004;350:1081-92.Piccart-Gebhart MJ, et al: Trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer. N Engl J Med 2005;353:1659-72.Romond EH, et al: Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. N Engl J Med 2005;353:1673-84.The BIG 1-98 Collaborative Group: A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. NEJM 2005:353:2747-57.

O’Shaughnessy J, Miles D, Vukelja S, et al: Superior survival with capecitabine plus docetaxel combination therapy in anthracycline-pretreated patients with advanced breast cancer: phase III trial results. J Clin Oncol. 2002 Jun 15;20(12):2812-23.Ravdin PM, Burris HA III, Cook G, et al: Phase II trial of docetaxel in advanced anthracycline-resistant or anthracenedione-resistant breast cancer. J Clin Oncol. 1995 Dec;13(12):2879-85.

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Seidman AD, Tiersten C, Hudis M, et al: Phase II trial of paclitaxel by 3-hour infusion as initial and salvage chemotherapy for metastatic breast cancer. J Clin Oncol. 1995 Oct;13(10):2575-81.Burstein HJ, Kuter I, Campos SM, et al: Clinical activity of trastuzumab and vinorelbine in women with HER2-overexpressing metastatic breast cancer. J Clin Oncol. 2001;19(10):2722-30.Hainsworth JD, Burris HA III, Yardley DA, et al: Weekly docetaxel in the treatment of elderly patients with advanced breast cancer: a Minnie Pearl Cancer Research Network phase II trial.J Clin Oncol. 2001;19(15):3500-5.Berry DA, Broadwater G, Klein JP, et al: High-dose versus standard chemotherapy in metastatic breast cancer: comparison of Cancer and Leukemia Group B trials with data from the Autologous Blood and Marrow Transplant Registry. J Clin Oncol. 2002 Feb 1;20(3):743-50.Loesch D, Robert N, Asmar L, et al: Phase II multicenter trial of a weekly paclitaxel and carboplatin regimen in patients with advanced breast cancer. J Clin Oncol. 2002;20(18):3857-64.Sledge G, Neuberg D, Bernardo P, et al: Phase III trial of doxorubicin, paclitaxel, and the combination of doxorubicin and paclitaxel as front-line chemotherapy for metastatic breast cancer: an intergroup trial (E1193). J Clin Oncol. 2003 Feb 15;21(4):588-92. GastrointestinalJournal Articles: Macdonald JS, et al: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725-30.Cunningham D, Allum WH, Stenning SP, et al: Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20.Lim L, et al: Adjuvant therapy in gastric cancer. J Clin Oncol 2005;23:6220-6232.

Boni AT, et al: Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med 2004;350:2343-51.Twelves C, et al: Capecitabine as adjuvant treatment for stage III colon cancer. N Engl J Med 2005;352:2696-704.Benson AB, et al: American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J Clin Oncol 2004;22:3408-3419.De Gramont A, et al: Randomized trial comparing monthly low-dose leucovorin and fluorouracil bolus with bimonthly high-dose leucovorin and fluorouracil bolus plus continuous infusion for advanced colorectal cancer. J Clin Oncol 1997;15:808-15.De Gramont A, et al: Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer. J Clin Oncol 2000;18:2938-47.Saltz LB, et al: Irinotecan plus fluorouracil and leucovorin for metastatic colorectal cancer. N Engl J Med 2000;343:905-14.Cunningham D, et al: Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med 2004;351:337-45.Goldberg RM, et al: A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2004 ;22:23-30.Hurwitz HI, et al: Bevacizumab in combination with fluorouracil and leucovorin: an active regimen for first-line metastatic colorectal cancer. J Clin Oncol 23:3502-8.Saltz, et al: Phase II trial of cetuximab in patients with refractory colorectal cancer that expresses the epidermal growth factor receptor. J Clin Oncol 2004;22:1201-8.Schrag D: The price tag on progress – chemotherapy for colorectal cancer. N Engl J Med 2004;351:317-9.Tournigand C, et al: FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study. J Clin Oncol 2004;22:229-37.

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Myerhardt JA, Mayer RJ: Drug therapy: systemic therapy for colorectal cancer. NEJM 2005;352:476-487.Cohen SJ, et al: Targeting signal transduction pathways in colorectal cancer – more than skin deep. J Clin Oncol 2005;23:5374Mehlen P, Fearon ER: Role of the dependence receptor DCC in colorectal cancer pathogenesis. J Clin Oncol 2004;22:3420-3428.

Sauer R, et al: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-1740.Rengan R, et al: Distal cT2N0 rectal cancer: is there an alternative to abdominoperineal resection? J Clin Oncol 2005;23:4905-12/Arnoletti JP, Bland KI: Neoadjuvant and adjuvant therapy for rectal cancer. Surg Clin N Am 2006;15:147-57.

Cummings BJ. Current management of anal canal cancer. Semin Oncol 2005;32(6 Suppl 9):123-8

Corless CL, et al: Biology of gastrointestinal stromal tumors. J Clin Oncol 2004;22:3813-3825.

GenitourinaryJournal articles: Nelson WG, et al: Prostate cancer. NEJM 2003;349:366-380.Petrulak DP: The current role of chemotherapy in metastatic hormone-refractory prostate cancer. Urology 2005;65(5 Suppl):3-7Ryan CJ, Small EJ: Progress in the detection and treatment of prostate cancer. Curr Opin Oncol 2005;17:257-60.Petrylak, et al: Docetaxel and estramustine compared to mitoxantrone and prednisone for advanced refractory prostate cancer. NEJM 2004;351:1513-20.Tannock et al: Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. NEJM 2004;351:302-12.D’Amico, et al: Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy. NEJM 2004;351:125-35.Thompson IM, et al: Prevalence of prostate cancer among men with a prostate-specific antigen level ≤ 4.0 ng per milliliter. NEJM 2004;350:2239-46.Parnes HL, et al: Prevention of hormone-related cancers: prostate cancer. J Clin Oncol 2005;23:368-77.

Rathmell, et al: Renal cell carcinoma. Curr Opin Oncol 2005:17:261-7.Cohen HT, McGovern FJ: Renal-cell carcinoma. New Engl J Med 2005;353:2477-90.Rini BI, Small EJ: Biology and clinical development of VEGF-targeted therapy in renal cell carcinoma. J Clin Oncol 2005;23:1028-43.McDermott DF, et al: Randomized phase III trial of high-dose IL-2 vs subcutaneous IL-2 and interferon in patients with metastatic renal cell carcinoma. J Clin Oncol 2005;23:133-41.Yang JC, Childs R: Immunotherapy for renal cell cancer. J Clin Onc 2006;24:5576-83.Yang, et al: A randomized trial of bevacizumab, an anti-VEGF antibody, in metastatic renal cancer. NEJM 2003;349:427-34.Flanigan et al: Nephrectomy followed by interferon alfa-2B compared with interferon alfa-2b alone for metastatic renal-cell cancer. NEJM 2001;345:1655-59.Motzer R, Bukowski RM: Targeted therapy for metastatic renal cell carcinoma. J Clin Onc 2006;24:5601-8.

Bosl GJ, Motzer RJ: Testicular germ-cell cancer. NEJM 1997;337:242-53.

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Bosl GJ, Changanti RSK: The use of tumor markers in germ-cell malignancies. Hematol Oncol Clin North Am 1994;8:573-87.de Wit R, Fizazi K: Controversies in the management of clinical stage I testis cancer. J Clin Onc 2006;24:5482-92.Varuni Kondagunta G, Motzer R: Chemotherapy for advanced germ cell tumors. J Clin Onc 2006;24:5493-502.Oldenburg K. Martin JM, Fossa SD: Late relapses of germ cell malignancies: Incidence, management, and prognosis. J Clin Onc 2006;24:5503-11.Huddart RA, et al: Cardiovascular disease as a long-term complication of treatment for testicular cancer. J Clin Oncol 2003;21:1513-23.

Grossman HB, et al: Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. NEJM 2003;349:859-66.Parekh DJ, Bochner BH, Dalbagni G: Superficial and muscle-invasive bladder cancer: Principles of management for outcomes assessments. J Clin Onc 2006; 24:5519-27.Rodel C, Weiss C, Sauer R: Trimodality treatment and selective organ preservation for bladder cancer. J Clin Onc 2006;24:5536-44.Garcia JA, Dreicer R: Systemic chemotherapy for advanced bladder cancer: Update and controversies. J Clin Onc 2006:24:5545-51.

GynecologicArmstrong D, et al: Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med 2006; 354:34-43.Ozols RF, et al: phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol 2003;21:3194-200.Markman M, Walker JL: Intraperitoneal chemotherapy of ovarian cancer: a review, with a focus on practical aspects of treatment. J Clin Onc 2006;24:988-94.Rao G, Crispens M, Rothenberg ML: Intraperitoneal Chemotherapy for Ovarian Cancer: Overview and Perspective. J Clin Oncol 2007;25:2867-72.Fader AN, Rose PG: Role of surgery in ovarian carcinoma. J Clin Oncol 2007;25:2873-83.Schmeler KM, et al: Prophylactic surgery to reduce the risk of gynecologic cancers in the Lynch syndrome. N Engl J Med 2006;354:261-9.Sabbatini P, Odunsi K: Immunologic approaches to ovairan cancer treatment. J Clin Oncol 2007;25:2884-93.Martin L, Schilder R. Novel approaches in advancing the treatment of epithelial ovarian cancer: the role of angiogenesis inhibition. J Clin Oncol 25:2894-901.Trope C, Kaern J: Adjuvant chemotherapy for early-stage ovarian cancer: review of the literature. J Clin Oncol 2007;25:2909-20.Cadron I, Leunen K, Van Gorp T, et al: Management of borderline ovarian neoplasms. J Clin Oncol 2007;25:2928-37.Gershenson DM: Management of ovarian germ cell tumors. J Clin Oncol 2007;25:2938-43.Colombo N, Parma G, Zanagnolo V, et al: Management of ovarian stromal cell tumors. J Clin Oncol 2007;25:2944-51.

Kautsky LA, et al: A controlled trial of a human papillomavirus type 16 vaccine. NEJM 2002:347:1645-51.Chan JK, Berek JS: Impact of the human papilloma vaccine on cervical cancer. J Clin Oncol 2007;25:2975-82..Monk B, Tewari KS, Koh W-J: Multimodality therapy for locally advanced cervical carcinoma: state of the art and future directions. J Clin Oncol 2007;25:2952-65.

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Long HJ: Management of metastatic cervical cancer: review of the literature. J Clin Oncol 2007;25:2966-74.

Fleming GF: Systemic chemotherapy for uterine carcinoma: metastatic and adjuvant. J Clin Oncol 2007;25:2983-90.

Montana GS, et al: Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study. Int J Radiat Oncol Biol Phys 2000;48:1007-13.

Head and NeckTextbooks: Head and Neck Cancer: A Multidiciplinary Approach, 2nd edition, ed Harrison, et al, LWW, 2004.Principles and Practice of Radiation Oncology, 4th edition, ed Perez, LWW, 2005.

Journal Articles: Cooper JS, et al: Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350:1937-1944.Bernier J, et al: Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med 2004;350:1945-1952.Fanucchi M, Khuri FR: Chemotherapy for recurrent of metastatic squamous cell carcinoma of the head and neck. Sem Oncol 2004;31:809-815.Al-Sarraf M, et al: Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: phase III randomized intergroup study 0099. J Clin Oncol 1998;16:1310-1317.Chan ATC, et al: Pathogenesis and treatment of nasopharyngeal carcinoma. Sem Oncol 2004;31:794-801.Chmura SJ, et al: Reirradiation of recurrent head and neck cancers with curative intent. Sem Oncol 2004;31:816-821.Kasperts N, et al: A review on re-irradiation for recurrent and second primary head and neck cancer. Oral Oncol 2005;41:225-243.Forastiere AA. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. NEJM 2003;349(22):2091-8.Chan ATC. Concurrent chemotherapy-radiotherapy compared with radiotherapy alone in locoreginally advanced nasopharyngeal carcinoma: progression-free survival analysis of a phase III randomized trial. JCO 2002;20(8);2038-2044.Ma J. Results of a prospective randomized trial comparing neoadjuvant chemotherapy plus radiotherapy with radiotherapy alone in patients with locoregionally advanced nasopharyngeal carcinoma. JCO 2001;19(5):1350-1357.Langendijk JA. The additional value of chemotherapy to radiotherapy in locally advanced nasopharyngeal carcinoma: a meta-analysis of the published literature. JCO 2004;22(22):4604-4612.Huguenin P. Concomitant cisplatin significantly improves locoregional control in advanced head and neck cancers treated with hyperfractionated radiotherapy. JCO 2004;22(23):4613-4621.Bernier J. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. NEJM 2004;350:1945-52.Cooper JS. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous cell carcinoma of the head and neck. NEJM 2004;350:1937-44.Forastiere A, Koch W, Trotti A, el al. Head and neck cancer. NEJM 2001;345(26):1890-1900.Posner MR, Hershock DM, Blajman CR, et al: Cisplatin and fluorouracil alone or with docetaxel in head and neck cancer. N Engl J Med 2007;357:1705-15.

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Thoracic

Epidemiology, Pathology and StagingAhmedin JA, Tiwari RC, Murray T: Cancer Statistics, 2004. CA Cancer J Clin. 54: 8-29, 2004 Travis WD. Pathology of lung cancer. Clin Chest Med 23:65-81, 2002.Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997;111:1710.

BiologyPaez JG, Janne PA, Lee JC, et al. EGFR Mutations in Lung Cancer: Correlation with Clinical Response to Gefitinib Therapy. Science. 2004;304:1497-500.Tsao M.-S., Sakurada A., Cutz J.-C., et al. . Erlotinib in Lung Cancer — Molecular and Clinical Predictors of Outcome N Engl J Med 2005; 353:133-144, Jul 14, 2005.

ScreeningPatz EF,. Goodman PC, and Bepler G. Screening for Lung Cancer 343:1627-1633, 2000

Non-Small Cell Lung Cancer

Stage I and II diseaseStrauss GM, Herndon J, Maddaus MA et al. Randomized clinical trial fo adjuvant chemotherapy with paclitaxel and carboplatin following resection in stage Ib non-small cell lung cancer: report of Cancer and Leukemia Group B protocol 9633. Proc Am Soc Clin Oncol 23: 2004.Arriagada R, Bergman B, Dunant A, et al. International Adjuvant Lung Cancer Trial Collaborative Group. Cisplatin-based adjuvant chemotharpy in patients with completely resected non-small-cell lung cancer. N Engl J Med 2004; 350(4): 351-60.Winton T, Livingston R, Johnson D, M.D., et al Vinorelbine plus Cisplatin vs. Observation in Resected Non–Small-Cell Lung Cancer352:2589-2597, 2005American Thoracic Society/European Respiratory Society. Pretreatment evaluation of non-small-cell lung cancer. Am J Respir Crit Care Med 1997;156:320.

Stage III Albain KS, Rusch VW, Crowley JJ: Concurrent cisplatin/etoposide plus chest radiotherapy followed by surgery for stages IIIA (N2) and IIIB non-small cell lung cancer: mature results of Southwest Oncology Group phase II study 8805. J Clin Oncol. 13:1880-1992, 1995Dillman RO, Seagren SL, Propert KJ, Guerra J, Eaton WWL, Perry MC, et al.: A randomized trial of induction chemotherapy plus high dose radiation versus radiation alone in stage III non-small cell lung cancer. N Engl J Med 1990:323;940-945.Sause WT, Scott C, Taylor S et al. Radiation Therapy Oncology Group (RTOG) 88-08 and Eastern Cooperative Oncology Group (ECOG) 4588: preliminary advanced results of a phase III trial of regionally unresectable lung cancer. J Natl Cancer Inst 1995;87:198-205.Furuse K, Fukuoka M, Kawahaa M, Nishikawa H, Takada, Kudoh S, et al. Phase III study of concurrent versus sequential thoracic radiotherapy in combination with mitomycin, vindesine, and cisplatin in unresectable stage III non-small cell lung cancer. J Clin Oncol 1999 Sep;17(9):2692-9Rosell R, Gomez-Codina J, Camps C, Maestre J, Padille J, Canto A, Mate JL, Li S, Roig J, Olazabal A, et al. A randomized trial comparing preoperative chemotherapy plus surgery with surgery alone in patients with non-small-cell lung cancer. N Engl J Med. 1994;330(3):153-8.

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Belani CP, Choy H, Bonomi P, Scott C, Travis P, Haluschak J, Curran WJ Jr. Combined chemoradiotherapy regimens of paclitaxel and carboplatin for locally advanced non-small-cell lung cancer: a randomized phase II locally advanced multi-modality protocol J Clin Oncol. 2005 Sep 1;23(25):5883-91. Epub 2005 Aug 8Schaake-Konig C, van den Bogaert W, Dalesio O et al. Effects of concomitant cisplatin and radiotherapy on inoperable non-small cell lung cancer. NEJM 1992; 326:524-30.

Stage IV Prognostic FactorsAlbain KS, Crowley JJ, LeBlanc M, et al: Survival determinants in extensive-stage non-small cell lung cancer: The Southwest Oncology Group experience. Am J Clin Oncol. 9:1618-1626, 1991Paesmans M, Sculier JP, Libert G: Prognostic factors for survival in advanced non-small cell lung cancer: Univariate and multivariate analyses including recursive partitioning and amalgamation algorithms in 1,052 patients. J Clin Oncol. 13:1221-1230, 1995First Line TherapyNon-small Cell Lung Cancer Collaborative Group. Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomized clinical trials. Br Med J 1995;311:899.Bonomi P, Kim K, Fairclough D, et al. Comparison of survival and quality of life in advanced non-small-cell lung cancer patients treated with two dose levels of paclitaxel combined with cisplatin versus etoposide with cisplatin: results of an Eastern Cooperative Oncology Group trial. J Clin Oncol. 2000 Feb;18:623-31.Wozniak AJ, Crowley JJ, Balcerzak S, et al. Randomized trial comparing cisplatin with cisplatin plus vinorelbine in the treatment of advanced non-small cell lung cancer: A cooperative group study. J Clin Oncol 10:1066-1073, 1992.Sandler A, Nemunatis J, Denham C, et al. Phase III trial of gemcitabine plus cisplatin versus cisplatin alone in patients with locally advanced and metastatic non-small cell lung cancer. J Clin Oncol 18:122-130, 2000.Schiller J H, Harrington D, Belani CP et al. Comparison of four chemotherapy regimens for advanced non-small cell lung cancer. N Engl J Med 10:92-8, 2002. Kelly K, Crowley J, Bunn PA et al. Randomized phase three trial of paclitaxel plus carboplatin versus vinorelbine plus cisplatin in the treatment of patients with advanced non-small cell lung cancer: a Southwest Oncology Group trial. J Clin Oncol 19:3210-8, 2001. Second and Third Line TherapyHanna N, Shepherd FA, Fossella FV, et al. Randomized Phase III Trial of Pemetrexed Versus Docetaxel in Patients With Non-Small-Cell Lung Cancer Previously Treated With Chemotherapy. J Clin Oncol. 2004 May 1;22(9):1589-97Shepherd F, Dancey J, Ramlau R et al. Prospective Randomized Trial of Docetaxel Versus Best Supportive Care in Patients With Non-Small-Cell Lung Cancer Previously Treated With Platinum-Based Chemotherapy. J Clin Oncol. 2000 May 10;18:2095-2103.Fossella FV, DeVore R, Kerr RN et al. Randomized phase III trial of docetaxel versus vinorelbine or ifosfamide in patients with advanced non-small cell lung cancer previously treated with platinum containing regimens. J Clin Onc, 2000 18:2354-2362.Fukuoka M, Yano S, Giaccone G. Multi-Institutional randomized phase II Trial of gefitinib for previously treated patients with advanced non–small-cell lung cancer. J Clin Oncol. 21:2237-2246, 2003Kris MG, Natale RB, Herbst RS: Efficacy of gefitinib, an inhibitor of the epidermal growth factor receptor tyrosine kinase, in symptomatic patients with non-small cell lung cancer: A randomized trial. JAMA 290:2149-2158, 2003

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Shepherd FA, Pereira JR, Ciuleanu T, Erlotinib in Previously Treated Non–Small-Cell Lung Cancer 353:123-132, 2005Duration of TherapySmith IE, Obrien MER, Talbot DC et al. Duration of chemotherapy in advanced non-small cell lung cancer: a randomized trial of three versus six courses of mitomycin, vinblastine and cisplatin. J Clin Onc 19:1336-1343, 2001.Socinski M, Schell MJ, Peterman A, et al. Phase III trial comparing a defined duration of therapy versus continuous therapy followed by second-line therapy in advanced-stage IIIb/IV non-small cell lung cancer. J Clin Oncol 20:1335-43, 2002.

Small Cell Lung Cancer

Prognostic FactorsAlbain KS, Crowley JJ, LeBlanc M, et al: Determinants of improved outcome in Small-Cell Lung Cancer: An analysis of the 2,580-Patient Southwest Oncology Group Data base. Am J Clin Oncol 8:1563-1574, 1990

Limited DiseaseTurrisi AT 3rd, Kim K, Blum R, et al. Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide. N Engl J Med. 1999 Jan 28;340(4):265-71Auperin A, Arriagada R, Pignon JP, et al. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J Med. 1999 Aug 12;341(7):476-84. Extensive DiseaseSundstrom, S, Bremnes, RM, Kaasa, S, et al. Cisplatin and Etoposide Regimen Is Superior to Cyclophosphamide, Epirubicin, and Vincristine Regimen in Small-Cell Lung Cancer: Results From a Randomized Phase III Trial With 5 Years' Follow-Up. J Clin Oncol 2002; 20:4665Noda K, Nishiwaki Y, Kawahara M, et al; Japan Clinical Oncology Group. Irinotecan plus cisplatin compared with etoposide plus cisplatin for extensive small-cell lung cancer. N Engl J Med. 2002 Jan 10;346(2):85-91.

Recurrent Diseasevon Pawel J, Schiller JH, Shepherd FA, et al: Topotecan versus cyclophosphamide, doxorubicin, and vincristine for the treatment of recurrent small-cell lung cancer. J Clin Oncol. 1999;17:658-67.

Other Issues in Lung Cancer Walsh GL, O'Connor M, Willis KM, et al. Is follow-up of lung cancer patients after resection medically indicated and cost-effective? Ann Thorac Surg. 1995;60:1563-70; discussion 1570-2.Betensky RA, Louis DN, Cairncross JG. Influence of unrecognized molecular heterogeneity on randomized clinical trials. J Clin Oncol 20:2495-2499, 2002.Kelly K, Bunn PA Jr. Is it time to reevaluate our approach to the treatment of brain metastases in patients with non-small cell lung cancer? Lung Cancer 1998;20:85.

Robinson BWS, Lake RA: Advances in malignant mesothelioma. NEJM 2005;353:1591-603.

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Lymphoma/Benign Hematology Outpatient Rotation

Mission StatementTo provide an opportunity to learn the art and science of clinical care in the outpatient setting of a tertiary teaching hospital in the subspecialty of hematology, and gain an understanding of the role of the various clinical labs in the diagnosis of benign and malignant hematologic diseasesTo provide state-of-the-art health care to patients with hematologic disorders

Program ObjectivesPatient Care: To improve basic clinical skills as applied to patients with hematologic diseasesMedical Knowledge: To learn diagnostic algorithms used in the evaluation of the various benign and malignant hematologic diseases en-countered in the outpatient clinicTo gain expertise in the interpretation of bone marrow aspirates and biopsies, and lymph node biopsiesPractice-Based Learning: see Core CompetenciesInterpersonal Skills and Communication: To improve skills in communicating with referring physicians and housestaff Professionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program Components• Fellows rotating on this service will be responsible for outpatient consultations of patients

with a variety of benign and malignant hematologic disorders, during the course of four half-day clinics and supplemental outpatient consultations at UMMS.

• The fellow participating in this rotation is responsible for assembling the necessary information to arrive at a diagnosis, and will see the patient in follow-up for the duration of the rotation (rotation with appended continuity clinic is six months). Together with the supervising attending, he/she communicates the laboratory findings and the diagnosis to the patient, and discusses the appropriate treatment and follow-up.

• In addition, the fellows will meet with Dr. Xiao, the hematopathologist, to review bone marrow aspirates and biopsies, and lymph node biopsies. The fellows will regularly interpret bone marrow aspirates with various hematologists who read them on a daily basis.

• The fellows will be involved in the selection and presentation of patients at the weekly Lymphoma Conference

Focused Areas for StudyHodgkin’s lymphoma: epidemiology, pathogenesis, pathology, viral factors, diagnosis, staging, imaging, prognostic factors, immunophenotypic profile, treatment by stage, treatment of refractory or relapsed disease, follow-up, fertility issues and treatment-related toxicityNon-Hodgkin’s lymphoma: epidemiology, pathogenesis, pathology, classification, cytogenetics, diagnosis, imaging, staging, prognostic factors, treatment by stage

Lymphoplasmacytic lymphomaSmall lymphocytic lymphomaFollicular lymphomaMantle cell lymphomaDiffuse large B-cell lymphoma, primary mediastinal large B-cell lymphoma, intravascular large B-cell lymphomaMALT, nodal marginal zone B-cell, splenic marginal zone

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Primary CNS lymphomaHIV-associated lymphoma, primary effusion lymphomaT-cell and NK cell neoplasms: mycosis fungoides, Sezary syndrome, cutaneous T-cell lymphoma, T-cell large granular lymphocytic lymphoma, angio-immunoblastic T-cell lymphoma, nasal T/NK cell lymphoma, intestinal T-cell lymphomaAnaplastic large cell lymphoma

Chronic lymphoid leukemias epidemiology, pathogenesis, diagnosis, staging, flow cytometry, cytogenetics, other prognostic factors and treatment by stageChronic lymphocytic leukemiaHairy cell leukemia

Plasma cell disordersMultiple myeloma, plasmacytomas, non-secretory myeloma, POEMS syndrome, plasma cell leukemiaMonoclonal gammopathy of uncertain significanceAmyloidosis

Histiocytic and dendritic cell neoplasmaCastleman’s diseaseNormal B and T cell developmentLymphopenia and lymphocyte dysfunction syndromes Granulocyte dysfunction disordersEvaluation and treatment of patients with chronic myeloproliferative disordersMyelodysplasia: diagnosis and treatmentEvaluation of erythrocytosis: differentiation between primary and secondary polycythemiaEvaluation and treatment of patients with plasma cell disorders: multiple myleoma, monoclonal gammopathy, amyloidosis, plasmacytomasHemolytic anemias (autoimmune, metabolic enzyme deficiencies, paroxysmal nocturnal hemoglobinuria, non-immune acquired)Red cell membrane disordersFamilial thrombocytopenias and platelet function disordersCryoglobulinsHemochromatosis: basic molecular and pathophysiologic mechanisms, clinical presentation, diagnosis, complications, treatmentMastocytosisPorphyrias: enzyme abnormalities, clinical presentation, diagnosis, treatment

Educator RoleThe fellow supervises the medical residents and medical students who participate in an elective rotation in the Cancer Center outpatient clinics, providing advice regarding the appropriate use of the medical center resources to assemble information. The fellow also assists the medical students in locating additional educational material.


Patient Care1) Gathers essential and accurate information about the patient through interviews, examination, and complete history; appropriately accesses additional sources of information, such as other health care facilities, non-UMMC or BVAMC physicians, family members.2) Interacts with other health-care professionals to facilitate the process of diagnosis and treatment planning

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3) Carries out patient management plans based on age, other co-morbid conditions, psychosocial issues, including arranging appropriate follow-up of diagnostic tests

Medical Knowledge1) Knowledgeable with regard to the differential diagnosis and treatment of the benign and malignant hematologic diseases encountered in an outpatient hematology setting2) Has become familiar with the laboratory testing available to more accurately diagnose hematologic problems, as well as the limitations of these tests3) At the conclusion of the second year, the fellow will be given a “practical “(asked to identify 5 bone marrow unknowns). If he/she is unable to do this, further work in this area will be assigned and the bone marrow practical will be repeated until the fellow can successfully identify a variety of pathologic states as they present in the bone marrow.





In the interest of improving the quality of the learning environment in the fellowship, the fellows must confidentially provide a written evaluation of each teaching attending at the conclusion of the rotation. We also require that they complete a self-assessment of their performance during the rotation, including a listing of conferences attended, with plans for remediation if they were not able to adequately complete the requirements for the rotation.

Reading ListTextbooks: See textbooks listed in Hematology Consult section. Also:Non-Hodgkin’s Lymphomas, ed. Mauch, et al. LW&W, 2004.Flow Cytometric Analysis of Hematologic Neoplasms, 2nd edition, Sun, LW&W, 2002.Journal Articles: Hjalgrim H, et al: Characteristics of Hodgkin’s lymphoma after infectious mononucleosis. N Engl J Med 2003;349:1324-32.Diehl V, et al: Clinical presentation, course, and prognostic factors in lymphocyte-predominant Hodgkin’s disease and lymphocyte-rich classical Hodgkin’s disease. J Clin Oncol 1999;17:776.Kuppers R, et al: Cellular origin of human B-cell lymphomas. N Engl J Med 1999;341:1520-9.

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Sears JD, et al: Definitive irradiation in the treatment of Hodgkin’s disease: analysis of outcome, prognostic factors, and long term complications. Cancer 1997;79:145-51.Canellos GP, et al: Chemotherapy of advanced Hodgkin’s disease with MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med 1992;327:1478-84.Diehl V, et al: The GHLSG standard and increased-dose BEACOPP compared with COPP-ABVD for advanced Hodgkin’s disease. N Engl J Med 2003;348:2386-95.Ng A, et al: Long-term survival and competing causes of death in patients with early-stage Hodgkin’s disease treated at age 50 or younger. J Clin Oncol 2002;20:2101-8.Coiffier B, et al: CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patient with diffuse large-B-cell lymphoma. N Engl J Med 2002;346:235-42.Wilson WH, et al: Dose-adjusted EPOCH chemotherapy for untreated large B-cell lymphoma a pharmacodynamic approach with high efficacy. Blood 2002;99:2685-93.Kelwalramini T, et al: Rituximab and ICE (RICE) as second-line therapy prior to autologous stem cell transplantation for relapsed or primary refractory diffuse large B-cell lymphoma. Blood 2004;103:3684-88.Velasquez WS, et al: Effective salvage therapy for lymphoma with cisplatin combination with high-dose ara-C and dexamethasone (DHAP). Blood 1988;71:117-22.Velasquez WS, et al: ESHAP – an effective chemotherapy regimen in refractory and relapsing lymphoma: a 4-year follow-up study. J Clin Oncol 1994;12:1169-76.Tilly J, et al: Intensive conventional chemotherapy (ACVBP regimen) compared with standard CHOP for poor-prognosis aggressive non-Hodgkin lymphoma. Blood 2003;102:4284-9.Batchelor T, Loeffler JS: Primary CNS lymphoma. J Clin Onc 2006;24:1281-8.Navarro WH, Kaplan LD: AIDS-related lymphoproliferative disease. Blood 2006;107:13-20.Ratner L, et al: Chemotherapy for HIV-associated NHL in combination with HAART. J Clin Oncol2001;19:2171-8.Little RF, et al: Highly effective treatment of acquired immunodeficiency syndrome-related lymphoma with dose-adjusted EPOCH: impact of antiretroviral therapy suspension and tumor biology. Blood 2003:101:4653-4659.Döhner J, et al: Genomic aberrations and survival in CLL. N Engl J Med 2000;343:1910-6.Kröber A, et al: VH mutation status, CD38 expression level, genomic aberrations and survival in CLL. Blood 2002;100:1410-6.Crespo M, et al: ZAP-70 expression as a surrogate for immunoglobulin-variable-region mutations in CLL. N Engl J Med 2003;348:1764-75.Rai KR, et al: Fludarabine compared with chlorambucil as primary therapy for CLL. NEJM 2000;343:1750-7.Leporrier M, et al: Randomized comparison of fludarabine, CAP, and CHOP in 938 previously untreated stage B and C CLL patients. Blood 2001;98:2319-25.O’Brien SM, et al: Results of the fludarabine and cyclophosphamide combination regimen in CLL. J Clin Oncol 2001;19:1414-20/Rai KR, et al: Alemtuzumab in previously treated CLL patients who also had received fludarabine. J Clin Oncol 2002;20:3891-3897.Montserrat D, Moreno C, Esteve K. et al: How I treat refractory CLL. Blood 2006;107:1276-83.Dimopoulos MA, et al: Diagnosis and management of Waldenstrom’s macroglobulinemia. J Clin Oncol 2005;23:1564-1577.Rizvi MA. Evems AM. Ta;;,am MS, et al: T-cell non-Hodgkin lymphoma. Blood 2006;107:1255-64.Suarez F, Lortholary O, Hermine O, et al: Infection-associated lymphomas derived from marginal zone B cells: a model of antigen-driven lymphoproliferation. Blood 2006;107:3034-44.

Schafer AI: Thrombocytosis. NEJM 2004;350:1211-9.

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Kralovics R, et al: A gain-of-function mutation of JAK2 in myeloproliferative disorders. NEJM 2005;352:1779-90.James C, et al: A unique clonal JAK2 mutation leading to constitutive signaling causes polycythemia vera. Nature 2005;434:1144-1148.Landolfi R, et al: Efficacy and safety of low-dose aspirin in polycythemia vera. N Engl J Med 2004;350:114-24.Harrison CN, et al: Hydroxyurea compared with anagrelide in high-risk essential thrombocythemia. N Engl J Med. 2005;353:33-45.Schafer A: Molecular basis of the diagnosis and treatment of polycythemia vera and essential thrombocythemia. Blood 2006;107:4214-22.Campbell PJ, Green AR: The myeloproliferative disorders. N Engl J Med 2006355::2452-66.Tefferi A: Pathogenesis of myelofivrosis with myeloid metaplasia. J Clin Onc 2005;23:8520-30.Talpaz M, Shah MP, Kantarjian H, et al: Dasatinib in imatinib-resistant Philadelphia chromosome-positive leukemias. N Engl J Med 2006;354:2531-41.Kantarjian H, Giles F, Wunderle L, et al: Nilotinib in imatinib-resistant CML and Philadelphia chromosome-positive ALL. N Engl J Med 2006:354:2542-51.Thiele J, et al: Bone marrow histopathology in myeloproliferative disorders--current diagnostic approach. Semin Hematol. 2005;42:184-95.Nimer SD: Clinical management of myelodysplastic syndromes with interstitial deletion of chromosome 5q. J Clin Onc 2006 16:2576-82.Drachman JG: Inherited thrombocytopenia: when a low platelet count does not mean ITP. Blood 2004:105:390-398.Van Wijk R. van Solinge WW: The energy-less red blood cell is lost: erythrocyte enzyme abnormalities of glycolysis. Blood 2005;106:4034-42.Elder GH, et al: The acute porphyries. Lancet 1997;349:1613-7.Parker C, Omine M, Richards S, et al: Diagnosis and management of paroxysmal nocturnal hemoglobinuria. Blood 2005;106:3699-3709.Taniguchi T, D’Andrea AD: Molecular pathogenesis of Fanconi anemia: recent progress. Blood 2006;107:4223-33.

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Medical Oncology Consultation Service

Mission StatementTo provide the opportunity for fellows to learn the art and science of clinical care in a tertiary teaching hospital in the subspecialty discipline of medical oncology, to include the approach to the patient diagnosed with or suspected of having a malignant disease as well as an introduction to the chemotherapeutic drugs used in the treatment of these diseases

Program ObjectivesPatient Care: To improve basic clinical skills as applied to the evaluation of patients with a known or suspected malignant diseaseTo learn how to maximally utilize the expertise of the diagnostic radiologists and pathologists, who collaborate with the medical oncologist in making the diagnosis of a malignancyTo learn how a multi-disciplinary approach to the cancer patient works in maximizing the services of physicians in different disciplines (surgery, radiation oncology, gastroenterology, pulmonary medicine, urology) to optimally care for the patient with cancerMedical Knowledge: To learn diagnostic algorithms used in the diagnosis of cancer (see below for areas of study specific to this rotation)To gain familiarity with the chemotherapeutic drugs and standard regimens used to treat cancer patientsPractice-Based Learning: see Core CompetenciesInterpersonal Skills and Communication: To improve skills in communicating with referring physicians, housestaff, and the support staff caring for the newly diagnosed cancer patientProfessionalism: Through exposure to the attending physician as a role model, to learn how communication with patients newly diagnosed with a malignant disease and their family members can be initiated, in an informative and compassionate mannerSystems-Based Practice: see Core Competencies

Program ComponentsThis rotation is involves seeing patients both at the University of Maryland Medical Center (UMMC) and the Baltimore Veterans Administration Medical Center (BVAMC). Services pro-vided by the Medical Oncology Consultation Service include:

Consultations at the UMMC on the medical inpatient units, surgical inpatient units, and intensive care unitsConsultations at the BVAMC on the medical inpatient units, surgical inpatient units, and intensive care unitsEmergency outpatient consultations in BVAMC Medical Oncology Outpatient clinic

In addition, the fellows will attend the various multi-disciplinary conferences (Thoracic Oncology, Urology, Breast, Head and Neck, Gastroenterology). They will spend a half-day with the chief research pharmacist and a half-day in the infusion center, gaining expertise on the preparation and administration of chemotherapeutic agents.

Focused Areas for StudyEvaluation of the patient with a suspected malignant diseaseMetastatic cancer of unknown primary: epidemiology, histologic types, diagnostic techniques, metastatic patterns predictive of potentially curable diseases, diagnostic evaluation (including history, tumor markers, imaging studies), treatment (role of surgery, radiation therapy, chemotherapy)

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Central nervous system malignancies (non-hematologic): epidemiology, pathogenesis, diagnosis, staging and prognostic factors, and treatment of the various sub-typesMelanoma: epidemiology, pathology, precursor lesions, risk factors, genetic factors, prevention, screening, diagnosis, imaging, staging, prognostic factors, treatment by stage (in situ, invasive, regional nodal metastasis/in-transit metastasis, metastatic disease), follow-up, supportive care, mucosal, ocular and unknown primary sitesOsteogenic and soft tissue sarcoma: epidemiology, pathology, genetic factors, diagnosis, imaging, staging, prognostic factors, treatment by stage (localized, local recurrence, metastatic), follow-upPharmacology of chemotherapeutic agents, to include pharmacokinetics, pharmacodynamics, metabolism and clearance, pharmacogenomicsChemotherapy administrationCommunication skills, to include communicating information about cancer and prognosis, delivering bad news, cross-cultural issues, communicating within multidisciplinary teamsOncologic emergencies: spinal cord compression, superior vena cava syndrome, tumor lysis syndrome, hypercalcemia, pericardial tamponade, bilateral ureteral obstruction, brain metastasisParaneoplastic syndromes: cytokine-related, immunologically based, cutaneous syndromes, association with specific tumor types

Educator RoleThe medical oncology fellow supervises the medical residents and medical students who participate in this elective rotation. The fellow evaluates the patient, has a preliminary discussion with the junior team member with regard to the diagnostic approach and the differential diagnosis, and makes suggestions for guidance to the appropriate resources. The fellow is also the person often responsible for communicating recommendations of the Medical Oncology consult team and the rationale for them back to the housestaff of the referring service during the follow-up period. During this rotation, the fellow is also responsible for the selection of patients for the Solid Tumor Conference, and leads the discussion of the diagnosis and therapeutic options available for the patients presented.



Medical Knowledge1) Understands the approach to the patient with known or suspected malignant disease2) Understands the principles of chemotherapeutic drugs and their administration3) Understands concepts regarding cancer of unknown primary, central nervous system malignancies, melanoma, sarcoma, oncologic emergencies, and paraneoplastic syndromes

Practice-Based Learning and Improvement1) Uses feedback to identify areas for improvement

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2) Seeks opportunities to strengthen deficits in knowledge/skills3) Demonstrates initiative in researching current scientific evidence using modern information technology and applying it to problems encountered in daily practice





Reading ListTextbooks: Clinical Oncology, 3rd edition, ed Abeloff, et al, Elsevier, 2004.Cancer: Principles and Practice of Oncology, 7th edition, ed DeVita, LWW, 2004

Journal Articles: Langer CJ, Mehta MP: Current management of brain metastases, with a focus on systemic options. J Clin Oncol 2005;23:6207Vogelbaum MA, Suh JH: Resectable brain metastases. J Clin Onc 2006;24:1289-94.Sanai N, et al: Neural stem cells and the origin of gliomas. NEJM 2005;353:811-822.Smith JS, et al: Alterations of chromosome arms 1p and 19q as predictors of survival in oligodendrogliomas, astrocytomas, and mixed oligoastrocytomas. J Clin Oncol 2000;18:636.Van den Bent: Can chemotherapy replace radiotherapy in low-grade gliomas? Time for randomized studies. Sem Oncol 2003;6 suppl 19:39-44.Stupp R, et al: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 2005;352:987-996.Athanassiou H, et al: Randomized phase II study of temozolomide and radiotherapy compared with radiotherapy alone in newly diagnosed glioblastoma multiforme. J Clin Oncol 2005;23:2372-2377.Lang FF, Gilbert MR: Diffusely infiltrative low-grade gliomas in adults. J Clin Onc 2006;24:1236-45.Reardon DA, Rich JN, Friedman HS, et al: Recent advances in the treatment of malignant astrocytoma. J Clin Onc 2006;24:1253-65.Butowski NA, Sneed PK, Chang SM: Diagnosis and treatment of recurrent high-grade astrocytoma. J Clin Onc 2006;24:1273-80.Miller AJ, Mihm MC: Melanoma. N Engl J Med 2006;355:51-65.

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Laboratory Hematology/Hematopathology/Transfusion Medicine

Mission StatementTo gain an understanding of the role of the various clinical labs in the diagnosis of benign hematologic diseasesTo acquire expertise in the preparation and interpretation of pathologic material, in particular bone marrow aspirates and biopsies, lymph node biopsies, in the diagnosis of hematologic disorders

Program ObjectivesPatient Care: To use hospital resources to appropriately gather information needed for the interpretation of the laboratory testingMedical Knowledge: To gain familiarity with the laboratory methods used to diagnose hematologic disorders, including the use of the automated blood counters, coagulation testing, protein and hemoglobin electrophoresesTo become familiar with the procedures involved in blood bankingTo gain expertise in the preparation and interpretation of bone marrow aspirates and biopsiesTo gain familiarity with the use of immunostaining, Practice-Based Learning: see Core CompetenciesInterpersonal Skills and Communication: see Core CompetenciesProfessionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program ComponentsIn this required two week rotation, fellows will spend time in a diverse group of clinical laboratories, in order to extend their knowledge of hematologic disorders and the role of the laboratory in their diagnosis. The mechanics, interpretation, and limitations of the various laboratory techniques will be discussed. In addition, the fellows will meet regularly with Dr. Hess to review laboratory hematopathology results and adverse transfusion reactions, and Dr. Zhou, the hematopathologist, to review bone marrow aspirates and biopsies. The fellows will regularly interpret bone marrow aspirates with various hematologists who read them on a daily basis. All fellows will be required to rotate through these labs for a minimum of two weeks. However, for fellows who are considering a career in hematology, stem cell transplant, malignant hematologic diseases or transfusion medicine, a minimum of one month on this rotation is recommended. Some of the material (particularly that pertaining to Transfusion Medicine) is also covered in the Hematology Consult rotation.

Focused Areas for StudyBlood smears: RBC size, shape, and hemoglobinization, WBC number and kind and distribution, recognizing abnormal WBC, estimating platelet number, granule content, clumping, recognizing unusual cells, recognizing blood parasites, malaria, Babesia, Erlichia, filarialBody fluid cell counting and identification

CSF – Inflammatory reactions, leukemic reactionsPleural and peritoneal – infection and inflammatory responses, cancer

Bone marrow aspirates – differential counts, myeloid, erythroid, lymphoid differentiation, megakaryocyte number and morphology, histiocyte inclusionsBone marrow biopsies – cellularity, tumor infiltration, megakaryocyte number, Correlation of aspirates and biopsiesCytochemistryHistopathologic techniques in diagnosis

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ImmunostainingFlow cytometry diagnostic and QC

Machine basicsCorrelation with blood, marrow, body fluid, or lymph node findingsStem cell QC

Correlation of morphology of the bone marrow aspirate and biopsy, histochemistry, immunochemistry, flow cytometry and clinical presentation to arrive at a diagnosis in patients with leukemia and lymphomaCytogenetics, including fluorescence in-situ hybridization (FISH)Hemoglobin electrophoresis

Hemoglobinopathies – sickle, Hb C, other, managing exchange transfusionsThalassemias – beta, alpha

Serum protein electrophoresisMonoclonal gammopathies in serum, urine and CSFOther protein abnormalities

Western blot analysis: HIV diagnosisCoagulation testing

PT, INR, PTT, TT, fibrinogenMixing studiesFactor levelsSend out tests – HIT antibodies

Osmotic fragilityRed blood cell enzyme assaysHigh pressure liquid chromatography (HPLC)Platelet function studiesBleeding timePolymerase chain reaction, with reverse transcriptionHLA typingBlood banking

Hemagglutination reactions – grading, cold and warm reactionsTyping, screening for clinically significant antibodies, crossmatchingAntibody evaluations – Rh, Kidd, Duffy, Kell, MNSs, Inventory issues – rare units, regional support from ARCProduct modification – leukoreduction, irradiation, volume reductionComponent manufacturing – making RBC, plasma, platelets, cryoprecipitateBlood collection – donor qualification, disease testing

Transfusion MedicineIndications for RBC, Plasma, Platelets, CryoprecipitateTransfusion reactions: allergic, graft versus host, delayed, hemolytic, febrilePlatelet refractorinessCoagulationApheresis – collections, therapeutic Stem cell and cellular therapyCell selection and processingTherapeutic phlebotomyExchange transfusionNMDPTransfusion Medicine specialist role in consultationTransfusion Medicine specialists role in disasters and emergencies

Career pathways in Hematology/Lab MedicineBlood Banking/Transfusion Medicine

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HematopathologyClinical Pathology/Laboratory Medicine

Educator RoleThe fellow participating in this rotation will act as a liaison between the physicians ordering specialized tests, or whose patients have developed a problem with transfusion, so that clinical information needed to interpret the tests can be communicated to the pathologists and the results and significance of the tests will be accurately transmitted to the patient’s team.


Patient Care1) Gathers essential and accurate information about the patient, largely through chart review and discussions with the patient’s physicians.2) Interacts with other health-care professionals to disseminate accurate information concerning specialized testing

Medical Knowledge1) Has become familiar with the laboratory testing available to more accurately diagnose hematologic problems, as well as the limitations of these tests2) Able to accurately interpret bone marrow aspirates and biopsies. This process will continue as part of the Lymphoma/Benign Hematology rotation. Knowledge of this skill will be assessed by means of a bone marrow “practical” at the end of the second year. Practice-Based Learning and Improvement1) Uses feedback to identify areas for improvement2) Seeks opportunities to strengthen deficits in knowledge/skills3) Demonstrates initiative in researching current scientific evidence using modern information technology and applying it to problems encountered in the daily work of the laboratory

Interpersonal and Communication Skills1) Communicates effectively with other members of the team2) Provides accurate and timely feedback to the referring physicians

Professionalism1) Adheres to laws and rules governing the confidentiality of patient information2) Adheres to the institution’s Code of Conduct

Systems-Based Practice1) Demonstrates a commitment to the practice of cost-effective medical care and resource allocation2) Partners with other members of the health-care team to manage complex patient issues

In the interest of improving the quality of the learning environment in the fellowship, the fellows must confidentially provide a written evaluation of each teaching attending at the conclusion of the rotation. We also require that they complete a self-assessment of their performance during the rotation, including a listing of conferences attended, with plans for remediation if they were not able to adequately complete the requirements for the rotation.

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Reading ListTextbooks: Blood Banking and Transfusion Medicine

Journal Articles: The following were judged the 10 articles that most significantly influenced the practice of transfusion medicine (Blajchman MA: Landmark studies that have changed the practice of transfusion medicine. Transfusion 2005;45:1523).TRAP Study Group. Leukocyte reduction and ultraviolet B irradiation of platelets to prevent alloimmunization and refractoriness to platelet transfusions. NEJM 1997;45:1861-9.Billote DB, et al: A prospective, randomized study of preoperative autologous donation for hip replacement surgery. J Bone Joint Surg Am 2002;8:1299-304.Corwin HL, et al: Efficacy of recombinant human erythropoietin in critically ill patients: a randomized controlled trial. JAMA 2002;288:2827-35.McCullough J, et al: Therapeutic efficacy and safety of platelets treated with a photochemical process for pathogen inactivation. The SPRINT Trial. Blood 2004;104:1534-41.Van de Watering LM, et al: Beneficial effects of leukocyte depletion of transfused blood on postoperative complications in patients undergoing cardiac surgery: a randomized clinical trial. Circulation 1998:97:562-8.Tobian AAR, King KE, Ness PM: Transfusion premedications: a growing practice not based on evidence. Transfusion 2007;27:1089.Finfer S, et al: The comparison of albumin and saline for fluid resuscitation in the intensive care unit. NEJM 2004;350:2247-56.Heddle NM, et al: The role of plasma from platelet concentrates in transfusion reactions. NEJM 1994;331:625-8.Rock GA, et al: Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. NEJM 1991;325:393-7.Rebulla P, et al: The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia. NEJM 1997;337:1870-5.Hebert PC, et al: A multicenter randomized controlled trial of transfusion requirements in critical care. NEJM 1999;340:409-17.

Silliman CC, et al: Transfusion-related acute lung injury. Blood 2005;105:2266.Klein J, Sato A: The HLA system. First of two parts. N Engl J Med 2000;343:702-9.Klein J, Sato A: The HLA system. Second of two parts. N Engl J Med 2000;343:782-6.The laboratory diagnosis of haemaglobinopathies. Br J Haematol 1998;101:783-92.Lilicrap D. Moleular diagnosis of inherited bleeding disorders and thrombophilia. Semin Hematol 1999;36:340-51.Ascasoy MO, Gallagher PG: Molecular diagnosis of hemoglobinopathies and other red blood cell disorders. Semin Hematol 1999;36:328-39.Old JM: Screening and genetic diagnosis of haemoglobin disorders. Blood Rev 2003;17:43-53.Hokland P, Pallisgaard N: Integration of molecular methods for detection of balanced translocations in the diagnosis and follow-up of patients with leukemia. Semin Hematol 2000;37:358-67.Gozzetti A, Le Beau MM: Fluorescence insitu hybridization: uses and limitations. Semin Hematol. 2000;37:320-33.Schrock E, Padilla-Nash H: Spectral karyotyping and multicolor fluorescence in situ hybridization reveal new tumor-specificd chromosomal aberrations. Semin Hematol 2000;37:334-7.Lichter P, et al: Comparative genomic hybridization: uses and limitations. Semin Hematol 2000;37:348-57.Gale RE: Evaluation of clonality in myeloid stem-cell disorders. Semin Hematol 1999;36:361-72.

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Langerak AW, et al: Heteroduplex PCR analysis or rearranged T cell receptor genes for clonality assessment in suspect T cell proliferations. Leukemia 1997;11:2192-9.

Radiation Oncology

Mission StatementTo provide medical oncology fellows with an understanding of the principles and practicalities involved in the use of radiation therapy for malignant disease, so that they understand its optimal use in the comprehensive care of the cancer patient

Program ObjectivePatient Care: To understand the factors that are involved in appropriate patient selection and treatment planning To become familiar with the toxicities of radiation therapy and how they can be managedMedical Knowledge: To gain an understanding of the biologic basis for the use of radiation therapy in the treatment of cancerTo gain a familiarity with the use of interstitial and intracavitary sources of radionuclides and gamma knife technologyPractice-Based Learning: see Core CompetenciesInterpersonal Skills and Communication: see Core CompetenciesProfessionalism: see Core CompetenciesSystems-Based Practice: see Core Competencies

Program ComponentsFellows will be assigned to one of the specialty services in the Radiation Oncology Department They will attend the daily morning didactic lectures and patient care conferencesThey will attend the New Patient Evaluation clinic, the weekly under treatment clinic, and the follow-up clinicThey will participate in inpatient consults for emergency radiation therapyWhen possible, they will observe special procedures, such as the placement of brachytherapy catheters

Focused Areas for StudyInteraction of radiation with biological systems, molecular mechanisms of DNA damage, molecular mechanisms of DNA repair, mechanisms of cell deathTumor microenvironment: tumor vasculature, angiogenesis, hypoxia in tumors and its relevance in radiation therapyTotal body irradiation and its side effectsMechanisms of normal tissue radiation responses, therapeutic ratio, time, dose, fractionationBrachytherapy, alternative dose delivery systemsInteraction of chemotherapy and radiation therapy, radiosensitizers, radioprotectorsRadiation carcinogenesis

Educator RoleRotations through other departments allow the fellows the opportunity to teach the radiation oncology residents some of what he/she has learned about medical oncology, while learning an approach to cancer from a different perspective. Since the care of cancer patients is optimized by good communication and mutual respect between members of the health care team, this rotation, together with the monthly Medical Oncology/Radiation Oncology Journal Club, is an important component in the effort to make cancer care truly multi-disciplinary.

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Assessment and FeedbackThe supervising attending physician will provide direct and written feedback to the fellow based upon direct observation and according to the following six competencies:


Medical Knowledge1) Understands the principles of that underlie the use of radiation therapy in the treatment of malignant disease2) Understands the clinical factors involved in the planning of radiation therapy3) Is familiar with the more common side effects associated with radiation therapy and their management





Reading ListClinical Oncology, 3rd edition, ed Abeloff, Chapter 26: The basics of radiation therapy.Cancer: Principles and Practice of Oncology, 7th edition, ed DeVita. Chapter 13: Principles of radiation oncology.

Khuntia D, Brown P, Li J, et al: Whole-brain radiotherapy in the management of brain metastasis. J Clin Onc 2006;24:1295-304.

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Continuity Medical Oncology/Hematology Clinic

General DescriptionThe continuity clinic provides a longitudinal experience in hematology and medical oncology for one half day per week for all three years of fellowship. The clinic allows the fellow to gain experience to patients with cancer over the full course of their disease trajectory: the patients are generally seen first by the fellow as a new inpatient or outpatient consult, the fellow with attending guidance directs the diagnostic and staging process, consults with the appropriate colleagues in multi-disciplinary settings, and initiates treatment, developing a relationship with the patient and family members in the process. For patients whose disease proves to be terminal, arranging palliative and end-of-life care in a patient-directed, compassionate and culturally-sensitive manner is the fellows’ task. In addition to the patients with oncologic problems, the fellows also follow patients with benign hematologic problems as well. This allows them to become exposed to the full spectrum of patients encountered in an outpatient hematology/oncology practice.

Fellow ResponsibilitiesThe fellows are expected to be the primary provider of medical oncology care. With attending guidance, the fellows perform histories and physical exams, document their findings, order and review imaging studies, and arrange for the appropriate consultations with other members of the multidisciplinary team (who is available in clinic?). Chemotherapy orders, when appropriate, are written and reviewed with the attending of record. Although each patient is expected to have a primary care provider, the complex nature of the problems encountered in medical oncology patients places demands on the fellows from an internal medicine standpoint. Fellows are contacted over the course of the week to address issues concerning their patients, and are expected to guide the medical teams who care for their patients when they are admitted to an inpatient service.

Educational ObjectivesLongitudinal follow-up of patients with malignant diseaseTumor assessment: measurement of masses, imaging, surrogate end pointsIssues regarding care of patients on clinical trials: appropriate monitoring and documentation of toxicity, adverse event reportingFollow-up care at the end of treatment: surveillance, screening for second cancers, monitoring for short and long-term toxicityPsychosocial support of patients with cancerCultural issues that impact on the management of diseaseIntegration of care: family members, pastoral care, nursing support, hospice, cancer support groupsPalliative care: pain management, appropriate use of narcotic and non-narcotic analgesiaGeriatrics: impact of age on normal physiology, pharmacokinetics, diagnosis and management of hematologic and oncologic diseases

Evaluation and FeedbackThe supervising attending physician will provide direct and written feedback to the fellow based upon direct observation and chart review, and according to the following six competencies:

Patient Care

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Gathers essential and accurate information about the patient through interviews, examination, and complete history; appropriately accesses additional sources of information, such as other health care facilities, non-UMMC or BVAMC physicians, family members.Interacts with other health-care professionals to facilitate the process of diagnosis and treatment planningCarries out patient management plans based on age, other co-morbid conditions, psychosocial issues, including arranging appropriate follow-up of diagnostic tests

Medical KnowledgeUnderstands the approach to the patient with known or suspected malignant diseaseUnderstands the principles of clinical trials managementUnderstands the diagnosis and treatment of outpatient hematologic disorders

Practice-Based Learning and ImprovementUses feedback to identify areas for improvementSeeks opportunities to strengthen deficits in knowledge/skillsDemonstrates initiative in researching current scientific evidence using modern information technology and applying it to problems encountered in daily practice

Interpersonal and Communication SkillsCommunicates effectively with other members of a multi-disciplinary teamMaintains a comprehensive, timely and legible medical recordCommunicates comprehensibly and compassionately with patients and their family membersProvides accurate and timely feedback to the referring physicians

ProfessionalismRecognizes ethical dilemmas and utilizes appropriate consultation where neededAdheres to laws and rules governing the confidentiality of patient informationAdheres to the institution’s Code of Conduct

Systems-Based PracticeDemonstrates a commitment to the practice of cost-effective medical care and resource allocationPartners with other members of the health-care team to manage complex patient issuesAdvocates and facilitates patient advancement through the health care system

In the interest of improving the quality of the learning environment in the fellowship, the fellows must confidentially provide a written evaluation of each teaching attending. Reading List:

Schnall M, Rosen M: Primer on imaging technologies for cancer. J Clin Onc 2006;24:3225-33.Barentsz J, Takahashi S, Oyen W, et al: Commonly used imaging techniques for diagnosis and staging. J Clin Onc 2006;24:3234-44.

Jaffe CC: Measures of response: RECIST, WHO, and new alternatives. J Clin Onc 2006;24:3245-51.

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Required Modules

The following descriptions cover areas of the curriculum taught over several rotations or throughout the duration of the fellowship, rather than in the context of a single 1-3 month rotation. The assessment of the degree to which the fellows have successfully mastered the material is incorporated into the individual rotation assessments.

Basic Scientific Principles

Fundamental to the training of fellows in hematology and medical oncology is the acquisition of knowledge concerning the basic scientific principles that underlie our understanding of cancer biology. Over the course of the three year fellowship, the fellows are expected to develop a working knowledge of the following areas:Biology of normal cells and the basic process of carcinogenesisGenomics: gene structure, organization, expression, regulationCell cycle: mechanisms, control by oncogenes, interactions with therapiesReceptors and signal transductionTumor cell kinetics, proliferation, programmed cell deathTumor invasion and metastasisAngiogenesisMolecular techniques: polymerase chain reaction, chromosomal analysis and cytogenetics, tissue microarray analysisCarcinogenesis: inherited and acquired genetic abnormalities, environmental, chemical and physical factorsTumor immunology: interrelationship between tumor and host immune system, regulatory actions of cytokines on the immune system and their effect on tumorsEpidemiology of cancer: cancer statistics, epidemiologic methodsExperimental therapeutics: monoclonal antibodies, radioimmunotherapy, gene therapy, transcription therapy, small molecule inhibitors, farnesyltransferase inhibitors, multi-drug resistance modifiers, novel delivery systems, mechanism of new drug development

This critical body of knowledge will be taught/acquired by the fellow in a number of ways. Several of the lectures given in the Hematology/Oncology Grand Rounds lecture series are focused to a large degree on this material. In addition, many of the lectures in the Fellows Lecture series contain information regarding pathogenesis and tumor biology, which is presented during lectures on specific tumors.

The recently established “Frontiers in Oncology” lecture series, given on a monthly basis, brings nationally prominent speakers who have amassed a significant body of work, which is in the transition from the laboratory to the clinical phase of development. In order to take advantage of this opportunity, the Fellows Journal Club is coordinated to review a paper relevant to the scheduled speaker in the week prior to the lecture.

Reading ListThe most current medical oncology textbooks contain introductory chapters with excellent reviews on molecular and cellular biology, in particular as they apply to the process of cancer development. Clinical Oncology, 3rd edition, ed Hoffman, chapters 1-16Cancer Medicine, ed Holland, 2003, chapters 2-26Cancer: Principles and Practice, 7th edition, ed DeVita, chapters 1-10

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Adjei AA, Hidalgo M: Intracellular signal transduction pathway proteins as targets for cancer therapy. J Clin Oncol 2005;23:5386-5403.Hahn WC, Weinberg RA: Rules for making human tumor cells. NEJM. 2002;347:1593-603Hahn EC: Role of telomeres and telomerases in the pathogenesis of human cancer. J Clin Oncol 2003;21:2034-2043.Beeram M, et al: Raf: a strategic target for therapeutic development against cancer. J Clin Oncol 2005:23:6771-6790.Herman JG, Baylin SB: Gene silencing in cancer in association with promoter hypermethylation. NEJM 2003;349:2042—2054Rowinsky EK: Targeted induction of apoptosis in cancer management: the emerging role of tumor necrosis factor-related apoptosis-inducing ligand receptor activating agents. J Clin Oncol 2005;23:9394-307.Schwarz GK, Shah MA: Targeting the cell cycle: a new approach to cancer therapy. J Clin Oncol 2005:23:9408-21.Quackenbush J: Microarray analysis and tumor classification. N Engl J Med 2006;354:2463-72.

Clinical Research: Design, Implementation and Analysis

A good understanding of the clinical research process and the ability to accurately assess the validity of the results from clinical trials is a skill that is imperative for hematology/oncology trainees to acquire. This training, of course, starts in medical school, and is further enhanced by internal medicine residency programs. A thorough understanding of the process gains a new immediacy during the fellowship years, as the need to incorporate constantly changing treatment regimens for malignant diseases into patient care in a prompt but appropriately cautious fashion becomes apparent.

An understanding of the process through which basic science research results are transmogrified into a treatment regimen is transmitted to fellows in our program through didactic and experiential means. A Fellows Journal Club meets three times a month, analyzing papers in the basic science as well as clinical arena. One of these Journal Club sessions is held together with the fellows and faculty from Radiation Oncology, enriching the analysis and discussion of the subject. Fellows beginning their second year take a 1week “Introduction to Clinical Research” course. Seminars and lectures on specific aspects of the clinical research process are held periodically.

Many of the fellows choose to do research projects that involve them in designing and carrying out clinical trials, which allows them to see first-hand the complexities of the clinical trials process.

Reading ListTextbooks: Each of the standard medical textbooks contain several chapters relevant to this topic: Clinical Oncology, 3rd edition, ed Hoffman, chapters 19, 20, 22Cancer Medicine, ed Holland, 2003, chapters 32-34Cancer: Principles and Practice, ed DeVita, chapter 18

Biostatistics: A Foundation for Analysis in the Health Sciences, 8th edition, Wiley, 2005.

Journal Articles: USER’S GUIDE TO THE MEDICAL LITERATURE SERIES, published in JAMA (also published in book form, available on the AMA website). This series, designed for primary care physicians and internists in practice, provides useful information for analyzing the literature, presented in a very readable form.

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I. How to get started. 270:2093-5, 1993.II. How to use an article about therapy or prevention. A. Are the results of the study valid? 270:2598, 1993.II. How to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? 271:59-63, 1994.III. How to use an article about a diagnostic test. A. Are the results of the study valid? 271:389-391, 1994.III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? 271:703-707, 1994.IV. How to use an article about harm. 271:1615-1619, 1994.V. How to use an article about prognosis. 272:234-237, 1994.VI. How to use an overview. 272:1367-1371, 1994.VII. How to use a clinical decision analysis. A. Are the results of the study valid? 273:1292-1295, 1995.VII. How to use a clinical decision analysis. B. What are the results and will they help me in caring for my patients? 273:1610-1613, 1995.VIII. How to use clinical practice guidelines. A. Are the recommendations valid? 274:570-574, 1995.VIII. How to use clinical practice guidelines. B. What are the recommendations and will they help you in caring for your patients? 274:1630-1632, 1995.IX. A method for grading health care recommendations. 274:1800-1804, 1995.X. How to use an article reporting variations in the outcomes of health services. 275:554-558, 1996.XI. How to use an article about a clinical utilization review. 275:1435-1439, 1996.XII. How to use articles about health-related quality of life. 277:1232-1237, 1997.XIII. How to use an article on economic analysis of clinical practice. A. Are the results of the study valid? 277:1552-1557, 1997.XIII. How to use an article on economic analysis of clinical practice. B. What are the results and will they help me in caring for my patients? 277:1802-1806, 1997.XIV. How to decide on the applicability of clinical trial results to your patient. 279:545-549, 1998.XV. How to use an article about disease probability for differential diagnosis. 281:1214-1219, 1999.XVI. How to use a treatment recommendation. 281(19):1836-43, 1999.XVII. How to use guidelines and recommendations about screening. 281:2029-2034, 1999.XVIII. How to use an article evaluating the clinical impact of a computer-based clinical decision support system. 282:67-74, 1999.XIX. Applying clinical trial results. A. How to use an article measuring the effect of an intervention on surrogate end points. 282:771-778, 1999.XIX. Applying clinical trial results. B. Guidelines for determining whether a drug is exerting (more than) a class effect. 282:1371, 1999.XX. Integrating research evidence with the care of the individual patient. 283:2829-2836, 2000.XXII: how to use articles about clinical decision rules. 284(1):79-84, 2000.XXIII. Qualitative research in health care. A. Are the results of the study valid? 284:357-362, 2000.XXIII. Qualitative research in health care. B. What are the results and how do they help me care for my patients? 284:478-482, 2000.XXIV, How to use an article on the clinical manifestations of disease. 284:869-875, 2000.XXV. Evidence-based medicine: principles for applying the Users’ Guides to patient care. 284:1290, 2000.

Korn EL, et al: Clinical trial designs for cytostatic agents: are new approaches needed? J Clin Oncol 2001;19:265-272.Lee JJ, Feng L: Randomized phase II designs in cancer clinical trials: current status and future directions. J Clin Onocl 2005;23:4450-4457.Rubenstein LV, et al: Design issues of randomized phase II trials and a proposal for phase II screening trials. J Clin Oncol 2005:23:7199-7206.Rosner GL, et al: Randomized discontinuation design: application to cytostatic antineoplastic agents. J Clin Oncol 2002;20:4478-4484.Sargent DJ, et al: Clinical trial designs for predictive marker validation in cancer treatment trials. J Clin Oncol 2005;23:2020-2027.Kaul S, Diamond GA: Good enough: A primer on the analysis and interpretation of noninferiority trials. Ann Int Med 2006;145:62-9.

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Key Procedures

Fellows are expected to become proficient in the performance of several procedures. This is accomplished though a brief introduction, one or more demonstrations by more senior fellows or faculty, then the performance of the procedures under the direct supervision of a senior fellow or attending. Over the course of the first two years, the fellow becomes proficient in the following procedures:Bone marrow aspirate and biopsy, ileac crest Bone marrow aspirate, sternumAccessing and caring for indwelling venous cathetersChemotherapy, intravenousChemotherapy, intrathecal, lumbar punctureChemotherapy, intrathecal, Omaya reservoirThoracentesis, administration of chemotherapy into the pleural cavityParacentesis, administration of chemotherapy into the abdominal cavityTumor assessment, measurement of masses on physical exam, CT, MRI

Reading ListHematology: Basic Principles and Practice, 4th edition, ed Hoffman, chapter 157: Bone marrow examinationClinical Oncology, ed Hoffman, chapter 52: Establishing and maintaining vascular accessCancer: Principles and Practice of Oncology, chapter 50, section 1: Vascular access and specialized techniques of drug deliveryHoch JR. Management of complications of long-term venous access. Semin Vasc Surg 1997;10:135-43.Dunlop TJ, et al: Use of combined oral narcotic and benzodiazepine for control of pain associated with bone marrow examination. South Med J 1999;92:477-480.Wolanskyj AP, et al: A randomized, placebo-controlled study of outpatient premedication for bone marrow biopsy in adults with lymphoma. Clin Lymphoma 2000;1:154-157.Lenz H-J: Management and preparedness for infusion and hypersensitivity reactions. The Oncologist 2007:12:601.

Radiation Oncology

For those fellows who plan an academic career with a focus on solid malignancies, or for those who are considering a career in clinical oncology, the two week Radiation Oncology rotation described on pages 58-59 is strongly suggested.

For those fellows whose career goals center around hematologic malignancies or who envision a career in basic science research, radiation oncology will be taught in the context of the diseases for which it is indicated. These fellows are expected to acquire a working knowledge of the following areas over the course of their Solid Tumor rotations:Principles of radiation biologyInteractions with chemotherapy, hormone therapy, biologic therapyAppropriate sequencing of the various therapeutic modalitiesFractionation and dosingRole of brachytherapy and focused radiation therapies (gamma knife, IMRT)

This knowledge will be obtained through discussions concerning patient care in multi-disciplinary conferences, through didactic study, and through discussions of relevant papers in the

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combined Medical Oncology/Radiation Oncology journal club (held monthly). Visits to the Radiation Oncology facilities (located on premises) will be encouraged to add a practical dimension to the knowledge obtained. A reading list can be found on p. 59.

Palliative Care

This critical body of information will be taught in several different ways. Under the direction of UMGCC faculty member Dr Doug Ross, an NCI-funded Hospice Educational Program for development of comprehensive curriculum of hospice, palliative care, and pain management education for medical students and physicians in all stages of training has been instituted. This includes a web-based course imparting a knowledge base on topics such as pain management, management of symptoms other than pain (fatigue, anorexia, cachexia, nausea, vomiting, constipation, altered mental status, dyspnea), communication techniques, psychosocial, cultural and spiritual issues, ethical and legal issues, and hospice care, which fellows complete during their first year.

Building on that knowledge base, the fellows participate in monthly case conferences, which focus on one of the topics from the web curriculum, during which the fellows discuss how they would apply the palliative care knowledge they have gained to a specific patient problem. This material is supplemented by additional lectures and a Palliative Care symposium held yearly.

During the three months that the fellows spend on the Leukemia /Lymphoma service, rounds are made with nutritional support, a palliative care specialist, and a social worker, which allows the fellows to recognize the contributions made by other members of a multi-disciplinary support team, as well as giving them practical advice as to how some of the many multi-faceted problems facing cancer patients can be managed.

Using the tools listed above, all fellows are expected to develop enough of an expertise in this area to be able to fashion a comprehensive symptom management and end-of-life plan for patients in their care, and analyze its effectiveness. For fellows with a particular interest in the field, a 1 month rotation can be arranged with Dr. Timothy Keay (see below) to further extend their experience.

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Research/Electives

Research

Fellows are expected to spend the majority of their elective time conducting a research project. This is done under the direction of a faculty mentor, and is tailored to the interest of the individual fellow. It is expected that the work will result in the submission of abstracts to national meetings and manuscripts to peer-reviewed journals.

Palliative Care

For fellows who desire to extend their knowledge of the palliative care field can participate in a Palliative Care rotation. This includes rounds with the Palliative Care consult team under the direction of Dr. Timothy Keay, design and evaluation of end-of-life care plans,

Pediatric Hematology-Oncology

The Department of Pediatrics offers an elective rotation for Hematology-Oncology fellows in their second and third years. The objective of this rotation is to familiarize fellows with benign and malignant hematologic disorders and solid tumors that occur commonly in children. The Pediatric Hematology-Oncology service consists of 5-10 inpatient beds on the Pediatrics Ward plus 1 laminar flow reverse isolation bed in the Pediatrics Intensive Care Unit for stem cell transplantation, as well as outpatient clinics.

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Documents

Oncology Curriculum.doc