PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 13: HEMATOLOGY/ ONCOLOGY
This section has been reviewed and approved by the Chief, Division of Hematology and
Oncology as well as the Program Director, Internal Medicine Residency Program at Prince
George’s Hospital Center.
______________________________
______________________________
Chief, Division Of Hematology/Oncology
Program Director, Residency Program
I. Overview
Medical Oncology involves the diagnosis and management of benign and malignant
neoplasms. The general internist should have a wide range of competencies in the
evaluation and management neoplastic disease. They must be able to do the following:
(1) Identify patients at risk for malignancy and counsel them regarding risk reduction and
screening
(2) Investigate clinical syndromes suggestive of underlying malignancy
(3) Undertake the palliative care of patients with common solid and hematologic tumors
(4) Identify neoplasms with a potential for cure and direct affected patients to the
appropriate centers or providers
(5) Participate in the difficult decisions regarding all aspects of management including
diagnostic evaluation and screening, treatment, and palliative care.
(6) Be familiar with the administration, side effects, and drug interactions of therapeutic
agents commonly used for the treatment of malignant disease.
Hematology relates to the care of patients with disorders of the blood, bone marrow, and
lymphatic systems. These disorders include the anemias, hematologic malignancies
and other clonal processes, and congenital and acquired disorders of hemostasis,
coagulation, and thrombosis. The general internist should be competent in the following:
(1) Detection of abnormal physical, laboratory, and radiologic findings relating to the
lymphohematopoietic system
(2) Assessment of the need for bone marrow aspirate and biopsy or lymph node biopsy
(3) Initial diagnostic evaluation and management of the hemostatic and clotting system
(4) Assessment of the indications and procedure for transfusion of blood and its
separate components
(5) Management of therapeutic and prophylactic anticoagulation
(6) Diagnosis and management of the common anemias
(7) Management of neutropenia / immunosuppression
(8) Recognition and management of elevated RBC, WBC and platelets
(9) Pharmacology and use of common chemotherapies
II. Principle Teaching Methods
It consists of frequent encounters with the attending physician regarding patient care.
The resident will discuss all patients with the attending physician and interpret clinical
data to formulate a differential. The attending will assign reading topics on a regular
basis and review the material with the residents. This will include accepted national
guidelines used in the diagnosis and treatment of various hematologic and oncologic
diseases. The faculty will also critique the residents consult notes, examination and
management plan. Rounds will include short 15-30 minute discussions on current topics
driven by patient encounters and initiated by resident and completed by the attending
physician on most days. Latest information dealing with the topic as provided by
literature search and pertinent articles should be discussed.
Residents will attend the outpatient clinic with Dr. Chhabra three half days each week
during the rotation to gain experience in issues related to outpatient management of
hematologic and oncologic illnesses. This includes issues related to :
 Intravenous Access for chemotherapy
 Follow-up of patients with malignancies and those on chemotherapy and
radiation therapy
 Follow-up of cancer survivors
 Follow up of patients with hematologic diseases like sickle cell
The Outpatient attendance sheet is attached at the end of this section. Residents must
have the sheet signed by the supervising attending for each outpatient encounter and
submit the sheet to the program coordinator at the end of the rotation.
There will be lectures on a Heme/Onc related topic each month (“Disease of the
Month”). The discussions will be as follows:
 January- lung cancer
 February- breast cancer
 March- colon cancer
 April- leukemia
 May- lymphoma
 June- myelodysplasia
 July- oncologic and hematologic emergencies
 August- anemias
 September- thrombocytopenia
 October- coagulopathies
 November- measuring performance status, introduction to malignant disease,
radiation therapy
 December- prostate cancer
The residents will therefore receive lectures and updates on cancer each month
throughout their residency. During their rotation in the subspecialty residents will be
required to present a case related to the Disease of the Month.
The resident must also review and discuss with the attending the topics highlighted in
the logsheet at the end of this section. The residents must print out a double sided copy
of the Logsheet and complete the requirements during the rotation. At the end of the
rotation the residents must submit the completed logsheet to the program coordinator as
requirement for successful completion of the rotation.
III. Strengths and Limitations
The residents will be exposed to a broad range of clinical problems typical of a
community-based practice with emphasis on inpatient illness and care. The teaching
faculty for the rotation is committed to teaching and patient care with strong role model
presentation. For patients with exceptionally unusual clinical problems, the care may
require transfer to a tertiary referral center. Outpatient experience in the subspecialty
can be obtained by shadowing the attending physician in their private office. Patients in
the continuity clinic at Glenridge Medical Center also offer some learning opportunities
regarding prevention, screening and long term follow-up of patients with hematologic
illnesses or cancers.
IV. Goals and Objectives
Legend of Learning Activities
Learning Venues:
1. Direct Patient Care/Consultation
2. Attending Rounds
3. Core Lecture Series
4. Self Study
Evaluation Methods:
A. Attending Evaluation
B. Direct Observation
C. Nurses’ Evaluation
D. In-training Examination
Competency: Patient Care
Learning Venues
Evaluation Methods
Demonstrate the ability to obtain an accurate
patient history regarding risks for cancer / prior
malignancy / hematologic abnormalities / bleeding
disorders / status of disease / prior treatment
Demonstrate the ability to perform a thorough
physical examination on patients with malignancy
and/or hematologic disease
1,2,4
A, B
1,2
A, B
Demonstrate ability to generate differential
diagnosis, diagnostic strategy, and to define
appropriate therapeutic plan and modifications to
ongoing therapy in patients with malignancy
1,2,3,4
A, B
Demonstrate the ability to generate differential
diagnosis, diagnostic strategy, and to define
appropriate therapeutic plan and modifications to
ongoing therapy in patients with a hematologic
disorder
1,2,3,4
A, B,
Competency: Medical Knowledge
Learning Venues
Evaluation Methods
Demonstrate the ability to recognize an oncologic
or hematologic emergency
1,2,3,4
A, B
Articulate the genetic predisposition to, and the
pathophysiology, evaluation, and management of
common hematologic disorders
1,2,3,4
A, B, D
Articulate the genetic predisposition to, and the
pathophysiology, evaluation, and management of
common malignancies
1,2,3,4
A, B, D
Demonstrate the ability to monitor a patient’s
progress and respond to a change in the patient’s
condition during treatment for malignancy
(chemotherapy)
1,2,4
A, B, C
Demonstrate the ability to order and interpret the
appropriate diagnostic tests and studies for a given
patient with hematologic abnormalities
(bleeding/clotting disorders)
1,2,4
A, B, D
Demonstrate the ability to order and interpret the
appropriate diagnostic tests and studies for a given
patient with malignancy
1,2,4
A, B, D
Demonstrate an understanding of pertinent
procedures in the work-up and treatment of
hematologic/oncologic disease (bone marrow
biopsy, lymph node biopsy, etc.), including
indications, risks and complications of the
procedures
1,2,4
A,B, D
Competency: Interpersonal and
Communication Skills
Learning Venues
Evaluation Methods
Interact in an effective way with physicians and
nurses participating in the care of patients with
hematologic/oncologic diseases
1,2
A, B, C
Show understanding of differing patient
preferences in diagnostic evaluation and
management of malignancy
Demonstrate the ability to maintain accurate
medical records
Demonstrate the ability to serve as a patient
advocate
1,2
A, B, C
1,2
A, B, C
1,2
A, B, C
Competency: Professionalism
Learning Venues
Evaluation Methods
Treat team members, primary care-givers, and
patients with respect and empathy
Demonstrate understanding of and adherence to a
code of medical ethics
1,2
A, B, C
1,2
A, B, C
Actively participate in consultations and rounds
1,2
A, B, C
Attend and participate in all scheduled conferences
3
Attendance, A
Competency: Practice-Based Learning
Learning Venues
Evaluation Methods
Identify limitations of medical knowledge in
evaluation and management of patients with
hematologic and oncologic disorders and use
medical literature (primary and reference) to
address these gaps in medical knowledge
1,2,4
A, D
Competency: Systems-Based Practice
Learning Venues
Evaluation Methods
Understand need for effective communication
between multiple caregivers and sites (eg,
hematologists,
oncologists,
primary
care
physicians, surgeons, radiation oncologists, chemo
nurses, social workers, hospitals, out-patient
infusion units) in delivering optimal care to
heme/onc patients
Understanding of clinical trial design and the
statistical methods for evaluating scientific studies,
in cooperation with attendings, fellows and
research nurses/personnel
1,2,4
A
1,2,5
A, B, C
V. Educational Content
A. Hemostasis and Thrombosis
1) Learn the causes and management of:
 Abnormal coagulation (abnormal prothrombin and partial thromboplastin
times)
 Anticardiolipin antibody syndrome
 Anticoagulation, fibrinolysis (therapeutic)
 Disseminated intravascular coagulation
 Hypercoagulable state
 Hyperviscosity syndrome
 Heparin, Coumarin, Fibrinolytic Agents and Thrombolytic Disorders
 Hemophilia
2) Know indications and interpretation of the following:
 Bone marrow aspirate, biopsy, and special stains
 Chromosome analysis-peripheral blood and bone marrow
 Clotting assay, including factor levels and mixing studies
 Hemoglobin electrophoresis
 Iron studies
B. Platelet disorders
 Platelet dysfunction
 Thrombocytopenia
 Thrombocytosis
C. Leukocyte disorders
 Leukemoid reaction


Immunosuppression
Neutropenia
D. Myeloproliferative disorders
1) Learn diagnosis and management of:
 Chronic myelogenous leukemia
 Polycythemia vera
 Essential thrombocytosis
 Polycythemia, secondary
 Acute Leukemia
 Chronic Leukemia
2) Understand indications and interpret results of
 Peripheral smear
 Radiologic, sonographic, and nuclear studies to assess adenopathy,
splenomegaly, and red cell mass etc.
E. Red Cell Disorders
 Anemia
 Hemoglobinopathies and Thalassemias
 Erythrocytosis
 Aplastic Anemia
 Pure Red Cell Aplasia
 PNH
 Myelodysplasia
 Transfusion and Component Therapy
 Transfusions reactions
 Iron Overload/ Hemochromatosis
F. Miscellaneous
 Hypersplenism
 Immunoglobulins
 Monoclonal Protein Disturbance
 The Soluble Coagulation System
 Febrile neutropenia
 Management of pain, emesis, and nutrition
 Advance planning and management of end-of-life issues
G. Dermatologic
 Actinic keratosis (see also Dermatology)
 Basal cell carcinoma (see also Dermatology)
 Melanoma (see also Dermatology)
 Squamous cell carcinoma (see also Dermatology)
H. Gastrointestinal
 Cancer of the anus
 Cancer of the colon, rectum
 Cancer of the esophagus
 Cancer of the gallbladder, bile ducts
 Cancer of the pancreas



I.
Cancer of the stomach
Hepatoma
Metastatic disease to various sites
Genitourinary
 Cervical dysplasia and cancer
 Endometrial cancer
 Kidney cancer
 Ovarian cancer
 Prostate cancer
 Testicular cancer
 Ureter, bladder cancer
J. Head and Neck
 Cancer of the head, neck
 Cancer of the parathyroid
 Cancer of the thyroid
K. Hematologic malignancies and lymphoma
1) Understand diagnosis and management of:
 Chronic lymphocytic leukemia
 Hodgkin’s and non-Hodgkin’s lymphomas
 Leukemia, acute
 Multiple myeloma
 Myelodysplastic syndrome
2) Understand indications and interpretation of results of:
 Lymph node biopsy and lymphoid cell immunophenotype
 Radiologic, sonographic, and nuclear studies to assess adenopathy,
splenomegaly, and red cell mass
L. Neurologic
 CNS lymphoma
 Metastatic disease to the CNS
 Primary brain tumors
M. Oncologic Emergencies
 Depressed CNS function due to brain malignancy
 Hypercalcemia
 Pericardial tamponade
 Renal failure due to uteral obstruction
 Spinal cord compression
 Tumor lysis syndrome
N. Pulmonary
 Bronchial carcinoid
 Cancer of the lung
 Mediastinal tumors
 Pleural malignancy
 Superior vena cava syndrome
O. Breast cancer
 Premenopausal and postmenopausal
 Estrogen and progesterone receptor positive and negative
P. Malignancies associated with HIV
VI.
Recommended Reading:
All residents are encouraged to complete reading MKSAP sections on Hematology and
Oncology. Additional readings on a case-by-case basis should be done using MD
Consult and Up to Date. Other recommended readings are as follows:
A. Anemia
1) Andrews, NC. Disorders of Iron Metabolism. N Engl J Med. 1999 Dec 23;
341(26): 1986-95.
B. Myelodysplasia
1) Heaney ML, Golde DW. Myelodysplasia. N Engl J Med. 1999 May 27; 340(21):
1649-60.
C. Acute Myeloid Leukemia
1) Lowenberg B, Downing JR, Burnett A. Acute Myeloid Leukemia. N Engl J Med.
1999 Sep 30; 341(14): 1051-62.
2) Cheson BD, Bennett JM, Kopecky KJ, et al. Revised Recommendations of the
International Working Group for Diagnosis, Standardization of Response Criteria,
Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute
Myeloid Leukemia. J Clin Oncol. 2003 Dec 15; 21(24):4642-9.
3) Pui CH, Relling MV, Downing JR. Acute Lymphoblastic Leukemia. N Engl J Med.
2004 Apr 8; 350(15): 1535-48.
D. Chronic Myeloid Leukemia
1) Sawyers CL. Chronic Myeloid Leukemia. N Engl J Med. 1999 Apr
29;340(17):1330-40.
2) Faderl S, Talpaz M, Estrov Z, et al. The Biology of Chronic Myeloid Leukemia. N
Engl J Med. 1999 Jul 15; 341(3): 164-72.
3) Goldman JM, Melo JV. Chronic Myeloid Leukemia- Advances in Biology and
New Approaches to Treatment. N Engl J Med. 2003 Oct 9; 349(15): 1451-64.
E. Chronic Lymphocytic Leukemia
1) Shanafelt TD, Call TG. Current Approach to Diagnosis and Management of
Chronic Lymphocytic Leukemia. Mayo Clin Proc. 2004 Mar; 79(3): 388-98.
F. Hodgkin’s Disease
1) DeVita VT. Hodgkin’s Disease-Clinical Trials and Travails. N Engl J Med. 2003
Jun 12;348(24):2375-6.
G. Non-Hodgkin’s Lymphoma
1) Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab
compared with CHOP alone in elderly patients with diffuse large B cell
lymphoma. N Engl J Med. 2002 Jan 24; 346(4): 235-42.
2) Ansell SM. Non-hodgkin lymphoma: diagnosis and treatment. Mayo Clin Proc.
2005; 89(8): 1087-1097
H. Multiple Myeloma
1) Barlogie B, Shaughnessy J, Tricot G, et al. Treatment of multiple myeloma.
Blood. 2004 Jan 1; 103(1): 20-32.
I.
Chronic Myeloproliferative Disorders
1) Tefferi A. Polycythemia Vera: A Comprehensive Review and Clinical
Recommendations. Mayo Clin Proc. 2003 Feb; 78(2): 174-94.
2) Tefferi A. Myelofibrosis with Myeloid Metaplasia. N Engl J Med. 2000 Apr 27;
342(17): 1255-65.
J. Hemachromatosis
1) Beutler E. Penetrance in hereditary hemachromatosis. The HFECys282Tyr as a
necessary but not sufficient cause of clinical hereditary hemachromatosis. Blood.
2003 May 1;101(9):3347-50.
K. Thrombotic Disorders
1) Rosendaal FR. Venous Thrombosis: A multicausal disease. Lancet. 1999 Apr
3;353(9159):1167-73.
2) Levine M, Gent M, Hirsh J, et al. A Comparison of Low Molecular Weight Heparin
administered primarily at home with Unfractionated Heparin administered in the
hospital for Proximal Deep Vein Thrombosis. N Engl J Med. 1996 Mar
14;334(11):677-81.
3) Quinlan DJ, McQuillan A, Eikelboom JW. Low Molecular Weight Heparin
Compared with intravenous Unfractionated Heparin for Treatment of Pulmonary
Embolism. Ann Intern Med. 2004 Feb 3;140(3):175-83.
4) Shapiro SS. Treating Thrombosis in the 21st Century. N Engl J Med. 2003 Oct
30;349(18):1762-4.
L. Bleeding Disorders
1) Mannucci PM, Tuddenham EGD. The Hemophilias-From Royal Genes to Gene
Therapy. N Engl J Med. 2001 Jun 7;344(23):1773-9.
2) Mannucci PM. Treatment of von Willebrand’s Disease. N Engl J Med. 2004 Aug
12;351(7):683-94.
M. Disorders of Platelets
1) Drachman JG. Inherited thrombocytopenia: when a low platelet count does not
mean ITP. Blood. 2004 Jan 15;103(2):390-8.
2) Cines DB, Blanchette VS. Immune Thrombocytopenia purpura. N Engl J Med.
2002 Mar 28;346(13):995-1008.
3) Stasi R, Provan D. Management of Immune Thrombocytopenia in Adults. Mayo
Clin Proc. 2004 Apr;79(4):504-22.
4) Moake JL. Thrombotic Microangiopathies. N Engl J Med. 2002 Aug
22;347(8):589-600.
5) George JN. Thrombotic Thrombocytopenic Purpura: From the Bench to the
Bedside, but Not yet to the Community. Ann Intern Med. 2003 Jan
21;138(2):152-3.
6) Alving BM. How I treat heparin-induced thrombocytopenia and thrombosis.
Blood. 2003 Jan 1; 101(1): 31-7.
N. Hemoglobinopathies
1) Olivieri NF. The ß- Thlassemias. N Engl J Med. 1999 Jul 8;341(2):99-109.
2) Steinberg MH. Management of Sickle Cell Disease. N Engl J Med. 1999 Apr
1;340(13):1021-30.
O. Breast Cancer
1) Clemons, M, Goss, P., Estrogen and the Risk of Breast Cancer, NEJM
344(4):276-85, January 25, 2001.
2) Meijers-Heijboer, H., et al., Breast Cancer after Prophylactic Bilateral
Mastectomy in Women with a BRCA-1 or BRCA-2 Mutation, NEJM 345(3):15964, July 19, 2001.
3) Vallis, K.A., et al., Assessment of Coronary Heart Disease Morbidity and
Mortality after Radiation Therapy for Early Breast Cancer, J Clinical Oncology
20(4):1036-42, February 15, 2002.
P. Colorectal Cancer/Other GI Cancer
1) Huang, J.Q., Meta-analysis of the Relationship between Helicobacter Pylori
Seropositivity and Gastric Cancer, Gastroenterology 114(6): 1169-79, June 1998.
2) Lieberman, D.A., et al., Use of Colonoscopy to Screen Asymptomatic Adults for
Colorectal Cancer, Veterans Affairs Cooperative Study Group 380, NEJM 343(3):
162-8, July 20, 2000.
Q. Lung Cancer
1) Newman, L., Larger Debate Underlies Spiral CT Screening for Lung Cancer, J
National Cancer Institute, 92(8):592-4, April 19, 2000.
R. Prostate Cancer
1) Sirovich, B.E., et al., Screening Men for Prostate and Colorectal Cancer in the
United States:Does Practice Reflect the Evidence?, JAMA 289(11):1414-20,
March 19, 2003.
S. Miscellaneous Topics
1) Arany, I., Safirstein, R.L., Cisplatin Nephrotoxicity, Seminars in Nephrology
23(5):460-4, September 3, 2003.
2) Callee, E.E., et al., Overweight, Obesity, and Mortality from Cancer in a
Prospectively Studied Cohort of U.S. Adults, NEJM 348(17):1625-38, April 24,
2003.
3) Lee, A., et al., Low-Molecular Weight Heparin versus Coumarin for the
Prevention of Recurrent Venous Thromboembolism in Patients with Cancer,
NEJM 349(2):146-53, July 10, 2003.
4) Rosen, L.S., et al, Long-Term Efficacy of Zolendronic Acid in Patients with Bone
Metastases, Cancer 100:2613-2621, 2004.
5) Walter, L.C. et al., Relationship between Health Status and Use of Screening
Mammography and Papanicolaou Smears among Women Older Than 70 Years
of Age, Ann Intern Med 140(9):681-688, 2004.
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
HEMATOLOGY/ONCOLOGY LOGSHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
TEST
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
PERIPHERAL
SMEAR
ROTATION MONTH_____________
BIOPSY
REVIEW
PATHOLOGY
REPORT(
RECEPTORS/
TUMOR
MARKERS)
STAGING OF
CANCER
RESIDENT NAME:
TEST
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
PERIPHERAL
SMEAR
BIOPSY
REVIEW
PATHOLOGY
REPORT(
RECEPTORS/
TUMOR
MARKERS)
STAGING OF
CANCER
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
HEMATOLOGY/ONCOLOGY OUTPATIENT ATTENDANCE SHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
DATE
ROTATION MONTH_____________
COMMENTS (IF ANY) BY ATTENDING
SIGNATURE OF
ATTENDING