Supplemental Material
Curriculum Considerations
Table S1 provides a list of potential educational experiences. We have used the chapters of the Chest
LCIII guidelines as a framework to develop objectives for training. Table S2 connects the topics within
this framework to the educational experiences that could be offered. Objectives are then listed under
the topic heading as “must be able to” or “should be able to” accomplish by the end of training. Finally,
evaluation tools are suggested. A summary of the framework, objectives, educational experiences, and
evaluation tools is provided in Table S3.
Educational Experience
Exposure during the Educational Experience
1. Pulmonary specialty and
multi-disciplinary clinics
All aspects of evaluation of patients with nodules, masses, and
confirmed cancer, prior to and after treatment, screening program
experience
2. Bronchoscopy training
Decision making and skillset to guided bronchoscopy and EBUS guided
bronchoscopy
3. Thoracic Surgery clinic
Surgical evaluation and management
4. Medical Oncology clinic
Medical Oncology evaluation and management
5. Radiation Oncology
clinic
Radiation Oncology evaluation and management
6. Cyto-Pathology
Review of ROSE, tissue processing, and pathologic evaluation
7. Radiology
Review of imaging, structured reporting, transthoracic needle biopsy
8. Palliative Medicine
Palliative Medicine evaluation and management
9. Tumor board
Multi-disciplinary discussions of cases
10. Classroom
Traditional education sessions
11. Journal Club
Review of new and classic articles
12. Local conferences
Conferences put on by the Lung Cancer Program for trainees and
practicing clinicians
13. National meetings
Lung cancer content at Chest and ATS meetings
14. Simulation
Bronchoscopy training
Table S1: Educational experiences for Pulmonary lung cancer sub-specialty training
Topic
Educational Experience
Epidemiology
10, 11, 12, 13
Molecular Biology
10, 11, 12, 13
Chemoprevention
10, 11, 12, 13
Treatment of Tobacco Use
1, 3, 4, 5, 8, 10, 11, 12, 13
Screening
1, 7, 9, 10, 11, 12, 13
Pulmonary Nodule Evaluation
1, 2, 3, 7, 9, 10, 11, 12, 13, 14
Clinical and Organizational Factors in the Initial Evaluation
1, 9, 10, 11, 12, 13
Establishing the Diagnosis
1, 2, 3, 6, 7, 9, 10, 11, 12, 13, 14
Physiologic Evaluation of the Resection Candidate
1, 3, 9, 10, 11, 12, 13
The Stage Classification
1, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13
Methods of Staging for NSCLC
1, 2, 3, 6, 7, 9, 10, 11, 12, 13, 14
Diagnostic Surgical Pathology
2, 6, 9, 10, 11, 12, 13
Diagnosis and Treatment of Bronchial Intraepithelial Neoplasia
and Early Lung Cancer of the Central Airways
1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13
Treatment of Stage I and II NSCLC
1, 3, 4, 5, 9, 10, 11, 12, 13
Treatment of Stage III NSCLC
1, 3, 4, 5, 9, 10, 11, 12, 13
Treatment of Stage IV NSCLC
1, 4, 5, 8, 9, 10, 11, 12, 13
Special Treatment Issues in NSCLC
1, 3, 4, 5, 7, 9, 10, 11, 12, 13
Treatment of Small Cell Lung Cancer
1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13
Complementary Therapies and Integrative Medicine
1, 8, 10, 11, 12, 13
Follow-up and Surveillance After Curative-Intent Therapy
1, 3, 4, 5, 9, 10, 11, 12, 13
Symptom Management
1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14
Palliative and End-of-Life Care
1, 2, 4, 5, 8, 9, 10, 11, 12, 13, 14
Table S2: Core topics based on the framework of the Chest LCIII guidelines, connected to educational
experiences from Table S1.
Table S3: Attached file.
Objectives
Epidemiology
Must be able to:
1. Discuss the public health impact of lung cancer.
2. Describe the risk factors for developing lung cancer.
Should be able to:
1. Demonstrate an understanding of the current state of molecular biomarkers of lung cancer risk.
Molecular Biology of Lung Cancer
Should be able to:
1. Discuss the impact of molecular drivers of lung cancer pathogenesis on current and future
clinical care.
Chemoprevention of Lung Cancer
Should be able to:
1. Demonstrate an understanding of the current state of lung cancer chemoprevention.
Treatment of Tobacco Use in Lung Cancer
Must be able to:
1. Describe the impact of cigarette smoking on lung cancer related outcomes.
2. Counsel patients about the importance of smoking cessation and provide counseling support for
smoking cessation efforts.
3. Provide pharmacotherapy support, when appropriate, for patients preparing to quit smoking.
Screening for Lung Cancer
Must be able to:
1.
2.
3.
4.
Describe the evidence of benefit from lung cancer screening.
Describe the potential harms related to lung cancer screening.
Counsel patients about the benefit and harms of low-dose chest CT based lung cancer screening.
Demonstrate an understanding of the impact of the risk of developing lung cancer on the
balance of benefit to harms in a lung cancer screening program.
5. Provide an overview of the components of high quality low-dose chest CT based lung cancer
screening programs.
Should be able to:
1. Discuss the resources required to successfully implement lung cancer screening with low-dose
chest CT.
2. Demonstrate an understanding of the current state of molecular biomarkers of risk prediction
and early detection of lung cancer.
Evaluation of Individuals With Pulmonary Nodules
Must be able to:
1. Describe a management strategy for solid sub-centimeter lung nodules, whether incidentally or
screen detected.
2. Describe a management strategy for sub-solid lung nodules, whether incidentally or screen
detected.
3. Calculate the probability that a solid nodule, 1-3 cm in diameter, is malignant.
4. Discuss the clinical utility of FDG-PET scanning, bronchoscopy (including guided bronchoscopy),
transthoracic needle biopsy, and surgical resection, in the management of solid and sub-solid
lung nodules.
5. Perform bronchoscopy, including guided bronchoscopy, for the evaluation of lung nodules.
Should be able to:
1. Demonstrate an understanding of the current state of molecular biomarkers for lung nodule
management.
Clinical and Organizational Factors in the Initial Evaluation of Patients with Lung Cancer
Should be able to:
1. Organize a lung cancer patient’s initial evaluation in a timely and efficient manner.
2. Discuss the potential benefits of multi-disciplinary care, including the participation in multidisciplinary tumor boards.
Establishing the Diagnosis of Lung Cancer
Must be able to:
1. Develop a plan for diagnosis that considers the clinical presentation, extent of disease, patient
comorbidities and preferences.
2. Perform bronchoscopy, including guided bronchoscopy for peripheral tumors, and
endobronchial ultrasound guided mediastinal sampling of enlarged lymph nodes.
3. Discuss the need to have adequate cancer tissue to permit accurate histologic characterization
and molecular testing.
4. Describe the processing of small tissue specimens to optimize the yield for accurate histologic
characterization and molecular testing.
Physiologic Evaluation of the Patient with Lung Cancer Being Considered for Resectional Surgery
Must be able to:
1. Identify patients with lung cancer being considered for surgery who have increased
perioperative cardiovascular risk.
2. Describe an algorithm for preoperative pulmonary physiology evaluation that can help to define
perioperative and long-term risk from traditional surgical resection in a patient with lung cancer.
3. Compare the benefits and harms of traditional surgical resection with sublobar resection and
ablative therapies for patients with localized and regionally advanced lung cancer.
4. Discuss interventions that may modify the risk of cancer treatment, such as smoking cessation,
pulmonary rehabilitation, and COPD therapy.
The Stage Classification of Lung Cancer
Must be able to:
1. Describe features of the tumor (T), node (N), and metastases (M) components of the lung cancer
staging system.
2. Identify a patients’ lung cancer stage based on their TNM status.
Methods of Staging for NSCLC
Must be able to:
1. Select appropriate imaging tests for mediastinal and extrathoracic staging of lung cancer.
2. Outline an approach to mediastinal staging in lung cancer patients with imaging based N0, N1,
and N2/3 disease.
3. Discuss the importance of the order of testing in the diagnosis and staging of lung cancer.
4. Discuss the importance of confirmation of imaging findings in the staging of lung cancer.
5. Perform bronchoscopy, including endobronchial ultrasound guided systematic staging of the
mediastinum.
6. Discuss the need to have adequate cancer tissue to permit accurate histologic characterization
and molecular testing.
7. Describe the processing of small tissue specimens to optimize the yield for accurate histologic
characterization and molecular testing.
Diagnostic Surgical Pathology in Lung Cancer
Should be able to:
1. Discuss the use of immunohistochemical assays to permit accurate histologic characterization of
lung cancer.
2. Describe the role of advanced molecular testing of lung cancer tissue.
Diagnosis and Treatment of Bronchial Intraepithelial Neoplasia and Early Lung Cancer of the Central
Airways
Should be able to:
1. Describe an approach to severe dysplasia and carcinoma in situ of the central airways.
Treatment of Stage I and II NSCLC
Should be able to:
1. Discuss features of a surgical resection that may influence outcomes, such as experience of the
surgeon/center, extent of the resection, use of minimally invasive techniques, and extent of
lymph node removal.
2. Discuss the indications for ablative therapies such as stereotactic ablative radiotherapy.
3. Describe the indications for adjuvant chemotherapy.
4. Describe the indication for adjuvant radiation therapy.
Treatment of Stage III NSCLC
Should be able to:
1. Discuss the current state of knowledge on the selection of treatment for stage III lung cancer
with discrete lymph node involvement definitive (concurrent chemoradiotherapy or induction
therapy followed by surgical resection).
2. Describe the treatment approach to occult stage III lung cancer (incidentally detected at the
time of resection despite complete preoperative staging).
Treatment of Stage IV NSCLC
Should be able to:
1. Describe the potential benefits and harms from palliative treatment with systemic therapies for
stage IV lung cancer.
2. Discuss the impact of tumor histology, tumor environment, and molecular features on the
selection and success of systemic therapies for stage IV lung cancer.
Special Treatment Issues in NSCLC
Should be able to:
1. Discuss an approach to the diagnosis, staging, and treatment of a patient with a Pancoast tumor.
2. Discuss an approach to the diagnosis, staging, and treatment of a patient with more than 1 solid
tumor nodule.
3. Discuss an approach to the diagnosis, staging, and treatment of a patient with multiple sub-solid
lung nodules.
4. Discuss an approach to the diagnosis, staging, and treatment of a patient with an isolated brain
or adrenal metastasis.
Treatment of Small Cell Lung Cancer
Must be able to:
1. Describe the Veterans Administration and American Joint Committee on Cancer/International
Union Against Cancer staging systems for small cell lung cancer.
Should be able to:
1. Discuss an approach to the treatment of limited stage and extensive stage small cell lung cancer.
Complementary Therapies in Integrative Medicine in Lung Cancer
Should be able to:
1. Discuss the value of complementary therapies and integrative medicine (e.g. yoga, massage,
exercise, pulmonary rehabilitation, acupuncture, and diet) in the management of anxiety, mood
disturbance, sleep disturbance, pain, and treatment related side effects for lung cancer patients.
Follow-up and Surveillance of the Patient with Lung Cancer After Curative-Intent Therapy
Must be able to:
1. Describe a schedule of surveillance imaging for patients with lung cancer who have been treated
with curative intent.
Symptom Management in Patients with Lung Cancer
Should be able to:
1. Guide their patients about the management of cancer related pain, pain from bone metastases,
spinal cord compression, cough, dyspnea, symptomatic malignant pleural effusions, SVC
syndrome, hemoptysis, and psychological distress.
Palliative and End-of-Life Care in Lung Cancer
Should be able to:
1. Discuss the value of Palliative Medicine in the care of lung cancer patients.
2. Initiate discussions about prognosis, the goals of care, and end-of-life care options.
Evaluation Tools
Evaluation of the Pulmonary lung cancer sub-specialty trainee would use formats common to other
training programs:
1. Direct observation: Of patient care in clinics and bronchoscopy suites, presentations at tumor
boards, classroom forums, and journal club.
2. OSCE: Structured questioning based on patient presentations.
3. Validated instruments: For bronchoscopy skills (e.g. EBUS-STAT, ref)
4. Training exams: As tests of knowledge.
Research
It is an expectation that the Pulmonary lung cancer sub-specialty trainee would develop and make every
effort to complete at least one research project. The trainee would gain experience in developing a
research question, designing a research study appropriate to answer the clinical question, performing
background literature searches on the research topic, creating the research proposal, submitting the
proposal to the IRB, collecting research data, analyzing the research data, synthesizing and presenting
the results. All activities would be mentored and performed as part of a team. Additional experiences,
based on the nature of the project, could include submission for funding, and time spent in a basic
science lab. Research topics in any of the core areas of training would be acceptable. Research training
would be augmented by the general Pulmonary fellowship research series and the institutions research
education programs.