MEDICAL ONCOLOGY
RESIDENCY TRAINING PROGRAM
of BC
GOALS & OBJECTIVES
(revised 2 May 2011)
TABLE OF CONTENTS
PAGE
1. General Overview……………………………………………03
2. Can MEDS Competencies…………………………………..04
3. Team Based Rotations and Schedules……………………...09
4. Basic Scientific Principles……………………………….......12
5. Basic Principles in Management and Treatment…………..13
6. Management and Treatment of Individual Cancers……….14
7. Other Rotations………………………………………………19
8. Useful Resources……………………………………………..22
9. Administrative Structure……………………………………..23
10. Appendix……………………………………………………...23
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1. GENERAL OVERVIEW:
The University of British Columbia Medical Oncology Training Program of BC, based at the
BC Cancer Agency, Vancouver Center (VC) and Vancouver General Hospital (VGH), is an
accredited subspecialty of Internal Medicine recognized by the Royal College of Physicians
and Surgeons of Canada. The BC Cancer Agency a provincial organization, whose mandate
is cancer care and research, is comprised of five regional cancer centers: Vancouver
Centre (VC) in Vancouver, Vancouver Island Center (VIC) in Victoria, Fraser Valley Center
(FVC) in Surrey and The Center for the Southern Interior (CSI) in Kelowna and Abbotsford
Centre (AC).
The overall objective is to enable trainees to function as competent independent medical
oncologists in a general hospital setting with continuing self-education and self-evaluation.
The trainee needs to develop internal medicine skills and knowledge in preparation for
the written and oral fellowship examinations and be expected to acquire the skills and
knowledge outlined in the Royal College Objectives Training in Medical Oncology to a level
at least sufficient to satisfy the examination requirements (http://rcpsc.medical.org/
residency/certification). Eligible trainees are also encouraged to obtain certification from
the Medical Oncology Subspecialty Board of the American Board of Internal Medicine.
The trainee will spend two years in the basic clinical program and will be encouraged to
consider an additional one or two years of training as a fellow in clinical or basic research
especially if they are interested in an academic career.
2-Year Program consisting of 26 (4-week) Blocks:
13 Blocks
General medical oncology in a structured "team-based" approach to provide
exposure to common and rare solid tumours
3 Blocks
Lymphoproliferative disorders
2 Blocks
Radiation oncology
1 Block
Leukemia/stem cell transplantation
1 Block
Palliative Care
1 Block
Gynecologic Oncology including Hereditary Cancer Program
5 Blocks
Electives
In Year 1 (PGY-4) the trainee will:
Be expected to learn the fundamental principles of the basic and clinical science of
oncology including etiology, molecular biology, diagnosis, staging, natural history,
treatment goals and evaluation of response and practical aspects of systemic therapy.
Be expected to interpret laboratory and imaging studies and demonstrate an ability to
manage common neoplasms and complications.
Develop experience in routine procedures including marrow biopsy, lumbar puncture with
intrathecal therapy, thoracentesis, paracentesis and the use of needle aspiration. Develop
experience with common examination techniques during the radiation and gynecology
rotations.
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Critically appraise and interpret medical oncology literature. Identify a clinical research
project.
Learn the fundamental aspects of pain control, symptom control, home hospice and
palliative care options for patients in their community.
Learn practical aspects of radiation oncology as it relates to medical oncology, including
modality interaction. Be able to outline the roles of curative, adjuvant and palliative
radiotherapy and radiotherapy planning.
In Year 2 (PGY-5) the trainee will:
Develop a more in depth understanding of the basic and clinical science underlying medical
oncology and the principles involved in the management and treatment of malignant
diseases.
Develop of consultative skills and long-range management planning.
Take a peer leadership role in the training program with supervision of junior trainees.
Learn the basics of stem cell transplantation, hematologic supportive care and infectious
complications.
Learn basic principles of clinical research and literature interpretation and complete and
submit a research project for presentation and publication (see section 7.IV.below)
Structure electives to focus on career path (eg community or academic)
The above is a very general overview of the structure and content of the training
program. The remainder of this document will focus on the CanMEDS roles and
competencies, the detailed structure of the program, and the basic science and clinical
curriculum. In addition the specific goals for the radiation oncology, hematology,
gynecology, community and research electives will be outlined.
2. CanMEDS ROLES AND COMPETENCIES: STANDARD ROYAL COLLEGE OF PHYSICIANS
AND SURGEONS OF CANADA REQUIREMENTS FOR TRAINING IN MEDICAL ONCOLOGY:
Specialists possess a defined body of knowledge and procedural skills, which are used to
collect and interpret data, make appropriate clinical decisions, and carry out diagnostic
and therapeutic procedures within the boundaries of their discipline and expertise. Their
care is characterized by up-to-date, ethical, and cost-effective clinical practice and
effective communication in partnership with patients, other health care providers, and
the community.
The following seven roles are considered integral to the training of a specialist in the
discipline of medical oncology. Each role contains key competencies. At the end of the
two-year training program in Medical Oncology at the BC Cancer Agency, a medical
oncologist should be experienced in the following roles:
2.1 MEDICAL EXPERT
Demonstrate the diagnostic and therapeutic skills necessary for the effective care of
patients with a wide spectrum of malignant neoplasms:
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Elicit a history that is relevant, concise, accurate and appropriate to the patient’s
problem(s)
Perform a physical examination that is relevant, sufficiently elaborate, appropriate
and meets and if necessary exceeds the standards expected of a medical oncologist
Select medically appropriate investigative tools in a cost-effective and useful manner.
Demonstrate the cognitive and process skills towards solving the individual patient’s
problem(s). Anticipate, diagnose and manage complications of cancer and its
treatment in both an in-patient and ambulatory setting.
Perform and document patient assessments and recommendations in both written and
verbal form as is expected of a subspecialty consultant.
Apply knowledge and expertise to performance of technical skills relevant to medical
oncology.
Be able to structure the patient centered problem to perform a systematic search of
the recent medical oncology literature, critically evaluate this literature and make
evidence-based decisions regarding patient care.
Develop the attitudes and skills necessary to stay up to date.
Access, retrieve, assist and apply relevant information of all kinds to problem solving
and introduce new therapeutic options to clinical practice.
Demonstrate medical expertise in situations other than those involving direct patient
care (eg formal presentations, medico-legal cases etc.)
Demonstrate insight into own limitations by self-assessment.
These goals will be obtained through:
 Tumor sites specific rotations in which an adequate of volume of patients are seen and
evaluated in the setting of a multidisciplinary approach to the treatment of cancer.
 A graded responsibility over the two years of training with senior trainees performing as
junior consultants.
 Demonstration of effective skills as a consultant with well documented consultation
notes that outline the diagnosis, plan for staging and ultimate treatment of the patient
with cancer.
 Demonstration of critical thinking in the review of current literature used in therapeutic
decision making.
 Attending subspecialty-orientated conferences.
 Learning the core procedures that are relevant to the practice of medical oncology
which will include thoracentesis, abdominal paracentesis, lumbar puncture and bone
marrow aspiration and biopsy.
 Demonstrating knowledge of basic science as applied to the clinical situations faced in
the ambulatory care clinic and the inpatient ward.
 Understanding the epidemiology of the common cancers and its application to patient
and community care.
These skills will be taught in the follow ways:
 Assignment to tumor site specific rotations with both outpatient and inpatient
responsibilities in a graded format.
 Watch, do and teach procedures in Medical Day Care
 Attendance at clinical and research rounds, Wednesday academic lectures, Journal Club
and tumor site specific teaching sessions.
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Development of critical thinking skills in reviewing clinical situations in the light of
current literature at tumor site specific disposition conferences and at the weekly
Journal Club.
These skills will be evaluated by:
 Monitoring attendance at formal teaching sessions.
 Review of consultation notes and plans of investigation and treatment with staff
consultants.
 In-training evaluations as per the ITERs.
 Quiz (written or oral) at the end of each rotation with the head of that service
regarding the ITER
 Formal examinations after completion of training by the Royal College of Physicians and
Surgeons in the subspecialty examination in medical oncology.
 Annual ASCO-SAP written multiple choice test for self assessment
2.2 COMMUNICATOR
 Establish effective relationships with patients who have a malignancy and with their
family and caregivers.
 Effectively explain prognosis, risks and benefits and management plans to patients and
their caregivers. Be able to break bad news with sensitivity.
 Interact with primary care physicians and other health professionals within the
community in order to obtain relevant information regarding the patient as well as to
bring about appropriate ongoing community-based care.
 Learn to effectively utilize written consultations and discharge summaries as well as
verbal interactions with medical colleagues.
 Effectively communicate with the members of an interdisciplinary team in the
resolution of conflicts, provision of feedback, and where appropriate, be able to assume
a leadership role.
These skills will be taught and evaluated by:
 Daily observation of trainee performance in the presence of the clinical supervisors with
ongoing dialogue to give appropriate feedback on approach and performance.
 Review of written records, including daily chart notes, consultation notes and discharge
summaries by the attending consultant with feedback to the trainee.
 Direct observation of the interaction between the trainee and the staff medical
oncologists during the rotations.
 Lectures on communication skills as part of Wednesday seminar series.
 Feedback from other members of the interdisciplinary team via 360º biannual
evaluations.
2.3 COLLABORATOR
 Know when it is appropriate to consult other physicians and health care professionals.
 Identify and describe the role, expertise and limitations of all members of an
interdisciplinary team required to optimally achieve a goal related to patient care, a
research problem, an educational task, or an administrative responsibility.
 Develop a care plan for patients including investigation, treatment and continuing care,
in collaboration with the members of the interdisciplinary team. Implement appropriate
discharge planning and ongoing community-based care.
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Participate in an interdisciplinary team meeting, demonstrating the ability to accept,
consider and respect the opinions of other team members, while contributing specialtyspecific expertise him/herself.
These skills will be taught by:
 Observation of the practice patterns of the attending staff medical oncologists during
the rotations.
 Active participation at the tumor group specific multidisciplinary weekly or twice
weekly conferences.
 Participation in discharge planning conferences and family meetings.
These skills will be evaluated by:
 Observation of trainee performance by the attending medical oncology staff.
 Feedback through in-training evaluations.
 Feedback from other members of the interdisciplinary team via 360º biannual
evaluations.
2.4 MANAGER
 Demonstrate the ability to utilize the available resources effectively and to balance the
needs of patient care with the realities of health care economics.
 Understand the interaction between government funding and health care institutions in
making decisions regarding resource allocation.
 Develop effective and efficient strategies for managing patients that stress obtaining all
relevant patient information from other health care sources where available, avoiding
duplication of services and accessioning of this information by use of sophisticated
information technology.
 Learn to effectively delegate responsibility to junior house staff and to supervise their
activities.
 Learn to manage the competing demands of clinical, academic and personal demands
during individual rotations and over the two year training period.
These skills will be taught by:
 Observation of and guidance by medical oncology staff consultants in their interactions
with other caregivers.
 Graded responsibilities that allow supervision of more junior house staff.
 Provision of a computer and instruction in accessing information through the systems in
place at BCCA.
 Attendance at presentations and rounds that discuss therapeutic priorities and resource
utilization.
 Taking responsibility for team related activities.
 Quarterly “fireside chats” at the home of attending physicians.
 Lecture on Drug Funding in BC (Oncology and Supportive).
These skills will be evaluated by:
 Observation of the trainees in their tumor-specific rotations by the attending medical
oncology staff with direct feedback.
 Formal evaluations as per the ITERS.
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2.5 HEALTH ADVOCATE
 Identify those factors that are important in the development of malignancies, their
treatments and outcome.
 Be able to discuss preventative strategies relevant to patients or to their families or
community.
 Intercede on behalf of patients where accessing services from other components of the
health care institutions is required.
 Recognize and respond to those issues where advocacy on the patient’s behalf is
appropriate.
 Describe how health care governance influences patient care, research and educational
activities at a local, regional, provincial and national level.
 Lecture on Drug Funding in BC (Oncology and Supportive).
These skills will be taught by:
 Formal lectures that address the epidemiology of various malignancies.
 Formal lectures that address the roles of various institutions in our health care system.
 Observation of the attitudes and practices of attending staff medical oncologists and
other members of the interdisciplinary care team.
 Quarterly “fireside chats” at staff homes.
 Opportunity to participate in tumor site specific patient education days.
These skills will be evaluated by:
 Provision of feedback through the ITERS
2.6 SCHOLAR
 Develop, implement and be able to document a long-term personal continuing
education strategy.
 Acquire the learning skills involved in the practice of evidence-based medicine.
 Develop effective techniques for teaching more junior house staff and other health
professionals.
 Develop a desire to contribute new knowledge to the field through participation in
research projects supervised by a faculty mentor.
These skills with be taught by:
 Learning how to critically review the literature at Journal Club and during discussions of
specific patient treatment plans.
 Attendance at Wednesday Seminar Series and rounds that didactically address relevant
topics.
 Opportunities to take faculty wide teaching courses
 Participation in research projects through the two years of residency, which is
mandatory in the training program.
These skills will be evaluated by:
 Regular feedback from the attending medical oncologists.
 Formal review and feedback through ITERS.
 Presentation of research projects at national and international conferences.
 Submission of manuscripts for publication.
 Presentations at the Medical Oncology Tuesday Noon Rounds.
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2.7 PROFESSIONAL
 Develop those skills that will allow the trainee to deliver the highest quality care to the
patient with cancer with integrity, honesty and genuine compassion.
 Understand their professional obligations to both patients as well as to colleagues.
 Exhibit the appropriate personal and interpersonal professional behaviors.
 Practice medicine ethically
 Demonstrate insight into own limitations of expertise by self-assessment.
These skills will be taught by:
 Observation of the daily practice and behavior patterns of attending physicians and
other health care workers at BCCA.
 Quarterly “fireside chats” at the home of attending physicians
 Lectures on ethics as part of Wednesday seminar series
 Web based ethics courses available through the Royal College of Physicians and Surgeons
of Canada
These skills will be evaluated by:
 Daily observations of trainees by attending medial oncologists.
 Formal evaluation through ITERS.
 Reviews with the program director and other members of the postgraduate training
committee.
3. TEAM-BASED ROTATIONS AND SCHEDULES
In order to develop the roles and key competencies of a medical oncologist, residents will
learn the specific problems associated with cancers of each anatomic site. These sites are
grouped into four medical oncology teams. Each year the trainee will spend two months
on each team. In the PGY-4 year the resident is expected to acquire basic knowledge of
the scientific principles, management and treatment of the individual cancers. In the
PGY-5 year a more sophisticated understanding of the biologic underpinnings,
management and treatment of the individual tumor sites is expected.
Each team consists of medical oncologists with overlapping interests in oncologic disease
sites, General Practitioners in Oncology (GPO) and one or two medical oncology trainees.
Residents from other specialties and subspecialties (eg internal medicine, radiation
oncology, hematology etc.) and medical students may also be training in any given month.
The other health care professionals associated with team activities are: ambulatory care
nurses, ward nurses, chemotherapy nurses, clinical trails nurses, pharmacists,
nutritionists, patient and family counselors and physiotherapists.
The faculty team leader is responsible for the overall clinical and teaching schedule and
smooth running of the team. He or she is also responsible for ensuring the in-training
evaluation report (ITER) is completed and delivered to the trainee at the end of the
rotation. The most senior resident on the team is responsible for coordinating the daily
assignments (in patient admissions, consultations, follow up clinics, procedures) of the
team.
The following pre-scheduled activities are part of each team: Referred new patient
consultations (REMO slots), active treatment and follow-up out-patient clinics, weekly
(team specific) teaching rounds, scheduled admissions and weekly tumor site specific
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multidisciplinary conferences (2nd floor conference room). These conferences include
radiation, medical and surgical oncologists, pathologists and radiologists with special
expertise in the particular tumor sites.
Teams also have the following divisional and academic activities on their schedules:
weekly Medical Oncology Tuesday Noon Rounds, weekly Friday morning Journal Club,
weekly British Columbia Cancer Research Centre Monday Noon Scientific Rounds,
Wednesday evening Seminar Series and biweekly Thursday morning Basic Science of
Oncology Rounds.
The following activities are also part of each team: In-patient consultations at VGH or
from radiation oncology at VCC, urgent admissions, rounding on in-patients, procedures
scheduled in Medical Day Care (often done by the GPO). A trainee in medical oncology
should be proficient at: thoracentesis, paracentesis, bone marrow aspiration and biopsy,
lumbar puncture, intrathecal (via LP or Ommaya reservoir) administration of
chemotherapy.
Given the number of specialists on each team there are frequently overlapping activities.
The team leader should clarify which activities in any given week are the priorities. The
trainee should attempt to get exposure to all tumor sites represented in a given rotation.
Since the bulk of patients in medical oncology are seen in the out patient clinics, the
trainee should try to complete rounds on the in-patients expeditiously each morning. In
the out-patient setting the trainee will learn patient management in a longitudinal
fashion. They will have the opportunity to see new patients with a wide variety of
cancers, develop consulting skills, become familiar with the indications, delivery and side
effects of systemic therapy (chemotherapy, hormonal therapy, immunotherapy,
investigational new drugs) and familiarize themselves with long term toxicities and
patterns of recurrence.
To maintain smooth running of the team, the most senior resident should send an e-mail
to all staff regarding trainee assignments for clinics and admissions the next day. They
should also remind the staff of scheduled teaching sessions.
Clinic schedules as follows:
Team I: Tumor Sites: Lymphoma, Endocrine, Melanoma, Sarcoma
 Staff Members:
Lymphoma: Drs L Sehn, J Connors, R Klasa, K Savage, P Hoskins, T Shenkier
Endocrine: Drs J Connors, M Knowling
Melanoma: Drs K Savage, R Klasa
Sarcoma: Drs M Knowling, L Sehn
Team Coordinator: Dr Laurie Sehn
Team II: Tumor Sites: Lung, GU, Sarcoma
 Staff Members:
Lung: Drs J Laskin, N Murray, B Melosky, S Sun, C Ho
GU: Drs K Chi, C Kollmannsberger, N Murray, A Tinker
Team Coordinator: Dr Nevin Murray
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Team III: Tumor Sites: Breast, CNS, Pain & Symptom Management
 Staff members:
Breast: Drs S Chia, K Gelmon, T Shenkier, S Sun, H Lim, C Lohrisch, J Laskin
CNS: Drs B Thiessen, M Knowling
Pain & Symptom Management: Drs P Hawley, E Beddard-Huber, M Lymburner
Team Coordinator: Dr Tamara Shenkier
Team IV: Tumor Sites: GI, Head & Neck
 Staff members:
GI: Drs H Lim, S Gill, B Melosky, C Kollmannsberger, H Kennecke, A Weiss, W Cheung
Head and Neck: Drs S Chia, J Laskin, C Ho
Team Coordinator: Dr Howard (Howie) Lim
Gynecology:
 Staff members: Drs P Hoskins, A Tinker
Team Coordinator: Dr Anna Tinker
Palliative Care:
 Coordinators: Dr Pippa Hawley
Radiation Oncology:
 Coordinator: Dr Roy Ma
Heme/SCT:
 Coordinator: Dr Kevin Song
GPOs may be associated with a particular team or a particular staff member. Dr Shirley
Howdle is the overall GPO liaison and coordinator. At the beginning of each rotation the
trainee should clarify the role of the GPO on that particular team.
The weekly schedules for the four teams and Gyne (including clinical and academic
events) are attached in the Appendix.
There are basic skills and procedures which a trainee in medical oncology should be
proficient at:
Thoracentesis
Paracentesis
Bone Marrow Aspiration and Biopsy
Lumbar Puncture
Chemotherapy Administration
 Care and access of indwelling venous catheters
 Knowledge of the acute toxicities of chemotherapy related to the
administration of drugs
 Administration of chemotherapy and biologics by all therapeutic routes:
intrathecal, intraventricular (Ommaya Reservoir), intraperitoneal, etc.
 Knowledge of the handling and disposal of chemotherapeutic and biologic
agents.
6. Understand when to order FNA and Punch Biopsy
1.
2.
3.
4.
5.
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Proficiency at the above will be obtained and evaluated through the team-based
rotations. Most of the procedures are performed in Medical Day Care except FNA.
Special sessions will be arranged via the Cancer Centre Pharmacy and Nursing to address
issues of Chemotherapy Administration.
4. BASIC SCIENTIFIC PRINCIPLES
As a foundation for treating malignant disease the trainee should understand the biology
of cancer, principles of therapy and proper conduct and interpretation of clinical
research.
These principles include:
4.1 Cancer Biology: Trainees should know the biology of normal cells and the basic
processes of carcinogenesis. They should have an understanding of gene structure,
organization, expression and regulation. They should have a fundamental understanding of
the cell cycle and its control and general concepts of signal transduction. They should
have an understanding of tumor cell kinetics including proliferation, apoptosis and the
balance between these two. Trainees should understand the concepts of tumor suppressor
genes and oncogenes. They should know various means of carcinogenesis including ionizing
radiation, chemical and viral. Trainees should understand the components of the
metastatic cascade and the concept of angiogenesis. Trainees should also be familiar with
the common techniques of molecular biology including PCR, blotting, cloning and
chromosomal analysis (see OTR).
4.2 Pharmacology and Pharmacokinetics: The trainee should be familiar with the basic
principles of pharmacology and be able to interpret basic pharmacokinetic information.
They should be familiar with the mechanism of new drug development and how these
agents are tested. They should also be familiar with the mechanisms of action and
metabolism of antineoplastic agents. They should also be familiar with the dosages, routes
of administration, toxicities and drug interactions of common antineoplastic drugs.
4.3 Tumor Immunology: Trainees should have a basic knowledge of the cellular and
humoral components of the immune system and regulatory role of cytokines. They should
understand the inter-relationship between tumor and host immune systems including
tumor antigenicity, immune mediated anti-tumor cytotoxicity and the direct effect of
cytokines on tumors.
4.4 Etiology, epidemiology, screening and prevention: The trainee should understand
the genetic and environmental factors in oncogenesis and have basic knowledge of
epidemiologic factors including sex, age, heredity, occupation and geography. They should
understand principles and roles of screening and risk assessment. They should understand
the principles and indications for genetic testing and counseling. They should know the
value of prevention (primary, secondary and tertiary) in cancer development.
4.5 Clinical Research including statistics: Design and conduct of clinical trials, phase I-IIIII studies, review of the ethical and regulatory issues involved in study design and
conduct, criteria for defining response to therapy, basic statistics including statistical
methods, requirements for patient numbers in designing studies and proper interpretation
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of data. How to critically evaluate publishes articles. Instruction in preparing abstracts
presentations and articles.
These issues will be covered in multiple formats including:
1. Wednesday Medical Oncology Seminar
2. Friday Journal Club
3. Thursday Basic Science of Oncology
4. Attendance at oncology conferences including the annual BC Cancer Agency,
Cancer Care Conference
5. Tuesday Medical Oncology Noon Rounds
6. Participating in a research project with the guidance of a mentor
7. BC Cancer Research Monday Noon Rounds when a relevant topic is presented
5. BASIC PRINCIPLES IN THE MANAGEMENT AND TREATMENT OF MALIGNANT DISEASES
The management of malignant disease requires interdisciplinary expertise. The trainee
should recognize the contributions of each of these subspecialties in making the diagnosis,
assessing the stage, and treating the underlying disease and its complications. The trainee
should be capable of assessing the patient’s comorbid medical conditions that affect the
toxicity and efficacy of treatment, including geriatric issues.
5.1 Pathologic Classification: Relative incidence of each type and treatment response
relative to histology. The trainee should have the opportunity to review biopsy material
and surgical specimens with a pathologist. They should appreciate the role of the
pathologist in confirming the diagnosis of cancer and in determining the severity and
extent of disease. Trainees should be familiar with newer pathologic techniques (eg
immunostaining, cytology, flow cytometry, fine needle aspiration). They should
appreciate the utility of tumor markers and recognize their limitations.
5.2 Extent of Disease: Clinical staging and systems of staging, pathological staging,
studies available to aid clinical staging (history and physical exam). Trainees should also
know the indications for imaging procedures including functional imaging techniques.
They should understand the anatomy and incidence of spread to various sites and how to
evaluate metastases. They should be familiar with the presentation and management of
metastases to particular sites (eg brain, leptomeninges, pleura etc).
5.3 Treatment of Primary Disease: Surgery: role in staging, cure and palliation;
contraindications (oncology specific), risks and benefits, post op complications. Radiation:
principles of radiation biology; indications as a curative or palliative modality; familiarity
with planning and dosimetry; sequencing and combined modality therapy; acute and late
toxicities. Systemic anticancer agents: indications and goals of treatment in primary and
recurrent malignant disorders; risk/benefit and indications for adjuvant, neoadjuvant or
metastatic treatment; knowledge of the pharmacology and the toxicity profile of the
various agents, including long-term hazards; how to adapt the dose and treatment
schedule according to comorbidities and toxicities; knowledge of the different categories
of systemic agents including, hormonal, classic antineoplastic, monoclonal antibodies,
targeted molecular therapy and other biologic agents. Use of Growth Factors: The
trainee should know the indications, proper use and side effects of cytokines including
filgrastim and erythropoietin.
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5.4 Supportive Care: Pain: The resident should be able to assess location, severity and
nature of pain and understand the basic principles of pain physiology. The resident should
be able to implement the World Health Organization pain ladder and understand the
pharmacology and toxicities of common analgesics including non-steroidal antiinflammatory drugs, opioids etc. They must be able to anticipate and manage these side
effects. The resident should be able to manage pain crises. The resident should
understand and implement the use of co-analgesics and be able to recognize indications
for palliative radiotherapy or surgery and the indications for anesthetic intervention
a. Infections and Neutropenia: The trainees should know the principles of diagnosis
and management seen in all types of cancer patients.
b. Nausea and vomiting: Trainees should understand the physiology of nausea/emesis
and understand the means by which drugs can modulate these states.
c. Mucositis: The trainee should be able to distinguish mucositis resulting from
infection from that resulting from chemotherapy. They should be aware of the
need for pain medications, topical anesthetics and antibiotics. They must
recognize when mucositis can result in a medical oncology emergency.
d. Diarrhea: The diagnosis and management of treatment induced diarrhea.
e. Constipation and bowel obstruction: Treatment and disease related, including
management.
f. Transfusion: The trainee should know the indications for and complications of red
cell and platelet transfusions. They should be aware of the options regarding
preparation and administration of these products.
g. Marrow and Peripheral-Blood Progenitor Cells. Trainees should be aware of
methods for their procurement and storage.
h. Malignant Effusion: Trainees should have a working knowledge of the indications
for paracentesis, thoracentesis and pleurodesis.
i. Indications: for and complications of enteral and parenteral support
j. Oncologic Emergencies: pain crisis, spinal cord compression, superior vena cava
syndrome, febrile neutropenia, metabolic emergencies, bowel obstruction,
obstructive uropathy, pericardial tamponade, extravasation of vesicants and
irritants.
k. Paraneoplastic syndromes: Diagnosis and management.
l. Palliative and end of life care: Pain (see above), palliation of other symptoms (eg
respiratory, GIT obstruction, neurologic, etc).
6. MANAGEMENT AND TREATMENT OF INDIVIDUAL CANCERS:
Having understood the general principles of treatment, the trainee should be instructed in
the care of individual cancer types and the unique considerations for each malignant
disease. For each specific disease, the trainee should know the epidemiology, pathophysiology, genetics, signs and symptoms, diagnostic work-up, treatment and follow-up.
The trainee should be able to communicate and discuss these topics with the patients. For
each tumor, specific items may be more important. They are stated below:
*next to the site indicates that a more detailed outline is available in the appendix
6.1 BREAST:* Trainees should be familiar with the interpretation of mammograms and
breast ultrasounds. They should understand which women are appropriate candidates for
breast conservation surgery. They should recognize the pathologic and prognostic features
that define the indications for adjuvant and neoadjuvant therapy. They should understand
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the rationale for the choices of therapy for advanced disease, including the appropriate
use of cytotoxic chemotherapy, hormonal therapy, biologic therapy (eg trastuzumab) and
supportive treatments such as bisphosphonates. They should understand the risk factors
for the development of breast cancer including the role of heredity.
6.2. CARCINOMA OF UNKNOWN PRIMARY SITE: The trainee should learn the importance
of tumor histopathology, pathologic analysis and tumor markers in directing the work up.
They should recognize setting in which treatment may affect survival versus when it is
palliative.
6.3 CENTRAL NERVOUS SYSTEM MALIGNANCIES: The trainee should be aware of the roles
of surgery, radiation therapy and chemotherapy in the management of both primary brain
tumors as well as other tumors that metastasize to the central nervous system.
6.4 ENDOCRINE CANCERS: Trainees should know the specific diagnostic work-up and
treatment of endocrine cancers. They should know that endocrine cancer may be part of a
cancer syndrome due to specific genetic defects. They should know the role of anti-cancer
drugs in the different endocrine cancers.
6.5 GASTROINTESTINAL CANCERS:*
a. Esophageal Cancer: Trainees should understand the risk factors for this malignancy
and understand the role of endoscopy in both diagnosis and staging. They should
understand the need for parenteral nutritional support. They should understand the
role of combined modality therapy as well as palliative chemotherapy and radiation.
b. Gastric Cancer: Trainees should understand the risk factors for this disease. They
should understand the potential curative role of surgery and the role of combined
modality therapy.
c. Colorectal Cancer: Trainees should know the risk factors and heritable risk
associated with this malignancy. They should understand the controversies in
screening for this cancer. Trainees should know the role of surgical staging and the
indications of both adjuvant chemotherapy and radiation therapy. They should also
understand the roles of palliative chemotherapy, surgery and radiation in advanced
disease.
d. Anal Carcinoma: This site provides a model of viral carcinogenesis. Combined
modality therapy with the goal of organ preservation should be appreciated.
e. Hepatobiliary Cancers: Trainees should understand the epidemiology and risk
factors associated with these malignancies. The role of alpha-fetoprotein in
screening, diagnosis and response to treatment should be understood. The potential
curative role of surgery for localized disease and the role of chemotherapy in
palliation should be addressed.
f. Pancreatic Cancer: Trainees should understand the genetic aspects of pancreatic
cancer as well as the role of endoscopy and molecular biology in diagnosis. The
potential curative role of surgery in rare patients and its palliative role in others
should be known. The palliative role of chemotherapy and combined modality
therapy in locally advanced disease should be understood.
6.6 GENITOURINARY CANCER:
a. Renal Cell Carcinoma: Trainees should understand the diagnostic dilemmas of this
disease as well as its paraneoplastic aspects. They should understand the
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potentially curative role of surgery in localized disease and the potential for
biologic therapy as palliation in advanced disease.
b. Urothelial Cancers: Trainees should know the risk factors of this disease, the
differences between localized and invasive disease and the propensity for local
recurrence of transitional cell carcinomas. Trainees should understand the role of
urine cytology and cystoscopy in the staging and follow-up of patients. The roles of
intravesical therapy and surgery in early-stage cancers should be understood. They
should also appreciate the role of combined modality therapy in locally advanced
disease, the indications for adjuvant or neoadjuvant therapy, and the management
of metastatic disease.
c. Prostate Cancer: Trainees should understand the epidemiology and controversy
over the screening of prostate cancer. They should know the role and controversy
of PSA in screening and follow-up. They should also understand the role of grade
and stage in planning therapy. They should also recognize the roles of surgery,
radiation therapy in the management of early stage disease and the role of
hormonal therapy and chemotherapy in advanced disease.
d. Germ Cell tumors: The trainees should be able to classify patients according to
the International Germ Cell Collaborative Group classification. Trainees should
know the utility of tumor markers in the diagnosis, prognosis and follow-up of
patients. They should know the roles of surgery, radiotherapy, and chemotherapy.
They should know that combination chemotherapy is curative in advanced disease.
6.7 GYNECOLOGICAL CANCERS:
a. Ovarian Cancer: Trainees should recognize the genetic aspects of this disease and
its implications for cancer screening. The role of surgery for initial treatment and
staging of the disease and the role of chemotherapy in both localized and
advanced disease will be appreciated.
b. Uterine Cancer: Trainees should recognize the roles of hormones and hormonal
therapies in the etiology of endometrial cancers. The curative role of surgery in
early stage disease and the value of radiation in the multidisciplinary approach to
advanced disease should be understood. Trainees should also appreciate the use of
chemotherapy and hormonal therapy in the palliation of metastatic disease.
c. Cervical Cancer: Trainees should understand the role of HPV in the pathogenesis of
cervical carcinoma. The role of screening, surgery and radiation for the treatment
of localized disease should be recognized. Trainees should also understand
treatment options for patients with advanced disease.
d. Vulva and Vaginal Cancers: Trainees should recognize the role of DES in the
induction of clear-cell carcinoma of the vagina. They should understand proper
surveillance and management of these patients. They should also recognize the
role of surgery in early stage disease and combination therapy in advanced disease.
The resident should have an organized approach to the vulval and pelvic
examination. They should be comfortable with the normal pelvic exam, the pelvic
exam after hysterectomy, and to be able to determine what's normal versus
pathologic. This would include speculum as well as bimanual examination. The
resident should know what's appropriate for the follow-up of patients (what is
pertinent in history, physical exam, and laboratory and imaging) after treatment
for gynecologic malignancies.
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6.8 HEAD AND NECK CANCER:
Trainees should be able to perform a proper head and neck examination. They should
understand the risk factors for head and neck cancers and the natural histories of the
individual primary tumor sites. The importance of panendoscopy in staging must be
emphasized. Trainees should understand the roles of surgery, radiation, neoadjuvant
chemotherapy and options for organ preservation. They should also be aware of the longterm management issues particularly surveillance for second malignancies.
6.9 HEMATOLOGIC MALIGNANCIES:
a. Chronic leukemias: Trainees should be able to distinguish the chronic leukemias
on peripheral-blood smear. Trainees should understand the current therapeutic
approaches in the treatment of the chronic leukemias in addition to understanding
the expectations of treatment. They should be aware of the indications for
marrow transplantation.
b. Lymphomas: Trainees should be familiar with the Ann Arbor Staging and World
Health Organization classification as well as its strength, limitations, and current
initiatives to improve upon the staging classification. They should understand the
role of PET scanning in the diagnosis and restaging of patients with lymphoma.
c. Hodgkin’s disease: Trainees should be experienced with the staging of Hodgkin’s
disease and the indications for surgical staging. They should be familiar with the
curative role of radiation therapy in early-stage disease. They should know the
indications for chemotherapy in stages II, III, and IV. Trainees should be aware of
the long-term complications of treatment and know what is entailed in the followup of patients. They should appreciate the indications for marrow transplantation
in patients with relapsed or refractory disease.
d. Non-Hodgkin’s lymphoma: Trainees should be aware of the association of
lymphomas with HIV and immunosuppression. They should be familiar with the
Revised European-American Lymphoma classification and the International
Prognostic Factors. They should be familiar with the different molecular subtypes
of lymphomas. They should recognize the curative role of chemotherapy and the
value of marrow transplantation in relapsed or refractory disease. They should
understand different types of low-grade lymphomas and appreciate when
treatment is indicated and when observation is appropriate. They should
appreciate the roles of radiation therapy, surgery, and chemotherapy, including
monoclonal antibodies in staging and treatment of intermediate grade nonHodgkin’s lymphomas. They should know the challenge and unique clinical
properties of high-grade lymphomas and the role for intensive treatment of this
subgroup.
e. Cutaneous T-cell lymphoma: Trainees should recognize the clinical appearance
of patients at different stages of the disease. They should be aware of the value
of immunophenotyping in the diagnosis. They should appreciate the roles of
psoralen and ultraviolet A, radiation therapy, and topical chemotherapy in the
initial management of patients. They should be aware of the palliative roles of
chemotherapy, biologic agents, and radiation therapy in advanced or refractory
disease.
f. Plasma cell dyscrasias: Trainees should know how to distinguish the plasma cell
dyscrasias: monoclonal gammopathy of unknown significance, Waldenstrom’s,
macroglobulinemia, plasmacytoma, multiple myeloma, POEMS (polyneuropathy),
organomegaly, endocrinopathy, monoclonal protein, skin changes), and plasma
cell leukemia. They should know the indications for treatment in each instance.
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g.
AIDS-associated malignancies: The trainee should be familiar with association of
central nervous system tumors with immunosuppression and AIDS. The trainee
should recognize the increased incidence of malignancy in the HIV-positive
population. They should know the indications for treatment of those cancers and
be aware of the potential of increased toxicities attributable to concurrent
medical problems. Trainees should know the appropriate prophylaxis and
treatment for common opportunistic infections.
6.10 LUNG CANCER: The trainee should be aware of the risk factors for the development of
lung cancer.
a. Small Cell Lung Cancer: The trainee should be familiar with the definitions of limited
and extensive stage of SCLC. The trainee should know and define appropriate staging
investigations for patients with SCLC. They should understand the importance of
staging in selecting treatment modalities (chemotherapy, radiotherapy) for patients
with SCLC. The trainee must have an understanding of factors influencing prognosis in
SCLC. They must also be familiar with the indications for prophylactic cranial
radiotherapy as well as understand issues surrounding treatment of SCLC in elderly
populations.
b. Non-Small Cell Lung Cancer: The trainee should become familiar with staging
system for NSCLC including indications for surgical staging. The trainee should
develop an understanding of the role of surgery, radiation and chemotherapy for
patients with NSCLC as well as develop an understanding of the current approaches
and controversies in combined modality treatment (chemoradiation) of NSCLC. The
trainee should understand the importance of prognostic factors in selection of
treatment. They should understand the indications for adjuvant systemic therapy in
early stage lung cancer. They should develop an understanding of the role of
combination chemotherapy versus single agent chemotherapy in patients with
advanced NSCLC and develop an approach to symptom management of patients with
advanced NSCLC.
c. Mesothelioma: The trainee should be familiar with the risk factors, criteria for
operability and the value of chemotherapy.
6.11 SARCOMAS:*
a. Bone Sarcomas: The trainee should recognize the predisposing factors for the
development of primary bone sarcomas. They should understand the indications
and considerations for limb preservation and the role of adjuvant chemotherapy
and combined modality therapy for specific tumors.
b. Soft Tissue Sarcomas: The trainee should understand the genetics involved in
some of these tumors. They should understand the appropriate surgery for initial
diagnosis, indications for limb preservation and the roles of chemotherapy, surgery
and radiation therapy. They should know the specific biology and targeted
treatment available for GI stromal tumors.
6.12 SKIN CANCER:
a. Melanoma: Trainees should understand the risk factors for melanoma and the
varied clinical presentations of melanoma and precursor lesions (dysplastic nevus).
They should be able to distinguish benign from potentially malignant lesions. They
should understand the use of depth and nodal involvement as prognostic factors
and the type of surgery required for diagnosis, staging and curative resection
including the rationale for sentinel node biopsy. They should be familiar with
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adjuvant therapies offered to patients with moderate to high-risk melanoma as
well as the value and limitations of chemotherapy and biologic therapy (interferon,
interleukin-2, and tumor vaccines) in patients with metastatic melanoma. They
should also use this as a model system to explore tumor-immune system
interactions. Trainees should also understand primary prevention in this disease
b. Basal Cell and Squamous Cell Cancers: Trainees should be able to recognize their
appearance and associate them not only with sun exposure, but also as a long-term
complication of cancer therapy.
7. OTHER ROTATIONS
7.I RADIATION ONCOLOGY: Radiation therapy is an important tool in the treatment of
cancer. Trainees will engage in a three-month rotation assigned to two or three radiation
oncologists per month. Trainees will attend their new patient, follow-up and review
clinics. They will also attend simulations and planning and participate in in-patient care.
They are also expected to attend Radiation Oncology Noon Rounds and the Radiation
Oncology Academic Half-Day if there is a topic of interest. During this rotation they should
also attend the weekly academic Medical Oncology activities (Tuesday Noon Rounds,
Wednesday Lecture Series and Friday Journal Club).
Medical oncology trainees should be familiar with principles of radiation biology
(radiation interaction with biologic materials; the 4 R’s of reoxygenation, repopulation,
repair, and redistribution; radiosensitivity and radioresistance); mechanisms of cell death
and normal tissue tolerance and toxicity and interactions with chemotherapy. They should
read the appropriate chapters in the 4th edition of The Basic Science of Oncology by
Tannock, Hill, Bristow and Harrington as preparation for this rotation.
They should have a basic understanding of physics and technology including properties of
therapeutic photons; radiation techniques including external beam radiation, brachytherapy, radionuclides; treatment planning including conventional simulation and CT-SIM
treatment planning process. With respect to clinical considerations, they should also be
able to:
a. Evaluate patients referred to radiation oncology assessing diagnosis, prior
management and need for additional staging
b. Develop an treatment plan in collaboration with other disciplines and understand
issues including:
- Simulation
- Computer dosimetry
- Choice of appropriate fractionation schedule
- Sequencing of radiation with chemotherapy and/or surgery
c. Account for the possible interactions and complications of multi-modality
treatment (surgery, radiation and chemotherapy).
d. Understand the short- and long-term effects of treatment and how to recognize
and manage these complications,
e. Understand palliative versus radical radiotherapy; commonly used doses and
rationale for fractionation
f. Recognize radiotherapy emergencies (airway obstruction, spinal cord compression,
superior vena cava obstruction).
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7.2 COMMUNITY ONCOLOGY ELECTIVE:
The resident may also participate in a community hospital cancer clinic(s) with a view to
contrasting the referral pattern; management approach and relationship with referring
physicians with the tertiary care centre. In addition, the resident will learn the operating
relationship between the community clinic and the tertiary care centre. For centers
outside the Lower Mainland, commuting and accommodation expenses will be reimbursed
by the program.
Trainees may choose to spend time at one of three BC Cancer Agency Regional Cancer
Centers: Vancouver Island Centre in Victoria, Centre for the Southern Interior in Kelowna
or Fraser Valley Centre in Surrey or in a private community oncologist practice. The
structure of the rotation and patient exposure during this month will vary depending on
the location of choice, but trainees should aim to fulfill the following objectives by the
end of the month.
a. To perform as an independent medical oncology consultant in a general community
hospital setting (medical expert and professional).
b. To work effectively with the various support services (medical and surgical
specialties, palliative care, nursing, pharmacy, social worker) available to provide
optimal patient care in the community (collaborator and communicator).
c. To recognize the limitations in resources in the community setting, and recognize
the proper indications for patient referral to a tertiary cancer centre (manager and
health advocate).
d. To become a valuable resource for community physicians and general public in the
education of other aspects of cancer management such as prevention, screening
and long-term follow-up of cancer survivors (health advocate).
e. To develop learning skills and become familiar with available resources for ongoing
education and practice of evidence-based medicine (scholar).
f. To become proficient as a general oncology consultant for addressing other aspects
of cancer management less commonly encountered by the resident at BCCA-VCC
i.e. work-up of solitary lung nodule, lymphadenopathy not yet diagnosed ( medical
expert).
g. If applicable, to learn the fundamentals of setting up a private community practice
affiliated with a community hospital (manager).
The resident will learn these skills by seeing patients with the community oncologist and
reviewing these cases under their supervision. If the elective is within the Lower Mainland
the resident is expected to attend the Wednesday seminar series lectures.
7.3 HEMATOLOGY/STEM CELL TRANSPLANT ROTATION:
a. Understand the classification scheme, the molecular and standard pathologic
diagnosis, the epidemiology (including therapy induced leukemia) and the current
therapeutic approach to the broad classes of myeloid malignancies in adults,
including the elderly. They should understand the differences between the chronic
and acute leukemias with respect to prognosis and treatment.
b. Understand the indications for high dose chemotherapy and stem cell
transplantation in myeloid and lymphoid malignancies. Understand the relative
merits and risks of autologous versus allogeneic procedures. Be able to describe
the types of donor sources and the range of conditioning options.
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c. Recognize the multiple acute and long term side effects of autologous and
allogeneic stem cell procedures (including infection, GVHD, VOD etc.). Be able to
manage the acute and long term consequences of autologous stem cell procedures.
d. Understand the indications for and risk of transfusion products, including RBCs,
platelets and immunoglobulin products.
In one month the resident will get a superficial introduction to each of these issues. They
will also learn about the available resources specifically from the website:
www.leukemiabmtprogram.org and the Medical Practice Handbook (aka the blue book).
The trainee will participate in direct patient care on Tower 15 of VGH or 6W at BCCA and
round daily with the attending physician. The academic component of this rotation is held
in Room 3326 at VGH and includes: new patient conference on Monday afternoon 4-7PM,
Wednesday Noon Lectures organized by Dr Tom Nevill and Friday Noon Journal Club. On
Fridays from 1-2PM there are in-patient sign out rounds and from 2-3PM and there is a
review of practice guidelines or tough cases.
The trainees are also welcome to attend the "Pizza Sessions” which are two-hour
presentations by fellows given every two-three months on BMT/Leukemia topics
(organized by Dr Kevin Song).
7.4 ELECTIVE ROTATIONS:
During the PGY-5 (second year) three months of elective time are available. The trainee
should discuss ideas with the program director and should structure this time to suit his or
her career goals. The following is only a partial list of possibilities.
1. Clinical Research Project: Completion of basic or clinical research project under the
supervision of a research mentor.
a. Objectives:
 To understand principles of research design, ethics, scientific method,
conduct and analysis
b. Participation in research activity should include:
 Preparation of a research proposal
 Collection and Analysis of Data
 Presentation of Results
c. Presentation at a national or international meeting is encouraged and will be
supported.
d. Preparation of a manuscript for submission to a peer-reviewed journal is
strongly encouraged.
2. Regional Centre or Community Elective
3. Surgical Oncology elective.
4. Elective at another national or international cancer center. Typically this is set up in
conjunction with plans to do a fellowship with a specific mentor at that center the
next year.
8. USEFUL RESOURCES
1. The BC Cancer Agency website www.bccancer.bc.ca contains the Cancer Management
Guidelines, Chemotherapy Protocols, the Cancer Drug Manual, Cancer Statistics and
information on the Research Ethics Board. Residents familiarize themselves with
webpages:
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Policy for drug reactions and chemotherapy induced emesis - www.bccancer.bc.ca/HP
Management of febrile neutropenia - www.bccancer.bc.ca/HPI/DrugDatabase
Supportive Care - www.bccancer.bc.ca/HPI/CancerManagementGuidelines
2. The h://drive on the BCCA intranet contains numerous shared files. One example is at
h:\lym_docs/Teaching which has teaching files on various lymphoma topics. Another is
h:\everyone\med onc for up-to-date oncall schedules, teaching and rotations etc.
3. The website of the Royal College of Physicians and Surgeons of Canada
www.rcpsc.medical.org contains the requirements for all the sub-specialties and
information about examinations and accreditation. It also has self contained learning
modules, regarding various topics such as ethics, for example:
4. Guidelines on Conference Leaves:
h:\Everyone\MedOnc\ResidencyTrainingProgram\Documents\Conference
5. These Objectives are also available at this link:
h:\Everyone\MedOnc\ResidencyTrainingProgram\Documents\Objectives\Medical
Oncology Residency Training Objectives.doc
6. The website for the UBC Faculty of Medicine Dean’s Office of Postgraduate Medicine
www.med.ubc.ca/postgrad
7. The Dept of Medicine maintains a password secure on-line evaluation and scheduling
system for all the residents is www.one45.com/webeval/ubc/admin/index.php
8. Information on fellowship opportunities and funding is available at the Canadian
Oncology Societies website. This society includes the Canadian Association of Medical
Oncology or CAMO www.cos.ca/camo/fellowships
9. VII. Recommendations of a joint ESMO/ASCO task force for a Global Core Curriculum in
Medical Oncology were published in Volume 22. Number 22 November 15 2000 in the
Journal of Clinical Oncology www.jco.org. They closely mirror the objectives outlined
in this document.
10. Rx&D Guidelines: www.canadapharma.org/Industry_Publications/Code.
11. New Website launched June 2010 www.MedicalEmployers.com
developed to
centralize medical job listings in Canada. It also includes medical cv and resume
building templates, world-wide medical conference listings, career guides including
tips on how to start a medical practice and legal employment contracts (locum, parttime, full time, hospital, private), accounting and banking guides and much more.
12. Reading Material:
 AJCC/UICC TNM Cancer Staging Manual 7th Edition.
 Essential reading for all trainees is The Biology of Cancer by Robert A Weinberg.
This contains all the basic science information outlined in the objectives above in a
comprehensive and readable format
 Cancer: Principles and Practice of Oncology 8th Edition, by DeVita, Hellman and
Rosenberg.
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





There are other site specific texts which are excellent. One example is the latest
edition of Diseases of the Breast by Harris, Lippman, Morrow and Osborne.
The Educational Books issued at the ASCO and ASH meetings are also valuable
resources for topic reviews and cutting edge information.
In 2005 the Journal of Clinical Oncology www.jco.org created a new series,
review topics and molecular oncology. A monthly issue covers these themes in an
up to date and comprehensive fashion. The NEJM has regular review articles in
basic science and clinical science of oncology. This website contains American
guidelines for 97% of tumour sites. It is updated annually. I recommend it as a good
starting point for thinking about treatments in a flow chart type of pattern
http://www.nccn.org/professionals/physician_gls /default.asp.
Oncologyeducation.ca. “Canada’s Education Website for Oncology Professionals”
uploads up-to-date lectures on various topics.
2010 Mastering Communication with Seriously Ill Patients, Anthony Back, Robert
Arnold, James Tulsky.
4th Edition The Basic Science of Oncology by Tannock, Hill, Bristow and
Harrington.
9. ADMINSTRATIVE STRUCTURE
The program director is Dr Tamara Shenkier. The assistant program director is Dr
Sharlene Gill. The program administrator is Carilyn Gascoyne. The site members from the
other centers are Dr Lyly Le from the Fraser Valley Cancer Centre, Dr Sheila Souliere
from the Victoria Cancer Center and Dr Daygen Finch from the Centre for the Southern
Interior.
The postgraduate training committee consists of all the above named staff members and
all trainees including the chief residents as well as Dr Shirley Howdle for the General
Practitioners of Oncology (GPOs). The committee meets four times per year to review
program design, goals and objectives, evaluation of the clinical and academic content of
the program, research topics and social events. Minutes are kept and issues that arise
from this committee are relayed to other members of the Division of Medical Oncology via
the monthly staff meetings.
The residents are welcome to meet with Drs Shenkier and Gill informally at any time.
Extraordinary meetings may be held at the request of residents or the staff.
There are two separate subcommittees of the RTC: one for annual interviews and resident
selection and another that meets every six months to discuss evaluations and promotions.
These committees feed back information to the RTC.
10. APPENDIX
I. BREAST:
Breast Imaging/Diagnosis
Screening mammography – mortality reduction, controversies
Diagnostic mammography
Use and interpretation of other diagnostic imaging modalities
Biopsy techniques FNA, Core, Open Biopsy
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Genetic Factors/tumor Suppressor Genes
BRCA1
BRCA2
Others
Family history
Lifetime risk of which
cancers
Breast Cancer: Molecular Biology
Hormone Receptor
Her2neu oncogene
Main signal transduction pathways
Non-genetic Risk factors
Gynecologic history
Environmental
Prior XRT
Non-malignant breast disease (eg ADH, fibroadenoma)
Premalignant/LCIS
DCIS
Definition
Main subtypes
Paget’s disease
Local management
Systemic
Pathology
Histology
Understanding the elements of the BCCA synoptic report
Prognostic/predictive markers: definition
Techniques to assess her2neu over expression
Working Knowledge of TNM staging 2009 (AJCC 7th Edition)
Including definition of locally advanced
Natural history and risk of recurrence for various stages
Local management of Invasive Breast Cancer
Indications/Contraindication for
Breast Conservation Surgery
Modified Radical or Total Mastectomy
Reconstruction (autologous vs implant)
Indications/Contraindications for Radiation
Systemic Treatment of Invasive Breast Cancer:
hormonal
chemotherapy
Adjuvant
targeted therapies
role of primary
systemic treatment
ongoing clinical trials
indications
benefit (risk reduction;
absolute and relative)
side effects
mechanism of action &
of resistance
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aromatase inhibitors
tamoxifen
cyclophosphamide
doxorubicin
epirubicin
5FU
paclitaxel
docetaxel
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Treatment of Locally Advanced and Inflammatory Breast Cancer
Natural history
Follow-up issues following Completion of Adjuvant Treatment
Treatment related
Menopause (managing symptoms)
Psychologic/spiritual
Lymphedema (workup and management)
Risk of ipsilateral or contralateral recurrence
Review Family History
Locoregional Recurrence
Risk factors
Work-up
Management
Management of Metastatic Breast Cancer
Prognostic factors for survival
Indications for Hormone vs Chemotherapy:
Choice of hormonal therapy:
Premenopausal
postmenopausal
response rate
mechanism of action
side effects
Choice of Chemotherapy:
single agent
Multiagent
monoclonal abx
(eg Trastuzumab)
response rate
mechanism of action
action – side effects
Site specific therapy of M.B.C
a. Bone mets
 Medical treatment (Mechanism of action/side effects)
 Local treatment
b. Brain mets
c. Malignant effusions
d. Solitary nodules (eg pulmonary, liver)
e. Leptomeningeal
f. Brachial plexopathy
Special
Male
Pregnant/post partum
Primary unknown axillary adenocarcinoma
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Palliative Issues
Community Services/Support available
Palliative Care Drug Benefit Program
Pain Control Issues - Mechanism of action and side effects of opioid and non-opioid
analgesics.
2. GASTROINTESTINAL
First Year: Understand the types of cancers of the GI system, their frequency, risk
factors, modes of presentation, diagnostic and staging procedures, the general principles
underlying therapy, and outcome for the different cancers.
Second Year: Understand the evidence behind recommendations for therapy, including
the basis for multi-modality therapy, screening procedures available and follow-up tests.
2.1 Sites:
The GI system comprises several organs. An understanding is required of the malignancies
arising in them with emphasis on those that are common.
Common cancers
Esophagus
Stomach
Colon
Rectum
Pancreas
Less common cancers
Anus
Liver
Gallbladder
Biliary tract
Small bowel (particularly carcinoid tumors)
2.2 Natural History and Diagnosis:
a. Changing incidence of certain cancer types and possible reasons (esophagus/GE
junction, anal, colorectal and hepatocellular cancers)
b. Presenting features
c. Diagnostic tests
d. Role of tumor markers (CEA in colorectal carcinoma, AFP in hepatocellular cancer)
e. Precautions re: biopsies of pancreatic cancer and hepatocellular cancer
2.3 Molecular Biology:
a. Adenoma-carcinoma sequence for colorectal cancer
b. Genetic syndromes
 Hereditary Polyposis Coli or HPC
 HNPCC
2.4 Risk factors:
a. Environment/lifestyle
 Role of diet (fat and fiber)
 Potential role of chemopreventive agents (NSAIDS, calcium)
b. Infectious agents
 Viral - Hepatitis B & C (hepatocellular carcinoma); HPV (anal carcinoma)
 Bacterial - H pylori (stomach carcinoma)
2.5 Screening:
a. Colorectal cancer
 Knowledge of randomized screening trials with fecal occult blood
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

Knowledge of current BCCA recommendations
Familiarity with guidelines for surveillance of high risk groups and those with
cancer susceptibility genetic syndromes
b. Controversy about screening for hepatocellular carcinoma
2.6 Pathology:
a. Histological subtypes of gastrointestinal cancers and the implications for therapy and
patient outcome
b. Prognostic/ predictive markers
2.7 Working Knowledge of the TNM Staging for all sites:
a. Natural history, risk of recurrence for various stages of all sites
2.8 Management of GI cancers:
a. Understand the role of surgery for the different GI cancers and where potential cure
or useful palliation can be achieved by surgery.
b. Understand the scientific basis for multi-modality treatment for different GI cancers.
c. Understand the systemic management of GI cancers
2.9 Systemic Treatment of GI Cancers:
a. Adjuvant therapy:
colorectal cancer
Chemotherapy
- indications
- benefit (risk reduction; absolute &
relative)
rectal cancer
Stomach cancer
Pancreas
Esophagus
timing and schedule of pelvic radiation
knowledge of SWOG trial 1999
knowledge of controversies in adjuvant
therapy
knowledge of controversies in
adjuvant/ neoadjuvant treatment
b. Follow-up issues following completion of adjuvant treatment
 Treatment related toxicity
 Colonoscopy follow-up in colon cancer
 CEA follow-up in colorectal cancer
c. Recurrence after adjuvant therapy
 Risk factors
 Work-up and management
2. Management of Advanced/Metastatic Cancer:
a. Prognostic factors for survival
b. Indications for chemotherapy
c. Choice of chemotherapy:
 Single agent vs. multi-agent regimens
 Use of biological agents (monoclonal antibodies)
 Response rates to chemotherapy/biological agents
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 Mechanisms of action of drugs
d. Side effects of the common agents:
 5-FU
 irinoteca
 Cisplatin
 oxaliplatin
 gemcitabine
 cetuximab
 bevacizumab
e. Role of liver resection in metastatic colorectal cancer
f. Role of radiofrequency ablative therapy for liver metastasis
g. Role of palliative radiation or surgery in management of obstructive symptoms.
h. Role of stents in management of biliary obstruction, colorectal obstruction,
esophageal obstruction.
i. Indications for laser therapy in management of esophageal or rectal cancer
3. Palliative issues:
a. Pain management
 mechanism of action and side effects of opioid and non-opioid analgesics
 role of palliative radiation for pain control
b. Management of chemotherapy-induced diarrhea
 recognition of potential severity
 role of antibiotics
 role of octreotide
c. Community services/support available
d. Palliative Care Drug Benefit Program
3. SARCOMA:
Sarcoma service will offer exposure to a wide variety of soft tissue neoplasms both benign
and malignant. At conference, most new patients are reviewed by multidisciplinary group for
primary management decision. Clinics are generally follow-up with new patient/consult
exposure outside clinic time.
Major Disease Group:
Residents will be exposed to patients with both benign and malignant soft tissue neoplasms
as well as bony tumors - mainly osteosarcoma, Ewings sarcoma and variants.
The trainees will be expected to acquaint themselves with the basic aspects of
epidemiology, etiology, and pathogenesis of the individual disorders.
The following clinical aspects will be covered: Staging and its implications for therapy and
prognosis, radiologic and other specialized diagnostic tools; use and implication of
chromosomal translocations to diagnose and prognosticate as well as; therapy: basis,
benefits and potential complications acute and chronic; post-therapy management and
treatment of failures and relapses.
Specific Learning Goals:
Residents will be expected to review epidemiologic features, presentations, staging and
management - including principles of biopsy, surgery, radiation therapy and chemotherapy
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that are important to management of sarcomas, treatment results, genetic abnormalities,
special immuno-histologic stains and management of recurrence.
Most important disease groupings include:
a. Osteosarcomas
b. Ewing’s Family tumors (PNET, Askins)
c. Adult soft tissue sarcoma – approach to management this multitude of diseases that at
this time are treated in a similar fashion including the locally advanced group
d. Gastrointestinal Stromal tumors
e. Desmoids – both musculoskeletal and FAP related
f. Rhabdomyosarcoma
g. Intraabdominal small round blue cell tumor
Attachment:
Palliative Care Curriculum in Oncology Residency/Fellowship: Objectives are based on
principles common to palliative care and oncology. They can be grouped under the broad
headings of the 4 “C”s:
Competence, Communication, Co-ordination and Compassion:
A reading resource list is attached for residents/fellows to pursue the curriculum
objectives. Dr Pippa Hawley is available to assist residents/fellows with any of the
curriculum components, pager 05081. A Palliative Care elective can be arranged if the
resident/fellow wishes and the Pain and Symptom Management/Palliative Care Clinics
are held on Tuesday afternoon; welcome residents/fellows by arrangement through Dr
Hawley.
Understanding Palliative Care and Death in Our Society:
1) Define Palliative Care
2) Describe its basic principles (as developed by the CPCA)
3) Describe current North American Attitudes towards death and dying
4) Identify different issues in death and dying among different cultures
5) Describe current blocks to providing better care to the dying including
misinformation, attitudes, organizational, cultural and financial
6) Understand ethical principles relating to palliative care
7) Define euthanasia and understand the different between the withdrawal and
withholding of treatment and euthanasia
The Oncologist is an Effective Clinician
1) Have an understanding of the natural history of diseases and be aware of treatment
accomplishments and limitations in advanced and progressive disease.
2) Have a systematic method of pain assessment and management leading to effective
pain management.
3) Be knowledgeable and comfortable with the use of commonly available opioid
medications.
4) Manage common physical symptoms especially dyspnea, nausea and vomiting,
constipation, delirium and mouth care.
5) Identify psychological issues and differentiate them from psychiatric illnesses
(depression) in patients with life-threatening illnesses.
6) Describe normal grief and be able to identify complicated grief.
7) Identify the principles of grief counseling and ensure access to services for families of
your patients.
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The Doctor-Patient Relationship is Central to Oncology and Caring for the Whole
Person is Central to Palliative Care
1) Describe the physical, psychological, social and spiritual issues of dying patients and
their families.
2) Demonstrate effective communication skills in delivering bad news.
3) Demonstrate effective communication skills in discussing death and dying with the patient
and their family and be able to discuss advanced directives and treatment options.
4) Demonstrate an ongoing commitment to a patient from the time of diagnosis of cancer
and be able to guide the patient and family through the disease as it progresses. This
includes working with other health care agencies (eg family doctor, home care
nursing).
5) Demonstrate a systematic approach to working with families of dying patients
6) Describe your own concerns about dealing with dying patients and their families
7) Demonstrate an awareness of how your own personal experiences of pain, death and
dying have influenced your attitudes towards these issues.
Oncology and Palliative Care is Community-Based
1) Provide or arrange for palliative care for patients in your hospital.
2) Describe the community resources available to support patients in their home and know
how to access them.
3) Be able to work as a team member with the interdisciplinary team of community
service providers.
4) Advocate for the needs of home care patients.
The Oncologist is an Effective Member of an Interdisciplinary Team
1) Describe the roles of other disciplines in providing palliative care in oncology.
2) Identify the limits of your own role and know when to involve other disciplines in the
care of the patient.
3) Participate in interdisciplinary team meetings.
4) Communicate effectively with other team members.
5) Be able to educate other members of the interdisciplinary team.
6) Recognize and describe areas where there are deficiencies in evidence-based care in
palliative care.
Resources
Books
Palliative Care: Towards a Consensus in Standardized Principles of Practice Canadian
Palliative Care Association, 1995. This is the booklet that contains the standard definitions
and principles of palliative care in Canada.
Oxford Textbook of Palliative Medicine, Second Edition, 1998. Doyle, Hanks, MacDonald
eds. Oxford Medical Publications. This is the gold standard reference book for palliative
care. Useful as a reference or if palliative care is your field of interest.
Medical Care of the Dying. Third Edition. 1998. Victoria Hospice Society. This is an
affordable manual that provides an excellent guide to palliative care. It is written with
our medical system in mind. Victoria Hospice Society 1900 Fort St. Victoria, BC V8R 1J8
Fax: 250-370-8625 $95
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Pocket Booklet Companion to Medical Care of the Dying. A pocket book summary of the
useful tables and information from the above manual. Victoria Hospice Society $10
4th Edition The Basic Science of Oncology by Tannock, Hill, Bristow and Harrington.
Shorter books
Palliative Medicine: a case-based manual. Edited by Neil MacDonald. Oxford Medical
Publications 1998. This is an excellent Canadian book that deals with palliation on a casebased approach. It is designed for medical students and residents.
The Pain Manual. Principles and Issues in Cancer Pain Management. S. Lawrence
Librach, Bruce P. Squires. 1997. Brief, useful manual on cancer pain management.
Available from Purdue Frederick pharmaceutical company
ABC of Palliative Care. Eds. Marie Fallon, Bill O’Neill. 1998 British Medical Journal
Books. UBC Health Sciences Centre Bookstore has it. This is a compilation of the ABC
series in palliative care that the BMJ ran in 1998. Well written, but very brief and may not
give enough details. BMJ originals are in BCCA library.
How to Break Bad News. A guide for Health Care Professionals. Robert Buckman 1992 UBC
Health Sciences Bookstore has it. A detailed guide on how to break bad news. Well worth
reading.
I Don’t Know What To Say. Rob Buckman. A book for families, valuable resource for
health care professionals to help families cope with cancer and dying. Available through
Dr Hawley or most public libraries.
Mastering Communication with Seriously Ill Patients. Balancing Honesty with Empathy &
Hope. Anthony Back. Robert Arnold. James Tulsky. 2009-2010
Books of Psychosocial Interest
Final Gifts. M. Callanan An excellent book about psychosocial issues around dying.
Dying Well. Ira Byock MD. A book about personal growth at the end of life.
Internet Sites of Interest
1) http://homebrew.cs.ubc.ca:8900/public/RNP/index.html
The UBC Department of Family Practice has a site for the rural network
program that has a site on palliative care. There is information about the
philosophy of palliative care as well as links to a good series of articles
called the ABCs of palliative care in the British Medical Journal. Will need
access code but you can sign up for it at the site.
2) www.palliative.org
The Edmonton Palliative Care site has information for both the physician and
patient and is well worth visiting. There is also access to the many symptom
assessment scales used by the Edmonton group.
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3) www.pallcare.org
The Ottawa Institute of Palliative Care has information for both the physician
and patient. There is also information on the philosophy of palliative care.
Both this site and the Edmonton site have good links to other palliative care
sites.
4) www.dyingwell.org
Dr. Ira Byock’s website has information on psychosocial and spiritual issues
around death and dying. It looks at the issues beyond symptom management.
5) www.aahpm.org
American Academy of Hospice Palliative Medicine website has information
on policies and curriculum. There are also learning modules for palliative care.
6) http//:pain.roxane.com/slideshow/
The Roxane Laboratories has a site and one part of it is a tutorial on cancer
pain management. Useful information and review.
7) www.growthhouse.org
Information for patient and physician from US organization. Has monthly
newsletter that you can receive via e-mail.
8) www.halcyon.com/iasp
The International Association for the Study of Pain. Many articles on pain and
pain management available at this site.
9) www.pain.com
Useful CME with monthly learning modules that address a wide range of
current topics in pain and pain management.
10) www.patientsafetyinstitute.ca/education/safetycompetencies.html
Enhancing patient safety across the health professions
Palliative Care
Palliative Care Websites & Books:
Recommended New Book from Palliative Care March 2010 Symptom Mangement in
Advanced Cancer – Fourth Edition by Robert Twycross, Andrew Wilcock & Clair Stark
Toller.
Website http://www.palliativebooks.com/index.php?act=viewProd&productId=280
Revised Palliative Website: 15 April 2008
http://www.fraserhealth.ca/Services/HomeandCommunityCare/HospicePalliativeCare/Pa
ges/SymptomGuidelines.aspx
The Journal of Palliative Care: Quarterly Canadian journal has mostly articles on
psychosocial aspects of palliative care in the BCCA library.
The Journal of Pain & Symptom Management: Monthly American journal. Good for learning
about new symptom management methods (in the BCCA library). Also can see topics on
the web: www.elsevier.nl/inca/publications
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Journal of Palliative Medicine: A new US journal which has good articles on palliative care
education and policies. Can access information from the web: www.liebertpub.com and is
in the BCCA library.
Palliative Medicine: English journal with articles on symptom management and palliative
care policies (in the BCCA library).
European Journal of Palliative Care: European journal. Summaries of current articles are
available on the web: www.ejpc.co.uk
Videos
On The Edge of Being. Five doctors talk about facing their own life-threatening illness and
how it has affected their life and practice of medicine (in the BCCA library).
Wit. Award-winning movie with Emma Thompson playing patient with ovarian cancer.
Available from Jack Critchley (Communities Oncology) or your local video rental store.
Revised: 2May2011
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