Curricula for the training of oncologist at the Central and Eastern European Academy of Oncology (CEEAO) are based on the recommendation of European Society for Therapeutic Radiology and Oncology (ESTRO), European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and European Society of Surgical Oncology (ESSO).

1.INTRODUCTION

The global cancer burden is expected to increase significantly over the next decades. It is predicted that by the next two decades there will be around 25 million new cancer cases and about 15 million cancer-related deaths. The distribution of the global cancer burden is very variable and will continue to be very uneven, with the majority of cases afflicting the developing regions of the world. Incidence rates of cancer in Europe are among the highest in the world. In the past decades complex oncological care has undergone significant development and today modern tumour diagnostic and multidisciplinary oncological therapies are able to offer effective cancer treatment of most of the malignancies, in the first instance for cases diagnosed in the early stage phase.

In Europe the introduction of populational screening programs (eg. breast, colorectal, cervix), the establishment of standards for the training of specialised health professionals dealing with cancer, the standardized requirements of comprehensive cancer centers and for example breast units, the quality indicators in oncological care, the evidence based medicine and the international consensus conferences have succesfully created and audited effective cancer care systems, supported by the European Parlament as an essential part of the major public health goal.

According to the recent developments and results in molecular genetics, diagnostic imagine, surgical oncology, medical and radiation oncology multidisciplinary oncology has evolved to an organ specific, highly sophisticated scientific field.

Different incidence, mortality and survival rates are due to different risk factors, availability of organized screening programmes and oncological health systems, exspecially access to special comprehenisve cancer centers and/or cancer units represents the differences between the regions and countries of the continent. Differences in national health policies, in healthcare systems, in economical and financial resources, in risk factors and cultural and historical traditions could have been counted as co-factors, responsible for worse oncological results in the developing countries of Europe.Amongst European countries, wide differences in quality of oncology care are observed. The comparison of status of oncology among countries in Central and Eastern European (CEE) region has never been performed and key barriers to deliver appropriate quality of care have not been identified yet. Registration and reimbursement process, a sufficient budget for oncology treatments, specially for novel oncology drugs, as well as updated national guidelines and regularly improved professional skills are means for mastered oncology status and should be investigated in this CEE region.

The incidence of many cancers is higher in Western European (WE) countries, but mortality is frequently higher in CEE countries. Furthermore, while cancer mortality has generally been decreasing in WE countries lately, this trend has not been observed in CEE countries. Moreover, the incidence rates of several cancers in CEE countries have already reached the rates in WE or Nordic countries. Possible explanations for such differences could be different prevalence of underlying risk factors and host susceptibility, variations in cancer detection, the distribution of cancer types (more deadly cancer types in CEE), more advanced stages, higher mortality from noncancer causes, and differences in cancer registration, as well as different treatment and follow-up care. Unfortunately, most probably because of a combination of the above-mentioned reasons, cancer survival in CEE countries is, in general, significantly lower than it is in the WE countries. Generally speaking, higher national income and health care budgets are associated with the higher cancer incidences and lower mortality in WE. Obesity is a risk factor for colon, rectal, breast (in postmenopausal women), endometrial, kidney, adenocarcinoma of the esophagus, and pancreatic cancer, and it is associated with a worse prognosis. Five (38%) CEE countries have nationwide primary prevention programs targeting obesity and insufficient physical activity. In CEE countries, the median proportion of the population with insufficient physical activity is lower than in neighboring WE, other WE, and Nordic countries; however, the prevalence of obesity is higher.The higher-income CEE countries are also characterized by higher alcohol consumption. This may be associated with higher incidences of cancers of the oral cavity, pharynx, esophagus, bowel, liver, larynx, and female breast. However, this higher alcohol intake is not accompanied by nationwide primary prevention programs targeting alcohol consumption; only approximately a quarter of CEE countries have implemented such programs. Thus, resources for prevention of alcohol consumption do not match the severity of the problem. Taxation of alcoholic beverages adjusted for purchasing power is lower in CEE countries than in Nordic countries.The higher prevalence of tobacco smoking in CEE countries than in WE countries or Nordic countries is the major cause for higher incidence of lung cancer and other smoking-related cancers and, consequently, the higher overall cancer mortality. Tobacco smoking is the cancer risk factor most often targeted by primary prevention programs in the region. Restrictions of direct and indirect forms of advertising, promotion, and sponsorship of tobacco products are similar in different CEE countries, and tobacco advertising legal limitations are comparable to those in WE or Nordic countries. Despite this, the prevalence of smoking is still higher, likely because the most effective antitobacco measure, that is, adjusting the cost of cigarettes for purchasing power, is missing. Consequently, cigarettes are more affordable in CEE countries than in WE or Nordic countries. Moreover, smoking cessation programs are lacking throughout the CEE region. Screening programs and early diagnosis are known to reduce mortality rates of colorectal, breast, and cervical cancers; however, only few CEE countries have implemented screening programs for cervical, breast, and colorectal cancers.

So it is very important to increase resources for primary prevention programs targeted toward common cancer risk factors. In particular, nationwide primary prevention programs targeting diet, physical activity, obesity, and alcohol consumption should be more widely implemented. Comprehensive, population-based, valid, and reliable cancer registries should be created in all countries.Screening programs for colorectal, breast, and cervical cancer should be implemented in all CEE countries, with continued effort on early detection of all cancers.

In order to faciliate the evolution of clinical oncology in CEE association of authoritative national institutes, cliniques and centres such as well experienced professionals should optimally join in a common scientific and clinical platform to increase the efficiency and speed of modernization of up to date oncological care in countries of CEE.

All CEE countries should develop and implement a National Cancer Control Plan (NCCP), with appropriate financial and political support. These plans should include detailed strategies on primary prevention, screening, diagnostics, treatment, and rehabilitation of cancer, research, and educational activities, as well as an implementation plan and outcome measures. The NCCP should be used to rationally improve nonmedical aspects of cancer care, such as reduction of social exclusions and facilitation of patients’ return to social, occupational, and family functioning, as well as psychological support.

Taking into account the above mentioned facts, improved education for all professionals involved in oncology care is needed. Special attention should be on training specialists in cancer management (radiation oncology, medical oncology, and surgery).

The aim of the core curriculum of CEEAO is to build on and harmonize the postdoctorial curriculas and requirements of surgical-, radio and medical oncologyand thereby to provide a foundational scaffolding for essential and common requirements for training of oncology professionals. The present curricula is aware that the training of oncological professionals worldwide is variable, so CEEAO is not intended to mandate specific content for training for each country of the region. It is hoped that this curricula of essential requirements will be used as a framework upon which to make modifications to suit the needs of the specific country in the future.

The CEEAO is aware of the diverse barriers to education in different parts of the world based on the sociocultural, geopolitical and financial constraints. Hence the curricula focuses on the aspects of training that are essential to incorporate into the training curriculum of a surgical-, medical and radiation oncologist.

2. BASIC ONCOLOGICAL PRINCIPLES

This should include a basic understanding of the ‘hallmarks of cancer’ and the processes that are key to cancer development and progression.

Cancer biology
Carcinogenesis
Tumour immunology
Aetiology of cancer
Carcinogens
Epidemiology of cancer
A good understanding of the current and future global cancer burden and a detailed understanding of the cancer demography of the surgeons’ own specialist area of practice in their geographical location is essential.

Cancer Prevention
Healthy lifestile
Screening for cancer

Principles of screening for cancer which should include:awareness of the essential criteria of Wilson and Jungner (1968) for effective screening, the types of screening in use both globally and in their geographic area, and the evidence on which their efficacy is based.

Knowledge of the risks and benefits of screening health economic issues.

Evidence based medicine, clinical trials and research methods
Biostatistics
Basic Principles in the Management and Treatment of Malignant Diseases
Pathology
Molecular pathology
Laboratory medicine
Translational research
Principles of personalised cancer medicine
Clinical staging
Diagnostic imaging
Molecular imaging
Recist
Multidisciplinary decision making
Multidisciplinary Team Meetings

3. SURGICAL ONCOLOGY

Almost all of the cancer patients will need surgical intervention at certain point of the multidisciplinary complex care. It is well known that the majority of patients with a cancer diagnosis do not have access to safe and/or affordable specialised cancer surgery.

Over the past decades cancer care has undergone a significant change. No longer is surgery the only treatment for most solid malignancies but neoadjuvant and/or adjuvant therapies with highly focussed radiotherapy, targeted molecular therapies and multi-modal chemotherapy are the standard of care. These multi-modal treatment regimes have had a great impact on cancer survival rates, as have improved diagnostics. Historically the general surgeon would often be the only specialist to have contact with most cancer patients but had little knowledge of the broader aspects of cancer care. Today, general surgeons can no longer work in isolation and must be part of a multi-disciplinary team. The surgeon must understand the contributions made by other disciplines and how this may impact on the adequate surgical procedure: he/she should be a Surgical Oncologist.

The technical side of surgery has also been transformed in the past few decades with advances in minimally invasive cancer surgery, improved understanding of surgical margins and organ preserving surgeries, robotic surgery, reconstructive surgery and enhanced recovery programmes etc.

For already specialised surgical oncologists, keeping up to date with these advances requires dedication and a significant commitment to continuous medical education.

While the causes are multifactorial, one factor impeding access to safe and affordable cancer surgery is the paucity of specialised surgeons who are trained and educated in the management of patients with various cancer diagnoses. The ability to develop a sustainably adequate surgical oncology workforce depends on the presence of robust educational systems that promote training in all oncologic domains, and also on help in maintaining competency for those in clinical practice. There are significant differences in cancer burden, cancer types, resource availability, oncologic management, and even in the definition of the oncologic workforce in different regions of Europe.

It is inevitable that in certain countries inadequate training may be just one of many complex factors acting as barriers to adequate cancer care, but having a higher level of up to dated training in surgical oncology organized by CEEAO will help to disseminate best practice, raise average standards of care, and reduce inequalities.

A surgical oncologist is an oncologist who also possesses the expertise to perform operative procedures and interventions. Every surgical oncologist should possess the required knowledge of the basic principles of oncology. According to the Core Curriculum of the European Society of Surgical Onology (ESSO) it is expected that a surgical oncologist will have a basic level of knowledge of all areas with advanced level knowledge of their own specialist subject.

3.1.Training in Surgical Oncology

The trainee of modern surgical oncology is faced with the task of mastering a subject which is continuously and rapidly evolving. High quality training, ensuring exposure to all treatment modalities in the multidisciplinary cancer care and adequate levels of hands on training is mandatory.

A core curriculum by the European Society of Surgical Oncology for specialist trainees in surgical oncology set out a series of recommendations for the knowledge and skills required by surgical oncologists and the optimal facilities required by an ideal training centre. Postdoctorial surgical oncology training would enable enhanced training opportunities within cancer centres of member states of the CEEAO.

The surgical oncologist will have a broad base of relevant knowledge that transcends site specialisation. This should be supplemented with a high level of advanced knowledge and technical expertise and experience in the practical conduct of the surgical procedures relevant to their main disease site of interest.

According to the above mentioned basic statements the main aims of the CEEAO are

– to increase the level of multidisciplinary oncological care exspeciall surgical oncology in the region

– to facilitate evidence based clinical practice in oncology

– to faciliate as standard of care the multidisciplinary tumor board decision making

– to facilitate the education and training of oncologists in the region

– to facilitate the establishment of the structure of centralised oncological care

– to facilitate high quality education in the field of surgical oncology

– to organize regular scientific meetings, workshops, live or via internet

3.2.Surgical procedures and techniques

Knowledge of the principles of clinically relevant anatomy applicable to surgical procedures.

Knowledge of the extent of resection for primary lesions and metastatic lesions.

Knowledge of the appropriate extent of lymphadenectomy (nodal sampling, sentinel-node biopsy, lymphadenectomy for different cancers).

An understanding of how to assess margins and different levels of adequacy

Awareness of the differences in management between curative-intent versus palliative-intent surgery.

An understanding of the balance between oncologic adequacy versus minimizing morbidity and preserving function in oncologic procedures.

3.3.Various surgical approaches

Competence in principles

of open surgical procedures

of minimal access procedures

of restorative, reconstructive and oncoplastic surgery

of endoscopic procedures

of robotic surgery

in natural orifice surgery and other novel techniques

in principles of interventional procedures

in principles of ablation (radiofrequency, microwave, cryoablation)

3.4.Patient selection

Competence to select patients for surgical procedures based on appropriate indications and more importantly, the ability to avoid surgical procedures in patients where the benefits are not evident.

3.5.Risk stratification prior to surgery

Knowledge of

– how to balance the risks and benefits of the proposed procedure.

– of some of the objective tools available to balance the risks and benefits prior to any surgical procedure (risk calculators, nomograms).

– of assessment of functional status based on objective tools (Karnofsky score etc.).

– of subjective assessment of functional status.

– of how to combine objective and subjective assessments to reach conclusions on the risk/benefit profile for each procedure.

3.6.Operative planning based on imaging/staging

Knowledge of

• how to tailor operative procedures on the basis of variations in preoperative staging and imaging.
• of how to tailor procedures based on the functional status of patient.
• of preoperative preparation such as bowel prep, when to stop anticoagulation, etc.

 

3.7.Obtaining consent for operative procedures

Knowledge

• of how to obtain consent that is informed and compassionate and that can lead to shared decision-making.
• of how to discuss the risks/benefits and pros/cons of not only operative procedures but also the alternatives to surgery.

Ability to tailor discussions based on the complexity of the procedure.

3.8.Intraoperative care

Knowledge

• of how to manage intraoperative complications
• of protocols to prevent intraoperative adverse events

Ability

• to work collaboratively with the pathologist
• to work collaboratively with anesthesiologists to provide effective team care.

3.9.Postoperative care

Awareness of major and minor postoperative complications.

Knowledge of

• how to prevent, diagnose and treat postoperative complications.
• how to treat complications such
• commonly used tools to quantify postoperative complications
• how to manage drains, ostomies, feeding tubes etc. in the postoperative period
• how to manage postoperative pain
• to coordinate postoperative care with multiple providers, including nursing,
• physiotherapy, palliative care, etc.
• to lead discussions with the patient and their family on the prognosis, based on pathological staging, and on determining further treatment options.

 

3.10.Postoperative critical care

Awareness of hemodynamic monitoring, of managing an intubated patient, of monitoring fluid status, resuscitation,

Knowledge and expertise regarding nutritional support in the pre-, peri- and post-operative period.

 

3.11.Management and treatment of cancers

To be able to perform specialist assessment, management and counselling of patients with cancer.

Knowledge of

• the indications for and impact of surgery, radiation therapy, systemic therapy
• of the limitations of therapy (eg, criteria of iresecaibilty)
• of the risk assessment workup of prognostic factors, especially the staging system for the main tumour types

Understanding

• of the role of systemic therapy in the management of patients with different stages of disease such as localised, locally advanced or metastatic disease
• of the complications that derive from disease progression and those that are treatment associated

 

3.12.Management and treatment of disease site cancers

Head and neck cancers
Thoracic malignancies
Small-cell lung cancer
Non-small-cell lung cancer
Mesothelioma
Thymoma and thymic cancer
Gastrointestinal cancers
Oesophageal cancer
Gastric cancer
Colon and rectal cancer
Anal cancer
Hepatobiliary cancers
Pancreatic adenocarcinoma
Genitourinary cancers
Renal cell cancer
Urothelial cancer
Penile cancer
Prostate cancer
Germ cell tumours
Gynaecological malignancies
Ovarian cancer (including Fallopian tube and primary peritoneal cancer)
Endometrial cancer
Cervical cancer
Vulvar and vaginal cancers
Gestational trophoblastic neoplasia
Breast cancer
Sarcomas
Bone sarcomas
Soft tissue sarcomas
Gastrointestinal stromal tumour
Skin cancers
Melanoma
Basal cell and squamous cell cancers of the skin
Endocrine tumours
Thyroid cancer
Neuroendocrine neoplasms
Peritoneal Surface Malignancies
Central nervous system malignancies
Carcinoma of unknown primary site
Lymphomas
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma

3.13.Rare cancers

To understand the collective size and significance of rare cancer cases in the practice of surgical oncology

 

3.14.Special issues in the diagnosis and treatment of cancers in adolescents and in young adults

To be familiar with the incidence and special characteristics of malignancies observed in adolescence and in young adults

3.15.Cancer and pregnancy

To be able to diagnose, stage, treat and counsel pregnant patients with cancer and to assess and counsel patients with pregnancies occurring after cancer

 

3.16.Geriatric oncology

To be able

• to perform/interpret geriatric screening and/or assessment of older patients with cancer
• to counsel on an optimal treatment strategy for each individual

 

3.17.Cancer treatment in patients with comorbidities

Knowledge toperform specialist assessment, treatment and counselling of patients with cancer and comorbidities

 

3.18.Hereditary cancer syndromes

Knowledge

• of the role hereditary predisposition plays in the development of many cancer subtypes
• of management ranging from weak predisposing genetic variants to moderate-risk and high-risk genes and potent genetic mutation holders, where not only targeted surveillance may be offered but risk-reducing surgery may be appropriate.

 

3.19.Psycho-oncology and communication skills

A professional surgical oncologist should be able to provide patient care that is evidence-based, wholly compassionate, and comprehensive to address all the multiple afflictions arising from the diagnosis of cancer.

 

3.20.Genetic counselling

Knowledge to perform an assessment of genetic susceptibility to cancer and to recommend appropriate testing

 

3.21.Patient education

Knowledge toprovide clear information regarding cancer treatments, including side effects and trade-offs, dosing and schedules, and interactions with other active medications for comorbid conditions

 

3.22.Surveillance

Knowledge of post-treatment surveillance protocols for different tumor types, algorithms, frequency, and the evidence for benefit.

 

3.23.Bioethical, legal and economic issues

• to integrate ethical and legal rules into the care of patients with cancer

Understanding of the human/compassionate side of medicine applicable to all socioeconomic and diverse cultural regions of the world.

 

4.RADIATION ONCOLOGY

Radiotherapy after surgery is the second most applied therapeutic modality for treating tumors. In the last 20 years, radiotherapy has developed rapidly (IMRT, tomotherapy, etc.) and concomitant medication (chemotherapy) has become commonplace in more and more tumors.There is an ongoing shortage of oncology services in Centarl and Eastern Europe, including RT equipment and personnel. Radiotherapy requires highly qualified personnel teams because of its technological complexity.

The fellow should be able to analyse, synthesise and evaluate the information acquired in the competency specific modules in radiotherapy preparation and delivery and patient support. In this taxonomy analysis is the ability to break down the information into its component parts and look for interrelationships and ideas, synthesise the information by combining information from a range of settings or experiences and evaluate or judge the value of the information and how it is best applied. The core curriculum consists of the required knowledge and abilities for radiation oncologists, medical physicists and radiotherapy assistants.

4.1.Core curriculum for radiation oncologists

Radiation oncologists have to have the knowledge

– of different tumor types and their lymphnode regions, tumorspreading, Tumor (T), Nodes (N), Metastasis (M) system of the tumors

– of the pathology, ethiology and epidemiology of tumors

– of the morbidity and mortality data of different tumors

– of the different modalities (electron, photon, proton, etc.) and the different modes of irradiation (external beam radiotherapy, brachytherapy)

– of the basic principles of different radiation planning and delivery techniques such as intensity modulated radiation therapy (IMRT), stereotactic, particle and adaptive radiotherapy

– of the principles of brachytherapy and radionuclide therapy

– of the basic principles of surgery, chemotherapy, hormontherapy, immunotherapy

– of how to sequence radiation therapy with other treatment options (surgery, chemotherapy, etc.)

– of different indications in different cancer types neoadjuvant/adjuvant and the metastatic and palliative settings

– to analyse the results of imaging procedures (CT, MRI, PET)

– of a therapeutic window between tumour control and normal tissue toxicity

– of different cancer types and their radiosenstivity

-of basic principles of radiation biology, including the effects of time, dose, fractionation and type of radiation

– of differences in radiation tolerance of organs/tissues at risk

– of the risks of re-irradiation based on normal tissue tolerance limits

– of understanding of the interaction between radiation and systemic drugs (concomitant, etc.)

– of the role of surgery, interventional radiology, radiation oncology, systemic antitumour therapy, symptom control and supportive/palliative care measures in patients with relapsed disease

– of understanding of the fundamental concepts of value-based healthcare

– of the importance of the multidisciplinary approach to treat patients with cancer

– of the risks, benefits, indications of radiotherapy

– of understanding of the biological basis of radiation-induced cytotoxicity, and the barriers and facilitators to efficacy (radiosensitizers, hypoxia).

– of the biological basis of radiotherapy and the efficacy

– of the acute and longer-term side effects

– of the importance of the multidisciplinary approach to treat patients with cancer

– of the difference between palliative and curative (definitive) radiotherapy indications

– of the existence of different radiation planning, delivery and position/dose-verification techniques

– of the published research evidence and guidelines for radiation oncology

– of quality control

– of recognition of the importance of value-based healthcare delivery

– of the basic principles of radiation biology

– of differences in radiation tolerance of organs/tissues at risk

– of understanding of the interaction between radiation and systemic drugs

– of the principles of different radiation position/dose-verification techniques (EPID, IGRT) – – of dosimetry (in vivo and in virtro)

– of treatment planning

-of treatment planning algorithms (Hounsfield units, calculations, ICRU recommendations, dose limits and determinants

– of treatment plan analysis and evaluation

– of relevant published research evidence, of the results of major randomised trials that have influenced present practice, of ongoing trials of radiation oncology and systemic therapy, and of national/ international guidelines

– of radioprotection (ALARA principle, etc.)

– of the importance of quality control

Radiation oncologists have to have the ability

– to deliver effective interdisciplinary consultations and contribute effectively to the discussions of multidisciplinary teams

– to elicit the patient’s wishes with regard to the aims of treatment and to give the treatment alone or in collaboration with other specialists

– to inform patients on different radiation treatment options and discuss the risk/benefit ratio and to explain these in lay terminology to patients and families

– to treat the side effects

– to follow the patients

– to communicate about considerations in prescribing external beam radiation and/or brachytherapy

– to communicate about basic considerations in prescribing various systemic agents and their potential interactions with radiation therapy

– to modulate the concomitant treatment of systemic drugs and radiation according to the patient’s situation in collaboration with the multidisciplinary team

– to communicate about different radiation planning, delivery and position/dose-verification techniques

– to discuss relevant clinical trials and evidence-based guidelines

– to discuss options of entering a clinical trial involving radiotherapy

 

4.2.Core curriculum for medical physicists

Medical physicist have to have the knowledge

– of the different modalities (electron, photon, proton, etc.) and the different modes of irradiation

– of the principles of different radiation planning and delivery techniques such as intensity modulated radiation therapy (IMRT), stereotactic, particle and adaptive radiotherapy

– of the principles of brachytherapy and radionuclide therapy

– of the basic biological basis of radiotherapy and the efficacy

– of the difference between external beam radiotherapy (‘teletherapy’) and internal radiotherapy (‘brachytherapy’)

– of the existence of different radiation planning, delivery and position/dose-verification techniques

– of the published research evidence in radiation physiscs

– of quality control

– of differences in radiation tolerance of organs/tissues at risk

– of the principles of different radiation position/dose-verification techniques (EPID, IGRT) – – of dosimetry (in vivo and in virtro)

– of operation of radiotherapy machines

– of treatment planning

-of treatment planning algorithms (Hounsfield units, calculations, ICRU recommendations, dose limits and determinants

– of treatment plan analysis and evaluation

– of relevant published research evidence, of the results of major randomised trials that have influenced present practice, of ongoing trials of radiation oncology and of national/ international guidelines

– of radioprotection (ALARA principle, etc.)

– of the importance of quality control

– of quality assurance

 

4.3.Core curriculum for radiotherapy assistants

Radiation therapists have to have the knowledge

– of the basic of different modalities (electron, photon, proton, etc.) and the different modes of irradiation

– of the basic principles of different radiation planning and delivery techniques such as intensity modulated radiation therapy (IMRT), stereotactic, particle and adaptive radiotherapy

– of the basic principles of brachytherapy and radionuclide therapy

– to demonstrate a sensitive and caring attitude to patients

– to inform the patient about the treatment

– to carry out best practice at all times (evidence dased medicine, literature)

– to participate in continuing professional development

– to prepare and produce immobilisation devices

– to complete accurate documentation

– to know the different applications of the imaging equipment

– to acquire images on all equipment routinely used

– to apply appropriate scanning conditions / parameters

– to demonstrate the ability to interpret and understand acquired images

– to assist in the virtual simulation procedure

– to set the reference / isocentre points

– to complete accurate documentation

– to interpret and evaluate a treatment plan and compare it to the treatment prescription

– to produce an appropriate treatment plan that meets the requirements of the treatment prescription

– to carry out the necessary data transfer checks

– to prepare the patient for their first treatment

– to position the patient for treatment

– to acquire the initial verification images

– to carry out corrective actions (recognise the critical organs on the verification images)

– to check the dose delivered

– to implement health and safety procedures

– to monitor, manage and record the patient’s side effects throughout the course of treatment

– to know the basic principles of quality assurance

– to carry out the daily quality control checks

– to report incidents

– to ensure radiation protection (in brachtherapy also)

– to assist in the brachytherapy procedure

– to participate in the implementation of national or international clinical trials into the department

 

5.MEDICAL ONCOLOGY

The increasing internationalisation of healthcare as well as the increased exchange of specialists and knowledge across borders, identified the need of international recommendations for the clinical training of physicians to qualify them as medical oncologist. Patients, wherever they live, should have an equal chance of receiving state-of-the-art treatment from well-trained physicians. Geographical, cultural, economic, religious and ethical issues may differ substantially, and patients’ expectations vary accordingly. It was perceived that the diversity of health and educational systems around the world may have rendered some curriculum recommendations and the developed training programmes in medical oncology.

Important advances in medical oncology have been achieved in recent years, notably in the integration of molecular pathology and molecular profiling to determine the presence of biomarkers as a rationale for the appropriate treatment selection. To integrate biomarker analysis of prognostic and therapy predictive factors into the treatment decision process, the individual patient’s marker signatures in the cancer cells and normal cells are mandatory in personalised medicine.

Medical Oncology is a broad-based clinical specialty with the responsibility to ensure that state-of-the-art therapies of established efficacy for the common cancers are delivered on a national basis, within a framework of care for the patient as an individual.Medical oncology training programs must provide an intellectual environment for acquisition of the knowledge, skills, clinical opinion, and attitudes essential to the practice of medical oncology. The clinical setting must include opportunities to observe and manage patients with a wide variety of malignant diseases on an in-patient and out-patient basis. The trainee must be given the opportunity to assume the continuing responsibility for both acute and chronically ill patients in order to learn the natural history of cancer, the extent of the effectiveness of the various therapeutic programs, and how to impart information to the patient, including bad news.

The programme must emphasise scholarship, self-instruction, development of critical analysis of clinical problems and the ability to make appropriate decisions, in addition to active involvement in regularly scheduled conferences and multidisciplinary clinics and/ or tumour boards. The programme should foster all aspects of the roles required of an oncologist, including being an effective communicator with patients, a collaborator in the treatment team, a manager of the healthcare system, a health advocate not just for the patient but for the community and a scholar with lifelong commitment and high professional ethics and standards.

They must therefore be trained to work as part of a multidisciplinary team, able to advise on all aspects of treatment including surgery and radiotherapy as well as having the skills in training to deliver specialist medical therapy. Understanding the role of the pathologist as part of the multidisciplinary team is essencial.

In this program the following main topics is essential to studied for Medical Oncologist:

 

5.1.Requirements from medical oncologists

5.1.1. Basic principles in the management and treatment of malignant diseases, evidence based medicine, clinical trials and research methods

5.1.1.1.Pathology of cancer

Knowledge

– about the main clinical diagnostic test modalities, namely cytogenetics, flow cytometry, immunohistochemistry (IHC), fluorescence in situ hybridisation (FISH), reverse transcriptase polymerase chain reaction (RT-PCR), Sanger sequencing, microarrays (eg, single-nucleotide polymorphism (SNP) chips) and NGS

– of the interpretation of genomic information of whatever kind (FISH, PCR, multiplex ligationdependent probe amplification (MLPA), mass spectrometry analysis (MSA), array comparative genomic hybridisation (aCGH), array SNP (aSNP), NGS, GEP etc) in association with personal medical and health information

– of the standards of scientific genomic and clinical evidence for all types of assays (FISH, PCR, NGS etc)

– on the current and near-future diagnostic applications of NGS

– that within NGS there is a conceptual distinction between panel sequencing, exome sequencing and genome-wide sequencing

– on the interpretation of key metrics and parameters that govern projects involving molecular pathology, especially when NGS is being used

– on how to ascertain patient preferences regarding the receipt of germline information and assessment on how to allow patients to decline receiving of germline information

– on how to apply basic concepts of cancer genetics, risk assessment and currently available testing into patient care practices

– on how to recognise genetic testing for common cancer syndromes and how to interpret variants of unknown significance (VUS)

– on the basic laboratory-specific concepts, the laboratory sample flow, different turn-around times for different molecular pathology techniques and understanding of the limitations of data generation using high throughput technologies such as NGS

– on the emergent strategies and the latest advances using molecular pathology techniques such as NGS in the early detection of cancers (breast, gastrointestinal etc)

– on the patient’s perspective on preferences for somatic testing, the importance of costs of the assay for the patient and the potential need of return of results when multiparameter testing is performed

– on the basic physiological and pathophysiological mechanisms of normal and diseased tissues, for example the immune system, DNA-repair mechanisms etc.

 

5.1.1.2. Molecular pathology

Knowledge of

-the standards of scientific genomic and clinical evidence for all types of assays (FISH, PCR, NGS etc)

– the basic physiological and pathophysiological mechanisms of normal and diseased tissues, for example the immune system, DNA-repair mechanisms etc.

– the patient’s perspective on preferences for somatic testing, the importance of costs of the assay for the patient and the potential need of return of results when multiparameter testing is performed

– how to apply basic concepts of cancer genetics, risk assessment and currently available testing into patient care practices

– how to ascertain patient preferences regarding the receipt of germline information and assessment on how to allow patients to decline receiving of germline information

– how to recognise genetic testing for common cancer syndromes and how to interpret variants of unknown significance (VUS)

– the current and near-future diagnostic applications of NGS

– the basic laboratory-specific concepts, the laboratory sample flow, different turn-around times for different molecular pathology techniques and understanding of the limitations of data generation using high throughput technologies such as NGS

– the interpretation of key metrics and parameters that govern projects involving molecular pathology, especially when NGS is being used

– the emergent strategies and the latest advances using molecular pathology techniques such as NGS in the early detection of cancers (breast, gastrointestinal etc)

 

5.1.1.3. Laboratory medicine

Knowledge of

– the importance of controls (positive, negative), assessment of data quality and limitations of techniques

– which laboratory testing is appropriate for diagnosis, staging, treatment decision-making and follow-up

– the relevant biomarkers and their clinical value

– review and interpretation of laboratory findings pertaining to the management of patients with cancer

– the principles of laboratory methods relevant for appropriate interpretation, including particularly cytogenetic and molecular analyses

– which clinical materials are required/appropriate for specific diagnostic tests

– adequate frequencies of laboratory diagnostic analyses in different clinical settings

– about some of the basic techniques (PCR, western blot, cell culture techniques, histology)

 

5.1.1.4. Translational research

Understanding of basic science research, translational research, investigation of new targets for cancer therapy research, epidemiology research, cancer burden research, disparities research, cohort and caseecontrol study design and their indications and potential limitations, randomized trial design and quality standards, psycho-oncology research and research into quality-of-life issues.

Understanding of the basic and (optionally) advanced statistical methods is essential to conduct research and also permit critical evaluation of research.

Knowledge

• about some of the basic techniques (PCR, western blot, cell culture techniques, histology)
• about: the types of sample that can be collected;
• about the need and process for gaining consent from the patient to collect specimens;
• about storage of samples, retrieving samples from biobanks
• about the type of biomarkers that can be studied

 

5.1.1.5. Clinical staging

Knowledge of

– the principles and general rules of staging systems, mainly the TNM (tumour-node-metastasis) staging system

– the relationship between the TNM system and contemporary practice in order to assign each stage

– the difference between clinical and pathological staging

– the use of post-therapy or post-neoadjuvant therapy staging and re-staging

– the correlation between stage and prognosis

– the differences in treatment choice based on staging

– to choose the adequate procedures such as physical examinations, imaging studies, laboratory tests and pathological or cytological examinations to do adequate staging

 

5.1.2. Basic principles in the imaging of malignant disease

5.1.2.1. Diagnostic imaging

Knowledge

– the various radiological modalities (ultrasound, CT, MRI, PET CT etc.) and their basic functioning principles

– the adequate staging protocols (organ-specific protocols with multiple phases) for the main cancer types and the indications for each imaging modality in cancer assessment and operative planning.

– the indications for radiological imaging in staging and cancer surveillance.

– the methods used to analyze preoperative imaging to help with operative decisionmaking (stereotactic localization etc.).

– to apply RECIST 1.1 and immun RECIST

– to use of interventional radiology in cancer care, such as stent placement, radiotherapy, cryotherapy and high-frequency ultrasound targeting, therapeutic vascular embolization, and chemotherapy delivery.

 

5.1.2.2. Molecular imaging

Knowledge of

– how to use molecular imaging adequately in daily practice

– different molecular imaging techniques and tracers

– the interpretation the physiological biodistribution, pathological uptake and pitfalls and artefacts of molecular imaging techniques

– the contribuion to the presentation of molecular imaging findings of patient cases

– how to use imaging information for patient care

– how to select the right indications for molecular imaging for staging and response measurements

– interpret left ventricular ejection fraction

– take care of patients who receive radionuclide therapy

 

5.1.3.Basic Principles in Anticancer Pharmaceutical therapy

5.1.3.1. Anticancer agents

Knowledge of

– the classification of an anticancer agent as cytotoxic chemotherapy, (anti)hormonal agent,

biological agent, targeted agent and/or immunotherapy

– the specific mechanisms of action of an individual anticancer agent

– the specific mechanisms of resistance that have been identified for an individual anticancer agent

– the key clinical pharmacology principles of individual anticancer agents, including absorption, distribution, metabolism and clearance/elimination

– the main clinical indications for an individual anticancer agent

– the recommended dosing for an individual anticancer agent and how to adapt it to individual tolerability

– the food–drug interactions for an individual anticancer agent, especially as they relate to the use of oral anticancer therapy

– drug–drug interactions, which include drug–herb and drug–nutritional supplement interactions, for an individual anticancer agent

– the main side effects associated with an individual anticancer agent

– the specific black-box warnings for an individual anticancer agent

– dosing of an individual anticancer agent in the setting of liver and/or kidney dysfunction

– specific considerations for an individual anticancer agent, such as potential interactions with the oral anticoagulants coumarin or warfarin, monitoring for signs and symptoms of fluid retention, close monitoring of complete blood counts (CBCs), monitoring of QT interval, monitoring for infusion reactions etc

– the use of molecular biomarkers and specific diagnostic tests for the selection of targeted agents in the treatment of specific cancer types

 

5.1.3.2. Chemotherapy

Knowledge of

– basic understanding of the general mechanism of action of key chemotherapy agents and their side effects, risks, benefits, indications for use, and duration of administration in the neoadjuvant/adjuvant and metastatic and palliative settings.

– how to sequence chemotherapy with other treatment options such as surgery and radiation therapy.

– the influence of chemotherapy on outcomes of subsequently performed operative procedures.

– the principles underlying single-agent regimens or poly-chemotherapy with established criteria to assess response to chemotherapy (response evaluation criteria in solid tumors, RECIST).

 

5.1.3.3. Targeted therapy

Knowledge of

– understanding of the newer biological agents and targeted therapies.

– the basic principles of monoclonal and small molecular targeting agentsand their specificity in a particular cancer

– updates of targeted/biological therapies for medical oncologists

– the common side effects of these agents.

– the health economic implications of these agents and how this must be taken into account by healthcare funders.

 

5.1.3.4.Immunotherapy

Knowledge of

– basic principles of immunotherapy (immune editing etc.), novel immunotherapeutic agents including check-point inhibitors, their indications, combination strategies, and their therapeutic potential.

– the common side effects of these agents.

– the health economic implications of these agents and how this must be taken into account by healthcare funders.

 

5.1.3.5. Hormonal treatment

– basic principles of hormonal therapy, hormonal therapeutic agents, their indications, combination strategies with other oncological treatment, and their therapeutic potential.

– the common side effects of these agents.

– the health economic implications of these agents and how this must be taken into account by healthcare funders.

 

5.1.3.6.Complications/toxicities of treatment

To be able to

• assess, diagnose and treat patients with complications/toxicities of anticancer therapies
• contribute actively to a wide variety of presentations of complications/toxicities of different classes of anticancer therapy
• to perform a thorough history and clinical examination
• to contribute actively to present patient cases
• to discuss potential diagnostic investigations including the merits and limitations of the tests
• to contribute to discussions on management strategies with reference to pharmacological and nonpharmacological methods
• to discuss the role of other healthcare professionals for each scenari
• to discuss prophylactic/preventative measures that can be instituted to protect patient safety

 

5.1.4. Principles of personalised cancer medicine

The ability to find to the patient the best treatment with the best result with less toxicity using pathological and molecular predictiv and prognostic factors and patient’s relevant karacteristics.

 

5.1.5. Principles in supportive and palliative care

– Knowledge of

– palliative symptom control (antiemetics, anti-diarrheals, laxatives, appetite stimulants, nutritional support, management of pain, dyspnea, cough, xerostomia, excessive oral and pharyngeal secretions, fever, anxiety, insomnia, delirium, palliative sedation at the end-of-life and palliative surgery (for example for relief of biliary or ureteric obstruction) and steroids to reduce cancer-related edema (liver metastases, brain metastases).

– the use of palliative chemotherapy and radiotherapy and the delicate balance between symptom palliation and treatment side effects (quality- adjusted time without symptoms or toxicity,).

– the coordination care with multiple teams and family members to lead end-of-life discussions.

 

5.1.6.Bioethical legal and economis issues

To be able to integrate ethical and legal rules into the care of patients with cancer

 

5.1.6.1. Legal issues

Knowledge of

– of the Good Clinical Practice (GCP) guidelines

– to apply the rules of GCP while performing clinical studies and clinical practice

– to communicate basic ethical and legal principles with patients and relatives

– to guide patients through the process of obtaining (or withdrawing) informed consent for clinical and research procedures

 

5.1.6.2.Economic issues

Knowledge of

– Understanding of the mechanisms for financing healthcare in one’s nation of residence

– Familiarity with the macroeconomics of cancer care

– Familiarity with the approaches that health economists employ to quantify value, eg, determination of qualityadjusted life years (QALYs), cost-effectiveness ratios etc

– Understanding of the multiplicity of factors underlying the rapidly rising costs of cancer care in one’s own national environment and worldwide

– Familiarity with the pathways that have been and are under development to guide high-quality, cost-effective cancer care

– To be able to determine the highest-value agents or regimens ― the optimal combination of clinical benefit, toxicity and cost―for a specific clinical indication

 

Thess objectives can only be achieved when appropriate resources and facilities are available.

 

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