Speciality of Medical Oncology
1. OFFICIAL NAME (ROYAL DECREE 127/84) OF THE SPECIALITY AND REQUIREMENTS
Medical Oncology.
Duration: 4 years.
Previous degree: Medicine.
2. INTRODUCTION
The complexity of the diagnostic and therapeutic methods developed during the second half of the 20th Century and the constant increase in malignant tumours as a cause of death in developed societies, has meant that the care given to those suffering from tumours requires special preparation on the part of doctors who wish to devote themselves to the care of these patients. Medical Oncology arose from the need to cover medical aspects which were different from the surgical and radiotherapy aspects which already existed years before the speciality of Medical Oncology was officially recognised in Spain, which occurred in 1978.
3. DEFINITION OF THE SPECIALITY AND FIELD OF ACTIVITY
Medical Oncology is a core speciality of Medicine, which requires basic and fundamental training in Internal Medicine, and which qualifies the specialist to evaluate and deal with cancer patients.
The medical oncologist specialises in caring for cancer sufferers as a “whole”. His aim is to care for the patients from the point of diagnosis, including treatment and monitoring, until they are cured or during the terminal period of the patients. He deals with the pathology associated with the illness and the complications arising from the treatment. He plays an active role in the emotional, social and psychological support needed by the patients and their families. He is responsible in particular for administering antineoplastic drugs, and must have a broad knowledge of their pharmacokinetics, interactions with other drugs and monitoring systems of their levels.
Field of activity of the medical oncologist
The medical oncologist devotes his attention to three main areas:
a) Patient care.
b) Teaching.
c) Research.
Medical oncologists must work as key members of the team dedicated to the care of cancer sufferers, using their experience in the medical handling of the disease. They must have their own patients and must also perform the duties of a consultant. They must play a role in the primary care of cancer sufferers, who need complicated medical treatment. They must collaborate in the teaching of other colleagues, members of the health team, patients and the community in general, both outside of the hospital and within the hospital environment. In university hospitals and special cancer centres, they must teach Oncology to medical students, residents and trainee staff.
4. GENERAL OBJECTIVES OF THE TRAINING
The objective is to acquire professional competence in the speciality. Competent is defined as the resident in Oncology who on completion of the 4 year period of training, is capable of providing complete and specialised medical care to cancer sufferers. He must be capable of performing a clinical analysis of the status of the patient by means of the elements extracted from a good medical history and physical examination. He must produce a diagnosis and consider the various possible differential diagnoses. He must be familiar with the methods of diagnosis and use them in a rational and efficient manner and apply the most suitable treatments, having assessed the possible benefits and side effects for the patient. He must be capable of relating to the patients, families and work colleagues in an appropriate manner and applying ethical principles to his care, teaching and research.
5. COMPONENTS OF THE SPECIALITY
a) THEORY
1. Epidemiology:
1.1. Epidemiological research methods.
1.2. Descriptive and analytical epidemiology.
1.3. Tumour registers.
2. Aetiology:
2.1. Genetic bases of cancer:
2.1.1. Basic concepts of cancer genetics.
2.1.2. Chromosomic anomalies and tumours.
2.1.3. Cancers with dominant inheritance.
2.2. Viruses and cancer:
2.2.1. Definitions and experimental methods.
2.2.2. Carcinogenic viruses, DNA and RNA.
2.3. Oncogenes:
2.3.1. Detection of oncogenes.
2.3.2. Activation of oncogenes.
2.3.3. Role of proto-oncogenes in normal and transformed cells.
2.4. Carcinogenesis due to chemical substances:
2.4.1. Biological characteristics of chemical carcinogens.
2.4.2. Concepts of carcinogenesis.
2.4.3. Chemical carcinogens as a cause of human cancers.
2.5. Physical carcinogenesis:
2.5.1. Mechanisms of carcinogenesis: types.
2.5.2. Cell damage, DNA repair and cell transformation.
3. Cancer biology:
3.1. Properties of malignant cells:
3.1.1. Concept of multipotential cell applied to tumours.
3.1.2. Tumour growth and heterogeneity.
3.1.3. Cultivation of tumour cells.
3.2. Cell kinetics:
3.2.1. Cell proliferation in normal tissue.
3.2.2. Cell proliferation in tumour tissue.
3.2.3. Thymidine index.
3.2.4. Flow cytometry.
3.2.5. Evaluation of tumour ploidy.
3.3. Tumour dissemination:
3.3.1. Dissemination mechanisms.
3.3.2. Properties of metastatic cells.
3.4. Tumour cell biochemistry:
3.4.1. Basic concepts of molecular biology and cell metabolism.
3.4.2. Enzymes in cancer cells.
3.5. Tumour markers:
3.5.1. Properties and detection.
3.5.2. Oncofetal proteins.
3.5.3. Hormones.
3.5.4. Enzymes.
3.5.5. Immunoglobulins.
3.5.6. Antigens associated with tumours.
3.5.7. Clinical usage of the markers:
• Sensitivity and specificity
• Tumour mass
• Prognosis
• Prediction of recurrence
• Guide for treatment
3.6. Hormones and cancer:
3.6.1. Mechanism of action.
3.6.2. Hormone production due to tumours.
3.6.3. Hormones as carcinogens.
3.6.4. Hormone treatments for cancer.
3.7. Tumour immunology:
3.7.1. Biology of the immune response.
3.7.2. Mechanisms of tumour immunity.
4. Prevention:
4.1. Primary prevention:
4.1.1. Detection of carcinogens and risk factors.
4.2. Secondary prevention or early diagnosis:
4.2.1. Detection of high-risk individuals.
4.2.2. Early diagnosis programmes:
1) Cancer.
2) Cervical cancer.
3) Colon cancer.
4.3. Educating the public.
5. Methods of radiodiagnosis of tumours:
5.1. Conventional x-ray, TAC and RM.
5.2. Radioisotopes.
5.3. Monoclonal antibodies.
6. Sampling techniques:
6.1. For bacteriological study.
6.2. For pathological studies.
a) Fine-needle puncture and aspiration.
b) Bone marrow biopsy.
c) Liquid aspiration.
d) Others: brushing, suction, etc.
6.3. Conservation and dispatch of samples:
6.3.1. Tissue for hormone receptors.
6.3.2. Glands.
6.3.3. Samples for cytology.
7. Natural history, diagnosis and treatment of the various cancers:
7.1. Intrathoracic:
7.1.1. Small cell lung.
7.1.2. Non-small cell lung.
7.1.3. Thymoma.
7.1.4. Mediastinal germ cell tumours.
7.1.5. Mesothelioma.
7.2. Breast:
7.2.1. Malignant breast tumours.
7.3. Gynaecological:
7.3.1. Ovarian.
7.3.2. Cervical.
7.3.3. Endometrial.
7.3.4. Trophoblastic.
7.3.5. Vulvar and vaginal.
7.4. Gastrointestinal:
7.4.1. Oesophageal.
7.4.2. Gastric.
7.4.3. Hepatobiliary system.
7.4.4. Early liver.
7.4.5. Small intestine.
7.4.6. Colon and rectal.
7.4.7. Anal canal.
7.4.8. Neuroendocrine tumours of the digestive system.
7.4.9. Pancreatic.
7.5. Genitourinary:
7.5.1. Renal.
7.5.2. Nephroblastoma.
7.5.3. Testicular: Seminoma and non-seminoma.
7.5.4. Prostate.
7.5.5. Upper unitary tract.
7.5.6. Bladder.
7.5.7. Penis and urethral.
7.6. Head and neck:
7.6.1. Nasopharyngeal.
7.6.2. Epidermoid, very distinct.
7.6.3. Saliva glands.
7.7. Central nervous system:
7.7.1. Malignant glioma.
7.7.2. Neuroblastoma.
7.7.3. Retinoblastoma.
7.8. Endocrine system:
7.8.1. Thyroid gland.
7.8.2. Suprarenal gland.
7.8.3. Endocrine pancreas.
7.8.4. Carcinoid.
7.8.5. Multiple endocrine neoplasia.
7.9. Skin, bone and soft tissue:
7.9.1. Melanoma.
7.9.2. Osteosarcoma and other bone sarcomas.
7.9.3. Soft tissue sarcomas.
7.9.4. Skin carcinomas (non-melanoma).
7.10. Tumours of unknown origin.
7.11. Leukaemias and lymphomas:
7.11.1. Adult myeloblastic leukaemia.
7.11.2. Adult lymphoblastic leukaemia.
7.11.3. Childhood acute leukaemias.
7.11.4. Chronic lymphatic leukaemia.
7.11.5. Chronic myeloid leukaemia.
7.11.6. Hodgkin’s disease.
7.11.7. Non-Hodgkin’s lymphomas:
1) Lymphatic.
2) Extra-lymphatic.
3) Mucus associated.
4) Childhood.
5) AIDS-associated.
7.11.8. Myeloma.
7.11.9. Myelodysplastic syndromes.
8. Study and treatment of other cases:
8.1. Disseminated illness.
8.2. Malignant pleural effusion.
8.3. Pericardial effusion.
8.4. Malignant ascites.
8.5. Paraneoplastic syndromes.
9. Assessment of the tumour patient and assessment of the response to treatment:
9.1. Study of area. Most common classifications: TNM, FIGO, lymphomas, etc.
9.2. Response criteria and their assessment.
9.3. Toxicity assessment.
9.4. Assessment of functional capacity.
10. Analysis and treatment of emergency cases:
10.1. Superior vena cava syndrome.
10.2. Intracranial hypertension.
10.3. Spinal cord compression.
10.4. Metabolic emergencies: Hypercalcemia, hyperuricemia, lactic acidosis.
10.5. Acute tumour lysis syndrome.
10.6. Surgical emergencies.
10.7. Urological emergencies.
11. Pain: assessment and treatment:
11.1. Pain aetiology.
11.2. Pharmacological treatment.
11.3. Neurosurgical treatment.
11.4. Neurostimulation.
11.5. Catheters and reservoirs.
12. Infections in the cancer patient:
12.1. Assessment of patient with fever.
12.2. Treatment of specific infections.
12.3. Prevention of infections.
13. Other supporting treatments:
13.1. Nutritional.
13.2. Whole blood and by-product transfusion.
13.3. Hematopoietic growth factors.
13.4. Psychosocial support.
13.5. Physical and psychosocial rehabilitation.
14. Basic concepts of oncology surgery:
14.1. Preventive surgery.
14.2. Diagnostic surgery.
14.3. Surgery with cancer treatment.
15. Basic concepts of radiotherapy:
15.1. Basic concepts of biophysics.
15.2. General indications.
15.3. Side effects.
16. Antineoplastic chemotherapy:
16.1. Alkylating agents:
16.1.1. Nitrogen mustard derivatives:
a) Busulfan.
b) Meclorethamine.
c) Chlorambucile.
d) Cyclophosphamide.
e) Ifosfamide and Mesna.
f) Melphalan.
g) Thiotepa.
16.1.2. Ethylene amines:
a) Hexamethylmelamine.
16.1.3. Others:
a) Dacarbazine.
b) Procarbazine.
16.1.4. Heavy metals:
a) Cisplatin.
b) Carboplatin.
16.2. Antimetabolites:
16.2.1. Cytosinarabinosid.
16.2.2. 5-Fluorouracil and other fluoropyrimidines.
16.2.3. 6-Mercaptopurine, 6-thioguanine.
16.2.4. Methotrexate.
16.2.5. Hydroxyurea.
16.3. Alternating substances:
16.3.1. Anthracyclines and derivatives:
a) Daunorubicin.
b) Doxorubicin.
c) Rubidazone.
d) Epirubicin.
e) Aclacinomycin.
16.3.2. Others:
a) Amsacrine.
b) Mitoxantrone.
16.4. Non-anthracycline antibiotics:
a) Bleomycin.
b) Mitomycin C, Actinomycin D, Mitramycin.
16.5. Vegetable derivatives:
a) Etoposide (VP-16).
b) Teniposide (VM-26).
c) Vinblastine.
d) Vincristine.
e) Vindesine.
f) Taxol and derivatives.
16.6. Nitrosoureas:
a) CCNU (Lomustine).
b) BCNU (Carmustine).
c) Streptozoticin.
16.7. Enzymes:
a) L-Asparaginase.
17. Hormones and antihormones as therapeutic agents:
a) Glucocorticoids.
b) Oestrogens.
c) Progestogens.
d) Antioestrogens (Tamoxifen and derivatives).
e) Cyproterone acetate.
f) Antiandrogens.
g) Aminoglutetimide.
h) LHRH agonists.
17.2. Hormone combinations + alkylating agents:
a) Estramustine.
b) Prednimustine.
18. Concept of high dose chemotherapy:
18.1. Reinfusion of peripheral multipotential cells.
18.2. Methodology of cell collection and reinfusion.
18.3. Indications for treatment.
19. Bone marrow transplant:
19.1. Concept of autologous and heterologous transplant.
19.2. Bone marrow transplant in cancer patients.
19.3. The major complications.
20. Biological response modulators:
20.1. Interferons and interleukins.
20.2. Colony growth factors.
20.3. Tumour necrosis factors and other differentiation factors.
21. Monoclonal antibodies:
21.1. Production of antibodies.
21.2. Human monoclonal antibodies.
21.3. Use in image diagnosis.
21.4. Application in the treatment of cancer.
22. Other cancer treatments:
22.1. Immunotherapy.
22.2. Hyperthermia.
22.3. Radiosensitisers and protectors
22.4. Photosensitisers.
22.5. Use of laser rays.
22.6. Cryotherapy.
23. Methods of administration of cytostatics:
23.1. Precautions in IV administration.
23.2. Intracavitary treatments.
23.3. Intra-arterial treatments.
23.4. Tumour perfusions.
23.5. Permanent catheters: Characteristics of problems arising from their use and care.
24. Tumour resistance to cytostatics:
24.1. Individual resistance mechanisms.
24.2. Multiresistance mechanisms.
24.3. Drug resistance modulators.
25. Medical interactions
26. Side effects of chemotherapy:
26.1. Immediate: Alopecia, nausea, vomiting and infections.
26.2. Delayed:
26.2.1. Cardiac toxicity.
26.2.2. Pulmonary toxicity.
26.2.3. Hepatic toxicity.
26.2.4. Neurological toxicity.
26.2.5. Gonadal dysfunction
26.2.6. Second tumours.
27. Treatment of the complications of chemotherapy:
27.1. Infections.
27.2. Digestive disorders.
27.3. Alterations in fertility.
27.4. Others.
28. Combined treatment of tumours:
28.1. Radiotherapy and chemotherapy.
28.2. Surgery +/- radiotherapy and/or chemotherapy.
29. Adjuvant chemotherapy:
29.1. Current guidelines.
29.2. Future guidance.
30. Caring for terminal patients:
30.1. Maintaining the patient’s wellbeing.
30.2. Caring for the patient in the terminal stage.
30.3. Home care programmes.
30.4. Ethical and legal aspects of caring for the terminally ill.
31. Psychosocial aspects of cancer patients:
31.1. Psychological impact of the illness.
31.2. Change in environments: family, work, etc.
31.3. Psychological support.
31.4. Social care and home help.
31.5. Informing the cancer patient.
32. Rehabilitation of the cancer patient:
32.1. Physical rehabilitation and prostheses.
32.2. Work rehabilitation.
32.3. Care of surgical stomas.
32.4. Psychological rehabilitation.
33. Design and evaluation of clinical trials in oncology:
33.1. Stages of trial with new therapeutic agents:
33.1.1. Chemotherapy.
33.1.2. Biological response modifiers.
33.2. Designing the studies:
33.2.1. Defining the objectives.
33.2.2. Data analysis.
33.2.3. Result analysis.
33.2.4. Ethical and legal concepts.
33.2.5. Basic concepts of statistics.
34. Teamwork:
34.1. Concept of teamwork.
34.2. Multidisciplinary programmes:
34.2.1. Intrahospital.
34.2.2. With Primary Care and home care.
34.3. Relationship with other health professionals:
34.3.1. Exchange of information.
34.4. Tumour committee.
6. ROTATIONS
The training period necessary for residents to acquire sufficient knowledge to enable them to practice the speciality is deemed to be four years. In the first year of the speciality, residents must undergo generic training in Medicine, requiring at least one year of Internal Medicine, and in the second year, quarterly rotations in the most important specialities in each centre, requiring 3 months of specific training in Oncohaematology.
In the Internal Medicine rotations, the residents must acquire the general knowledge of Medicine required to enable them to be familiar with the most common pathologies, their differential diagnosis, appropriate methods of diagnosis and specific medical treatments. Medical Oncologists must perform the medical duties required of them depending on the structure of the hospital. These duties must be comparable to those of any other resident in the Medical units. In the event that the hospital has specific duties for the Medical Oncology units, the Residents shall perform specific duties in that Unit from the third year of their residency. During their Haematology and Radiotherapy rotations, where these units have specific duties, they shall work the shifts required which must be comparable to those of residents in the same year taking these specialities.
7. SPECIFIC OPERATIONAL OBJECTIVES/ACTIVITIES PER YEAR OF RESIDENCY
a) SPECIFIC OPERATIONAL OBJECTIVES
Specific knowledge
This shall include the elements required to practice the speciality, in the assessment and care of patients and the practical application of these elements to specific problems. It must include: tumour biology, natural history of tumours, staging, assessment of therapeutic results, response criteria, pharmacology of antineoplastic agents (pharmacokinetics, interaction of common drugs and therapeutic control of drugs by means of plasma monitoring), dealing with the complications of cancer (including pain and the various neurological, infection, metabolic or endocrine problems), and the interpretation of diagnostic procedures (radiology, laboratory, pathological anatomy). All of this knowledge is acquired through daily care practice, both in outpatient consultations and with inpatients, and through scientific sessions designed to cover the theoretical knowledge of the speciality, such as bibliographic sessions, monographic subjects and clinical/pathological review sessions. This knowledge is acquired over the three years of residency specific to Medical Oncology. The instructions and implementation of radiotherapy, surgery, haematological support and biological compounds must be learned mainly in the months of rotation in the Haematology and Radiotherapy units, completing their knowledge during the fourth year of residency.
Skills
Level 1:
The training period necessary for residents to acquire sufficient knowledge to enable them to practice the speciality is deemed to be four years. In the first year of the speciality, residents must undergo generic training in Medicine, requiring at least one year of Internal Medicine, and in the second year, quarterly rotations in the most important specialities in each centre, requiring 3 months of specific training in Oncohaematology. In the Internal Medicine rotations, the residents must acquire the general knowledge of Medicine required to enable them to be familiar with the most common pathologies, their differential diagnosis, appropriate methods of diagnosis and specific medical treatments. Medical Oncologists must perform the medical duties required of them depending on the structure of the hospital. These duties must be comparable to those of any other resident in the Medical units. In the event that the hospital has specific duties for the Medical Oncology units, the Residents shall perform specific duties in that Unit from the third year of their residency. During their Haematology and Radiotherapy rotations, where these units have specific duties, they shall work the shifts required which must be comparable to those of residents in the same year taking these specialities. a) SPECIFIC OPERATIONAL OBJECTIVES This shall include the elements required to practice the speciality, in the assessment and care of patients and the practical application of these elements to specific problems. It must include: tumour biology, natural history of tumours, staging, assessment of therapeutic results, response criteria, pharmacology of antineoplastic agents (pharmacokinetics, interaction of common drugs and therapeutic control of drugs by means of plasma monitoring), dealing with the complications of cancer (including pain and the various neurological, infection, metabolic or endocrine problems), and the interpretation of diagnostic procedures (radiology, laboratory, pathological anatomy). All of this knowledge is acquired through daily care practice, both in outpatient consultations and with inpatients, and through scientific sessions designed to cover the theoretical knowledge of the speciality, such as bibliographic sessions, monographic subjects and clinical/pathological review sessions. This knowledge is acquired over the three years of residency specific to Medical Oncology. The instructions and implementation of radiotherapy, surgery, haematological support and biological compounds must be learned mainly in the months of rotation in the Haematology and Radiotherapy units, completing their knowledge during the fourth year of residency. Level 1:
a) Obtaining the appropriate clinical history: accurate, reasonable, complete and reliable.
b) Performing specific and expert physical examinations to observe subtle signs indicating the patient’s problem.
c) Demonstrating understanding and efficiency, avoiding risks or disturbances when determining the diagnostic studies which must be carried out.
d) Acting swiftly and efficiently in cases of medical emergency, haemorrhage, sepsis, shock, etc. This knowledge must be acquired during the first and second year of residency.
e) They must be able to choose the treatments which cause the least harm from the effective treatments available.
f) Recognising the complications of the illness and the physical, emotional and economic side effects suffered by patients. Treatment, being capable of implementing the necessary therapeutic measures in cases of emergency and severity, such as drug extravasations, overdoses, aplasia, etc.
g) Transmitting knowledge on prevention of the disease and effective methods for its early diagnosis.
Specific technical procedures are:
• Serial measurement of tumour masses.
• Bone marrow biopsy and aspiration.
• Administration of antitumour drugs and biological modulators via all routes; IV, intrathecal, and through catheters or implanted systems, etc.
• Care of intravenous subcutaneous catheters.
This knowledge must be acquired during the third year of residency.
Level 2:
a) They must be capable of applying chemotherapy treatments previously agreed upon in the unit by means of work protocols, designing sensible clinical trials capable of giving a concrete response to unclear aspects of the illness, its diagnosis or treatment.
b) Gather the patients’ clinical data in an orderly manner and produce conclusions and suggestions based on this. It is advisable for this data to be easily computerised.
c) Knowledge of certain procedures such as indirect laryngoscopy, skin biopsy, biopsy by puncture and aspiration of lymph glands, subcutaneous masses, breast nodules and bone marrow extraction.
This knowledge must be acquired during the fourth year of residency.
Level 3:
a) They must be familiar with the organisational structure of a care unit and the inherent responsibility of each of its members.
b) Training in design and analysis of screening studies in the general population for the most common tumours.
It is desirable to acquire basic laboratory knowledge in methods of molecular biology applied to tumours, as well as methodology and analysis of phase I clinical trials.
This knowledge must be acquired during the fourth year of residency or subsequent to qualification as a specialist.
Attitudes towards the patients:
a) Human activities: Medical residents must show respect and compassion towards the patient and their families, communicate with the patient in an honest and committed manner, gain their trust and respect the patient’s need for information.
b) Professional attitudes: Demonstration of essential attitudes, behaviour and communication to deal with and instruct the patients, their families and fellow professionals. These include the ability to describe the diagnosis and clinical process, the therapeutic options (benefits, side effects), the clinical recommendations (histories, consultations, correspondence). Furthermore, they must behave in accordance with the rules of professional ethics.
b) ACTIVITIES
Care
Residents shall provide care both in outpatient and inpatient consultations; during the first and second years they must be directly supervised by more qualified members of the team; their fundamental tasks are to take the clinical histories of patients, perform physical examinations and produce a justifiable diagnosis and request diagnostic tests which do not put the patient at risk. They must also practice punctures of various cavities or punctures for cytological diagnosis, under the supervision of other medical staff.
Scientific
They must attend general hospital sessions and those specific to Medical Oncology.
General sessions:
• Clinical sessions.
• Clinical/pathological.
• Autopsy review.
Sessions specific to Medical Oncology:
• Monographic subject session.
• Bibliography session.
• Histology reviews.
• Joint tumour sessions: thoracic, digestive, ENT, gynaecological
They must participate as speakers in the various specific and general sessions.
They must deliver presentations at speciality conferences, in the form of lectures and communications, at least once a year. They must participate in continued training activities, collaborating in the design and implementation of clinical or experimental studies, attending speciality meetings and accurately assessing the results of developments relating to Medical Oncology.
They shall participate in clinical research protocols, knowing the reasons for the study, its objectives and the results obtained.
When the unit has its own research area, they must undergo a period of rotation in this and familiarise themselves with the working techniques and inform themselves of the lines of research in progress. There must be a suitable period in which to at least initiate their own research work which will lead to the production of their doctoral thesis.
