pediatric hematology-oncology fellowship curriculum
TRANSCRIPT
1
Pediatric Hematology-Oncology Fellowship Curriculum
2013-2014
Children’s Hospital Los Angeles
2
Table of Contents
Program Summary…………………………………………………………………………..……3
Education and Teaching……………………………………………………………………….....6
Faculty…………………………………………………………………………………...………....8
Clinical Program Curricula……………………………………………………………………….11
Bone and Soft Tissue Tumor Program…………………………………………………………11
Hematology Program……………………………………………………………………..……...15
Hematopoietic Stem Cell Transplant Program……………….………………………………..16
Leukemia/Lymphoma Program………………………………………………………….……...19
Neuro Oncology Program …………………………………………………………………..…..21
Cancer Survivorship Program…………………………………………………………...……...23
Research Curriculum…………………………………………………………………………….24
3
Pediatric Hematology-Oncology Fellowship Curriculum Children’s Hospital Los Angeles
A. PROGRAM SUMMARY
The fellowship program is administered under the supervision of the Program Director, Rima Jubran, MD, MPH, MACM at Children’s Center for Cancer and Blood Diseases and Blood and Marrow Transplantation at Children’s Hospital Los Angeles (CHLA). It is a 3-year program accredited by the Accreditation Council for Graduate Medical Education (ACGME). Fellows who have successfully completed the program and are certified by the American Board of Pediatrics are eligible for the Subspecialty Board in Pediatric Hematology-Oncology. In order to successfully complete the training, a Fellow must be active for a minimum of 33 months in the fellowship, which starts in July of each year. Fellows rotate through 6 clinical programs during the first year, the Leukemia/Lymphoma Program, Solid Tumor and ABMT Program, Hematology/Hemostasis Program, Allo-BMT Program, Blood Bank Laboratory and Clinical Radiation Oncology.
Year 1: Clinical Activities
The first year consists of 2 weeks of orientation and 12 one month clinical rotations, ending mid July of the second year. During this year the Fellow acquires training and experience in the following areas:
1. Leukemia and Lymphoma (12-14 weeks) 2. Solid Tumors and ABMT (12-14 weeks) 3. Bone Marrow Transplantation (8 weeks) 4. Hematology and Homeostasis (12-14 weeks) 5. Radiation Oncology (1 week) 6. Hematology Lab /stem cell processing lab/blood bank(2 weeks) 7. Ambulatory Care (1 to 2 half days/week) 8. Vacation (3 weeks)
First year fellows share at home night call with second and third-year Fellows under the supervision of the attending faculty.
Leukemia-Lymphoma Service Newly diagnosed and relapsed leukemia and lymphoma patients and those with complications are admitted to this service. The Fellows is responsible for evaluating these patients, making specific diagnostic and treatment plans, supervising the pediatric house staff and nurse practitioners in carrying out these plans and in the administration of chemotherapy. The Fellow is actively involved in maintaining appropriate communication between the family, the patient, and the medical tea, and participates in diagnostic and treatment conference s. The Fellow supervises, together with nurse practitioners and attending, patients admitted for routine chemotherapy and performs all inpatient consultations for leukemia-lymphoma patients. Fellows also participate in the weekly leukemia-lymphoma team meeting. During this rotation the Fellow assumes responsibility as primary physician for the care of a certain number of patients. He/she also is actively involved in teaching the pediatric house staff. A faculty member serves as attending and supervises the Fellow during this rotation.
4
Solid Tumor/ Autologous BMT Service All Neuro-Oncology, bone and soft tissue, and solid tumor patients for autologous stem cell transplantation are admitted to this service. The duties of the Fellow are the same as on the leukemia-lymphoma service. In addition, the Fellow participates in bone marrow and peripheral blood stem cell (PBSC) harvest, and PBSC and bone marrow infusions. He/she supervises the administration of routine chemotherapy under the supervision of the attending, and is responsible for in-house consults on solid tumors.
Hematology-Hemostasis Service Patients with hematology/hemostasis diagnosis are followed by a resident team. The duties of the Fellow are the same as on the Leukemia-Lymphoma service. In addition, the Fellow supervises the care of routine hematology admissions for PRBC transfusion and Desferal infusion, etc. and performs all in-house hematology-hemostasis consultations under the supervision of the attending. Every Tuesday the fellow is freed from inpatient responsibility and attends the comprehensive hemophilia clinic. In addition, the fellow reviews most referrals made to the hematology/hemostasis program and assists in triaging patients to appropriate clinics. The fellow sees new referral patients in the Hematology New Referral Clinic under the supervision of the inpatient attending.
Allogeneic Bone Marrow Transplantation This rotation on a 14-bed service provides the fellow with exposure to the clinical and laboratory aspects of allogeneic bone marrow transplantation. Fellows participate in the care of these complex patients and make rounds with faculty members. Fellows primarily care for a number of BMT patients during the rotation and supervise, the attending, the pediatric hospitalists and nurse practitioners on the ward. Fellows also learn FACS analysis and immunophenotyping and perform bone marrow harvests during this rotation.
Ambulatory Care/Continuity Clinic Fellows participate in the outpatient clinics one ½ day per week, providing care to their own patients under the supervision of a faculty attending. The Ambulatory Care rotation allows fellows to see a large number of patients referred for diagnostic evaluation of malignant and hematological diseases. Fellows spend the first year in leukemia- lymphoma clinic and then rotate to hematology and solid tumors clinic in their 2nd and 3rd year, they carry a group of patients with as they move clinic days every year.
Radiation Oncology As of June 1994, the Radiation Oncology Division became part of the Division of Hematology-Oncology. Fellows spend a one-week rotation in Radiation Oncology, becoming familiar with the basic principles of radiation therapy.
Mentorship Each Fellow chooses a Center faculty mentor for the three years of the fellowship. The role of the mentor is to advise Fellows in regard to their career goals and help them to progress during their training. At the beginning of the second year, fellows choose a research mentor (basic or clinical research) who will guide him/her in regard to their research interests. In addition each fellow has a Scholarship Oversight Committee (SOC) consisting of 3 mentors who oversee the research activities of the fellow.
Teaching Activities Fellows are encouraged to actively participate in the teaching activities that are organized for the medical students,pediatric house staff and nurses by the Center.
Research Activities Fellow attend a research faculty “show and tell” even in November of their first year. This provides them with the opportunity to interact with research faculty in an informal setting and ask questions regarding potential projects. In addition, fellows are encouraged to attend weekly Saban Research Institute as well as monthly Division Team Science senior staff meetings in which division faculty discuss their research projects. Towards the end of the first
5
year, fellows will identify a research mentor and research project. This is accomplished with the guidance of the program director and SOC chair.
Year 2: Research is an essential aspect of the fellowship training, and 80 percent of a second-year Fellow's time is protected for this activity.
Research Activities The fellowship program offers many research opportunities, within the Center, in other Divisions of CHLA, or in laboratories at the Norris Center at the University of Southern California. The type of research to be performed is determined during the first year, after the fellows have had the opportunity to meet various principal investigators and to match personal interests with the opportunities offered. A scholarship oversight committee composed of several faculty members (MDs and PhDs) from the Center and other divisions advises fellows to make an appropriate decision and to evaluate their progress. Fellows are expected to conduct their own project, and to actively participate in research seminars and other research activities of the program.
Clinical Activities The second year fellows participate in one half day of clinic per week, continuing care for a selected group of patients accrued in the first year and picking up new patients in another specialty clinic as assigned by the fellowship director. Additionally, fellows participate in night and weekend calls from home.
Survivorship Ambulatory Experience Fellows attend 3 half day clinics in each of their 2 and 3rd year of fellowship. They join a multidisciplinary team made up of a faculty member, nurse practitioners and a social worker who staff the comprehensive LIFE clinic. Fellows complete a thorough chart review and late effects assessment prior to seeing an assigned patient. They present patients and lead the discussion with the team after reviewing survivorship guidelines and make recommendations for follow-up and evaluation tailored to assigned patients’ diagnosis and therapy.
Teaching Activities Fellows are also expected to give lectures at the Hematology-Oncology Grand Rounds and to present their research progress at Research Seminars. Fellows also actively participate in Tumor Board, Journal Club and Morbidity and Mortality conference.
Year 3: In the third year over 80 percent of fellows’ time is spent on research activities. Clinical involvement is limited to one half day of outpatient clinic per week, and night and weekend calls. During this year, the fellows spend 2 weeks on the ward as the “Pretending” supervising fellows, residents and medical students. A faculty member supervises their work during that time.
6
Expectations It is expected at the end of the three-year training program that fellows will be familiar and comfortable with all diagnostic and therapeutic aspects of pediatric hematology-oncology, and will also understand the importance of social and behavioral support needed by patients and families. Fellows are evaluated twice a year by the attending faculty and it is expected that they maintain an overall rating of 3.0 (good, on a 1.0 to 5.0 scale) or better. If the rating is below 3.0 pm 2 occasions, the fellowship may be terminated if recommendation efforts are not successful. It is expected that the fellow will have the opportunity to develop talent as a teacher, and finally, after two years of active research experience, will be able initiate independent research and realize its unique role in the progress of modern medicine. More specifically, it is expected that fellows will be first author of at least one publication in a peerreviewed journal, will give a minimum of one presentation at a national or international scientific meeting, and will write one grant proposal during the three years of fellowship. Summaries of education and teaching, the first year curriculum and teaching faculty are given below followed by the description of the various clinical and basic research curricula.
B. EDUCATION AND TEACHING
Summary of Conferences and Lectures
Formal educational opportunities and meetings of the fellowship program are shown below:
Activity Time Year Purpose
Orientation 2 weeks 1 to become familiar with the Center and CHLA.
Hematology Conference 1 hr/wk 1-3 Case based reviews on relevant topics and review of hematology and transfusion medicine for the Board exam. Monthly “smear” rounds.
Journal Club 1 hr/wk 1-3 Critical review and update of literature
Fellows Lectures 1 hr/wk 1-3 Review of oncology and bone marrow transplant topics in preparation for the Board exam
Hem-Onc Grand Rounds 1 hr/wk 1-3 Presentation of hematology-oncology topics by in- house and outside speakers
Morbidity and Mortality Conference 1hr/3 months 1-3 Presentation of hematology-oncology cases
with unexpected or undesirable outcomes
Tumor Board 1 hr/wk 1-3 Multi-disciplinary conference on complex oncology cases
Saban Research Seminar 1 hr/wk 2-3 Presentation of ongoing research by faculty and seminars by invited speakers
7
Summary of Program Curriculum The following table summarizes the standard curriculum for trainees.
Year of
Rotation
Orientation
Leukemia-Lymphoma
Solid Tumor-ABMT
BMT Unit
Hematology-Hemostasis
Radiation Oncology
Hematology lab/stem cell processing/blood bank
Ambulatory Care
Survivorship Clinic
Night/Weekend Call
Research
Educational Leave
Vacation
Duration Training Activities
2 weeks 1 Introduction to emergencies, protocols, etc.
12-14 weeks 1 Daily rounds, new patient evaluation, relapse, complications, chemotherapy; leukemia- lymphoma in-house consults; 29 bed unit
12-14 weeks 1 Daily rounds, new patient evaluation, relapse, complications, chemotherapy, solid tumor consultation in-house; autologous stem cell and bone marrow harvest and infusion; 19 bed unit
8 weeks 1 Allogeneic bone marrow transplantation; 11 bed unit
12-14 weeks 1 Daily rounds on new and established patients, in- house consultation for hematology-hemostasis, blood banking, coagulation, and morphology
1 week 1 Patient evaluation, discussion of treatment plan and approach
2 weeks 1 Coagulation tests, transfusion medicine
1/2 to 1 day/week 1-3 Follow-up of fellow's own patients (c. 10) and rotation in subspecialty clinics
½ day X 6 2-3 Multidisciplinary team evaluation and recommendations for cancer survivors
Every 5th-7th day 1-3 First call (on beeper) with faculty on second call
22 months 2-3 Fellows conduct own clinical, translational, or basic science research project under supervision of an assigned principal investigator
1 week/year 1-3 Attendance at national meeting (ASH, ASCO, ASPHO, AACR); $1500 travel allowance
3 weeks/year 1-3
8
C. FACULTY
Division of Hematology-Oncology The Division of Hematology-Oncology full-time faculty is composed of 22 MDs, 9 PhDs, and 3 MD/PhDs, in addition to a large support staff. Clinical activities and research interests of these faculty members are outlined below. A description of faculty research interests can be found at http://www.childrenshospitalla.org.
Faculty Title/Responsibilities Clinical/Research Interests Hisham Abdel-Azim Assistant Professor of Pediatrics Shahab Asgharzadeh, MD Assistant Professor of Pediatrics Childhood Neural Tumors Vassilios I. Avramis, PhD Associate Professor of Pediatrics Clinical trials; pharmacokinetics
and Molecular Pharmacology and and pharmacodynamics of Toxicology nucleotide analogues; drug
resistance in leukemias
Jacquelyn Baskin, MD Assistant Professor of Clinical Hematology/global health Pediatric
Ilanit Brook MD, MSHS Assistant Professor of Pediatrics Palliative Care
Thomas D. Coates, MD Professor of Pediatrics Director, Hematology Program
Yves A. De Clerck, MD Professor of Pediatrics and Biochemistry; Vice President, Research and Dir, Research Inst
Girish Dhall, MD Assistant Professor of Clinical
Pediatrics
Anat Erdreich-Epstein, MD, PhD Associate Professor of Pediatrics
Jonathan Finlay, MB, ChB Professor of Clinical Pediatrics David Freyer, MD Visiting Professor of Clinical
Pediatrics
Disorders of red cell and white cell function, biophysics, computer image analysis
Role of matrix proteins in tumor progression
CNS Tumors, Phase I Trials
Tumor angiogenesis; integrin signal transduction; brain tumor research
Primary childhood brain tumors
LIFE program and Survivorship research Cancer Survivorship
9
Paul S. Gaynon, MD Professor of Clinical Pediatrics New protocols for leukemias and lymphomas
Charles J. Gomer, PhD Professor of Pediatrics, Radiation Photodynamic therapy; radiation Oncology, and Molecular biology; anti-angiogenesis Pharmacology & Toxicology
Edward Gomperts, MD Professor of Clinical Pediatrics Clinical Trials; hemostasis; hemophilia
Josephine HaDuong, MD Assistant Professor of Clinical Development therapeutics.solid Pediatrics tumors Thomas C. Hofstra, MD Assistant Professor of Clinical Hemoglobinopathies and
Pediatrics hemophilia
Kathleen A. Ingman, PhD Assistant Professor of Clinical Psychosocial issues in pediatric
Pediatrics cancer Ambrose Jong, PhD Associate Professor of Pediatrics Control of cell cycle progression
and Microbiology and cell proliferation
Rima Jubran, MD, MPH, MACM Assistant Professor of Clinical Retinoblastoma/ Histiocytic Pediatrics disorders of childhood/ Education Deputy Division Head for Education
Ernest Katz, PhD Associate Prof of Clinical Psychosocial impact of cancer Pediatrics and chronic diseases Director, Behavioral Sciences
Neena Kapoor, MD Professor of Pediatrics Clinical Director
Kimberly Kayser, PhD Assistant Professor of Clinical Neuropsychology
Pediatrics
Richard Ko, MD Assistant Professor of Clinical Leukemia/lymphoma and Pediatrics hemostasis
Kris Mahadeo, MD Assistant Professor of Clinical Pediatrics
Araz Marachelian, MD Assistant Professor of Clinical Neuroblastoma/Developmental Pediatrics/Dir. NANT consortium therapeutics
Leo Mascarenhas, MD Associate Professor of Clinical Bone and soft tissue tumors; Pediatrics/Dir. Clinical trials office developmental therapeutics
William May, MD Associate Professor of Clinical Bone and soft tissue tumors Pediatrics
10
Chintan Parekh, MD, MBBS Assistant Professor of Pediatrics Leukemia/Lymphoma Arthur J. Olch, PhD Associate Professor of Clinical Radiation oncology physics
Pediatrics
John J. Quinn, MD Professor of Clinical Pediatrics Leukemia/Lymphoma Director of Clinical Affairs
Nathan Robison, MD Assistant Professor of Pediatrics CNS Tumors
Kathleen S. Ruccione, RN, MPH Professor of Clinical Pediatrics & Clinical trials, cancer Nursing, Director, Advanced epidemiology, late effects Oncology Nursing and Patient/ Family Education
Robert C. Seeger, MD Professor of Pediatrics Neuroblastoma, autologous bone Deputy Division Head for marrow transplantation in solid Research Dir, ABMT and tumors Neuro-onc Pgms
Stuart E. Siegel, MD Professor of Pediatrics Bone and soft tissue sarcomas, Division Head infectious complications in cancer
Weili Sun, MD Assistant Professor of Clinical Leukemia/lymphoma Pediatrics
David Tishler, MD Assistant Professor of Pediatrics Solid Tumors
Hung C. Tran, MD Assistant Professor of Pediatrics Neuroblastoma
Judith G. Villablanca, MD Associate Professor of Clinical Neuroblastoma, Pediatrics
Rajkumar Venkatramani, MD Assistant Professor of Clinical Developmental therapeutics/solid Pediatrics tumors
Alan S. Wayne, MD Professor of Pediatrics, Division Head Leukemia/Lymphoma, Develops Therapies
Kenneth Wong, MD Assistant Professor of Pediatrics Radiation oncology and Radiation Oncology; Head, Radiation Oncology Program
Guy Young, MD Associate Professor of Clinical Hemostasis & Thrombosis Pediatrics
11
D. CLINICAL PROGRAM CURRICULUM
Bone and Soft Tissue Tumor Program
The curriculum and scholarly activities described below form the core of the education and training of fellows during their three-year fellowship with the Bone and Soft Tissue tumor program at CHLA. These educational activities will occur in various forums, which include inpatient attending rounds on the solid tumor service, outpatient clinic, tumor board, grand rounds, clinical protocol education rounds, biology course, case conferences, weekly team meetings and bimonthly multidisciplinary team meetings. The team members are also available for one on one interaction with each of the fellows to support their education and research objectives. Fellows are encouraged to author at least one case report or case series during their clinical year and will be mentored in clinical protocol development during their research years if desired.
Listed below are the curriculum objectives listed first as general oncology and later by disease specific categories. Upon completion of training, fellows should have knowledge of the following areas:
I. General Oncology Main Objective: To understand the epidemiology, molecular and cellular biology and etio-pathogenesis of cancer with special reference to bone and soft tissue tumors.
A. Epidemiology of cancer
1. Age-related incidence 2. Race-related incidence 3. Genetic factors 4. Chemical-related factors 5. Environmental factors 6. Immunologic factors
B. Tumor molecular and cellular biology factors
C. Oncogenesis and cell growth regulation factors II. Radiation therapy Main objective: To know the mechanism of action, indications, complications and management of bone and soft tissue tumor patients undergoing radiation therapy.
A. Radiation Biology B. Complications of Radiotherapy, Early and Late
III. Chemotherapy Main objective: To know the mechanism of action, indications, toxicities and management of chemotherapeutic agents used in patients with bone and soft tissue tumors.
A. Principles of chemotherapy
12
1. Principles of combination chemotherapy 2. Principles of drug resistance 3. Specific agents
IV. Special diagnostic tests Main Objective: To know the indications of using the studies referred to below in the diagnosis and monitoring of bone and soft tissue tumor patients.
A. Bone marrow aspiration and biopsy B. Diagnostic x-ray studies/scans C. Examination of the cerebrospinal fluid D. Biochemical markers
V. Supportive care Main Objective: To know the issues related to Nutrition, Dental care and hygiene, Central venous access, Pain control, Anti-emetics, Rehabilitation and End of life care as related to patients with bone and softy tissue tumors.
A. Nutrition B. Dental care and oral hygiene C. Central venous access D. Pain control E. Fatal illness and terminal care F. Antiemetics G. Schooling
VI. Immunologic Abnormalities Main Objective: To know the management of infections in immunocompromised bone and soft tissue tumor patients.
A. Bacterial Prophylaxis B. Fungal Prophylaxis C. Viral Prophylaxis D. Treatment of infection in immunocompromised patients
VII. Specific Diseases
A. Osteosarcoma 1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis
13
7. Complications/late effects
B. Ewing Sarcoma 1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
C. Liver Tumors 1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
D. Renal tumors 1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
E. Rhabdomyosarcoma
1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
F. Soft tissue sarcomas other than rhabdomyosarcoma 1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
14
G. Gonadal/Germ cell tumors 1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
H. Langerhan Cell Histiocytosis
1. Epidemiology/predisposing factors/genetics 2. Pathology 3. Clinical presentation 4. Diagnosis and staging 5. Treatment 6. Prognosis 7. Complications/late effects
I. Neuroblastoma J. Retinoblastoma
15
Hematology Program The Hematology program runs a very active outpatient and inpatient service with over six hundred new patients and consults per year. The ethnic diversity of Southern California and large population of Los Angeles provide substantial exposure to many genetic red cell disorders as well as a large referral base for many consults. There are well-established comprehensive programs in sickle cell and hemoglobinopathies, thalassemia and coagulation defects. These programs are federally funded and involved in national multi-center trials as well as basic and translational research in various areas of non-malignant hematology. The section provides full service management for children and outpatient consultative management for adults with inherited hematological disorders. The training experience in hematology includes both clinical and laboratory training as well as opportunities for basic, translational, and clinical research.
Upon completion of training, fellows should have knowledge of the following areas:
I. General Hematology A. Bone Marrow failure syndromes B. Disorder s of neutrophils and immunodeficiency C. Comprehensive care of chronic diseases
II. Red Cell Hemoglobinopathy
A. General approach to anemia B. Sickle cell disease C. Thalassemia and other hemoglobinopathies D. Red cell membrane defects, enzymopathies, and hemolytic anemia E. Iron overload
III. Coagulation
A. Mechanism of clotting B. Evaluation of abnormal coagulation tests C. Inherited coagulation disorders D. Platelet dysfunction E. Acquired bleeding disorders
16
Hematopoietic Stem Cell Transplant Program
The hematopoietic stem cell transplant procedure is one of the accepted alternative, adjuvant, and sometimes primary therapeutic modalities in the treatment of many malignant, hematological and immunological diseases. The Academy of Pediatrics has also recognized this sub-specialty and in the Hematology -Oncology board exam there are number of questions on the subject of hematpoietic stem cell transplantation. Therefore, during the Hematology Oncology fellowship, it is essential that fellows receive training in the field of hematopoietic stem cell transplantation. To be sure that the Hematology/ Oncology Fellows receive appropriate training in hematopoietic stem cell transplant, they will have two one month rotations on the Hematopoietic Stem Cell Transplant service with the Red Team and two months with the Blue Team (Details of curriculum for Blue Team are covered separately under specific solid tumor). After completion of training, fellows should be knowledgeable in the following areas:
Rational, principles, procedures and types of Hematopoietic stem cell transplant Management of patients undergoing hematopoietic stem cell transplant and immune-compromised patients Stem cells (Bone marrow and Peripheral blood stem cells) procurement Clinical immunology and histocompatibility laboratory tests and interpretation
Fellows will actively participate in clinical as well didactic instruction under the close supervision and direction of the transplant attending physician on service. I. Rationale, principles, procedures of Hematopoietic stem cell transplant Fellows will attend the daily didactic lecture given by attending physician. Following these teaching sessions, the fellows should achieve the knowledge of following topics:
A. Oncological, hematological, Immunological, metabolic and autoimmune diseases which are correctable with transplant procedure
B. Rationale for transplant for a given disease or disease status, such as for high-risk malignant
disease C. Urgency of the workup of a patient with diagnosis of severe aplastic anemia, and the
identification of a suitable histocompatible sibling donor so that transplant procedure can be undertaken as soon as possible, before multiple transfusions are given
D. Pre-transplant evaluation process (to evaluate organ function) to determine the suitability of an individual patient to undergo transplant procedure
E. Methods in which transplant recipients are conditioned for the transplant procedure, as well as
rationale for the specific transplant conditioning regimen and design of the conditioning regimen F. Sources of hematopoietic stem/progenitor cells available for the procedure of stem cell
transplant, as well as the rationale for the selection of a particular source of stem cell product G. Process of acquisition and procurement of stem cells, as well as the rationale and the
procedures utilized for the processing of the stem cells prior to transplant procedure
17
H. Immunosuppressive therapy for the prevention of graft versus host disease, graft rejection the mode of administration of these agents, as well as their respective benefits and side effects
I. Acute, delayed and chronic complications associated with the transplant procedure and
management of these complications, i.e. acute and chronic GvHD, veno-occlusive disease, immunodeficiency, infections, bleeding complications, acute organ failure, delayed organ dysfunctions including growth and development, endocrine functions, and effect on neurocognitive function
II. Management of patients undergoing hematopoietic stem cell transplant and immunocompromised patients
A. Fellows will be responsible for primary patient care in consultation with and under supervision
of the attending physician. They will participate in family conferences, consent conferences and update rounds with the attending physician. They will lead the daily rounds with the house staff during second half of the first month.
B. After the first month rotation, fellows will attend the outpatient BMT clinic on Monday,
Wednesday and Friday for the Allo Team. During this rotation, they will learn about hematological and immunological recovery, prevention of management of graft versus host disease, effects of chronic GVHD and other late effects of procedure of transplantation. Fellows will learn the clinical and histolopathological changes with GVHD and use of drugs and procedures appropriate for the treatment of CGvHD.
C. Fellows will implement all the guideline approved by the Division for the care of immuno- compromised patients including limiting environmental exposures to micro organisms by proper isolation measures, maintenance of the patients in proper air handled environment, and administration of prophylactic antimicrobial therapy.
D. After their rotation with transplant Allo team, fellows will have acquired the knowledge of Stem
cell procurement process. This process will include the evaluation of the patient for suitability for the procedure, consenting process for the procedure, collection of the product (Bone Marrow harvest under general anesthesia or collection of the peripheral blood stem cells by apheresis procedure) and evaluation of the product collected.
III. Histocompatibility laboratory, Stem Cell processing Laboratory and Clinical immunology Laboratory experience
A. Fellows will spend at least 2 days in HLA Lab to learn the basic concept of HLA typing and the
process of selection of a donor on basis of histocompatibility testing. They will also acquire the knowledge of various techniques used in HLA typing, significance of these techniques in identifying related versus unrelated donors.
B. Fellows will have the opportunity to observe the processing of stem cell products (Peripheral
blood stem cells/bone marrow), the process of assessment of the stem cell graft in the stem cell processing laboratory, and the stem cell cryo-preservation procedure of at least one product.
18
C. Fellows will spend 2 days in the clinical immunology laboratory learning about tests utilized for
immune function evaluation and FACS analysis of leukemia and stem cell products. IV. Educational and academic activities The first year fellows will have the opportunity to participate in preparation and presentation of clinical and scientific topics related to hematopoietic stem cell transplants. These types of presentations will act as practice sessions for their subsequent presentations at national and international meetings. They will also have an opportunity to see various laboratories and interact with physician scientists and investigators, which will help them to plan for their research activities during the second and third years of the fellowship. To accomplish this goal, the fellows will participate in following activities:
A. Tuesday Science rounds and presentation of cases and pertinent literature to the team. They will attend the Thursday research seminar and clinical protocol development meeting.
B. Fellows will also attend Friday clinic case review conference where all clinic patients, new referrals and cases on which conferences were completed are reviewed.
C. Fellows will participate in Noon conference, where each fellow will choose one BMT related topic to
be presented to all the fellows with the detailed review of the literature. A BMT attending will moderate the session.
D. Over the year, the allo and auto BMT teams will participate in two Journal Club presentations. The topic will be presented by the fellow on blue or red team on a topic related to the transplantation. The attending physician will act as a moderator.
E. Each quarter, first-year fellows will present a transplant case (from allo of auto team) to the tumor board. The discussion will be moderated by the BMT attending physician.
F. During their rotation on the BMT service, fellows will prepare two lectures for the resident staff on the service. Presentations will be observed and evaluated by the attending physician.
G. Elective research opportunities will be available for the fellows to study a specific clinical question
related to transplantation.
19
Leukemia/Lymphoma Program
The core curriculum educational activities of the Leukemia/Lymphoma Program will occur in the context of leukemia/lymphoma service and outpatient clinic time in addition to the fellow-oriented didactic educational sessions for the leukemia and lymphoma diseases. These educational sessions will be incorporated on a rotating basis with the Friday Fellow Lecture, Hematology-Oncology division grand rounds, Journal Club, and Tumor Board. The New Fellow Orientation; held at the beginning of each academic year for first year fellows, includes specific introductory didactic sessions on leukemia and lymphoma. Upon completion of training, fellows will have knowledge of the following areas:
I. Acute Lymphoblastic Leukemia (ALL)
A. Diagnostic Work-up B. Pathophysiology of ALL C. Molecular Biology, Genetics and Epidemiology D. Clinical Management and Clinical Research E. Long term follow-up and Late Effects of Treatment F. Procedures and Practical Skills
II. Acute Myeloid Leukemia (AML):
A. Diagnostic Work-up B. Pathophysiology of AML C. Molecular Biology, Genetics and Epidemiology D. Clinical Management E. Long Term Follow-up and Late Effects of Treatment F. Procedure and Practical Skills
III. Rare Pediatric Leukemias
A. Chronic Myeloid Leukemia (CML) B. Juvenile Myelomonocytic Leukemia (JMML)
IV. Non-Hodgkin’s Lymphoma
A. Diagnostic Work-up B. Pathophysiology of NHL C. Molecular Biology, Genetics, and Epidemiology D. Clinical Management E. Long Term Follow-up and Late Effects of Treatment: F. Procedure and Practical Skills
20
V. Hodgkin’s Disease (HD)
A. Diagnostic Work-up B. Pathophysiology of HD C. Molecular Biology, Genetics, and Epidemiology D. Clinical Management E. Long Term Follow-up and Late Effects of Treatment F. Procedure and Practical Skills
21
Neuro-Oncology Program
The curriculum and scholarly activities described below form the core of the education and training of fellows with respect to the Neuro-Oncology program. These educational activities will occur in various forums, which include inpatient attending rounds, outpatient clinic, tumor board, grand rounds, biology course, weekly team meetings and multidisciplinary team meetings. The team members are also available for one on one interaction with each of the fellows to support their education and research objectives.
Upon completion of training, fellows should have knowledge of the following areas:
I. Central Nervous System Tumors A. Diagnostic Work-up B. Pathology of Brain Tumors C. Molecular Biology and Genetics of Childhood Brain Tumors D. Clinical Presentation and “Natural History” of Childhood Brain Tumors E. Role of Surgery in Childhood Brain Tumors F. The Role of Radiation Therapy in Childhood Brain Tumors G. The Role of Chemotherapy in Childhood Brain Tumors H. Other Therapies I. The Late Effects of Childhood Brain Tumors
II. Retinoblastoma A. Diagnostic Work-up B. Histopathology C. Genetics of retinoblastoma D. The central role of ophthalmologists in retinoblastoma E. The role of radiation therapy in retinoblastoma F. The role of chemotherapy in retinoblastoma G. The late effects of retinoblastoma
III. Neuroblastoma A. Diagnosis B. Pathology of Neuroblastoma C. Immunocytology D. Purging and Cryopreservation of Autologous Hematopoietic Stem Cells (AHSC) E. Molecular Biology and Genetics of Neuroblastoma F. The Clinical Presentation and “Natural History” of Neuroblastoma G. The Role of Surgery in Neuroblastoma H. The Role of Radiation Therapy in Neuroblastoma I. The Role of Chemotherapy, Immunotherapy, and Biotherapy in Neuroblastoma J. The Late Effects of Neuroblastoma
22
IV. Attendance and Participation in Neuroblastoma Conferences
A. Fellows rotate for one month through the Neural Tumors Clinic. During this period they are expected to attend the weekly Neuro-oncology Tumor Board, Neuro-pathology Conference (twice monthly) and the Neural Tumor Program Clinical Research Meeting (twice monthly).
V. Elective opportunities A. Fellows may undertake clinical research studies within the Neural Tumor Program, leading to
presentation at a Conference and first-authored publication in a peer-reviewed journal, as well as coauthorship in a review article. These fellows are also encouraged to assist in the development of an inhouse clinical trial.
23
Cancer Survivorship Curriculum
The overall objective of this rotation is to improve the fellow’s knowledge of key health issues in childhood cancer survivorship and the ability to manage these patients. The rotation is based in the LIFE Cancer Survivorship & Transition Program, which delivers clinical care to cancer survivors and conducts cancer survivorship research in the Children’s Center for Cancer and Blood Diseases at Children’s Hospital Los Angeles. While spending time in the LIFE Program, fellows are welcomed and encouraged to consider themselves valued member of the team. Fellows will attend a total of 6 clinics during their 2 and 3rd year of fellowship. A multidisciplinary team made up of a physician faculty member, nurse practitioners and a social worker staffs the New to LIFE Clinic, where first- time comprehensive survivorship evaluations are conducted. New to LIFE Clinic is held every Thursday morning from 8:30-1:00 pm on the 10th floor of Hollywood Presbyterian Doctors Tower. During the New to LIFE Clinic, the Fellow will “shadow” supervising LIFE physician and other team members to see all survivors scheduled that day. The survivor to be seen during the New to LIFE Clinic session will be assigned by the Director of the LIFE Program. For each of the 6 survivors assigned to the fellow, fellows are expected to provide comprehensive physician-level care that includes the following: - Pre-Clinic abstraction of the survivor’s medical record, including the underlying cancer diagnosis, treatment exposures, and other relevant medical information, utilizing the LIFE Cancer Treatment Summary Form provided by the LIFE Program.
- Clinical assessment of the survivor, including an appropriate supplementary history and physical examination, utilizing the LIFE Clinical Assessment Form provided by the LIFE Program. During the New to LIFE Clinic, the fellow will also accompany the LIFE medical social worker during that portion of the survivor’s comprehensive evaluation. - Ordering of appropriate, risk-directed diagnostic studies as indicated by the clinical assessment and utilization of the current Children’s Oncology Group Late Effects Guidelines for Survivors of Infant, Childhood and Adolescent Cancer. - Preparation of a satisfactory LIFE Clinical Summary in a timely manner, utilizing the template provided by the LIFE Program. The fellow’s summary will be reviewed by the supervising New to LIFE Clinic physician and revised, as necessary, by the fellow, prior to finalization of the document in the CHLA EMR. As part of this step, the fellow will follow-up on any pending diagnostic studies and discuss the results with the supervising LIFE physician.
- The following Wednesday, the Attendance at the next LIFE Clinical Management Conference where the fellow will present the survivor’s case to the comprehensive team, which includes a psychologist and representative of the School Transition and Re-entry (STAR) and Teen Impact Programs.
Fellows will be progressively exposed to three groups of survivors representing increasing complexity: Low Risk survivors of cancers such as standard risk ALL, and low-stage Wilm’s tumor (Group 1); Intermediate Risk survivors of cancers such as bone sarcoma, high-risk ALL, AML or intermediate risk rhabdomyosarcoma (Group 2); and High Risk survivors of cancers such as brain tumors, head/neck rhabdomyosarcoma, or bone sarcoma in a pelvic site (Group 3). Patients will be assigned to fellows by the Director of the LIFE Program commensurate with their experience.
24
Research Program Curriculum The overall goal of the research training program is to promote the academic careers of Hematology/Oncology Fellows to become successful laboratory or clinical researchers. This goal will be achieved by providing laboratory and/or clinical research training, concurrent with didactic research education. These training components are separately described. I. Basic Laboratory Research Training Mission: To provide a structured research training program that inspires Hematology/Oncology Fellows to perform a laboratory research project that investigates the mechanisms underlying a specific oncologic or hematologic pediatric illness.
The guiding principle of the proposed training program is the idea that fellows will perform a laboratory research project under the mentorship of an experienced laboratory scientist. Selection of the research mentor shall be done by the fellow, but must be approved by the Research Guidance Committee of the Hematology/Oncology Fellowship. In addition to the laboratory mentor, a “Thesis Committee”, composed of at least 3 experienced academic researchers, one of whom must be an outside member as required by the ABP will be assigned to the trainee. The Thesis Committee members are members of the Research Guidance Committee of the Hematology/Oncology Fellowship. This guidance committee will review the initially proposed research project and will routinely assess the progress made by the trainee in his/her project. Written comments and recommendations will be provided to the trainee, his/her mentor and the members of the Thesis Committee regarding progress of the research project and the career of the trainee.
A. Written proposal During the first month of the 2nd year in the Hematology/Oncology Fellowship, the fellow and his/her mentor shall jointly outline a research project, and a written proposal shall be produced according to established guidelines. According to these guidelines, the application shall have an abstract, a clear hypothesis, defined and achievable specific aims, a section explaining the significance of the proposal to pediatric hematology/oncology, and a section describing the experimental design. This proposal shall be developed in collaboration with the laboratory mentor, but must be written by the trainee. The trainee will then orally present the proposal to the members of the Scholarship Oversight Committee of the Hematology/Oncology Fellowship, who will make recommendations to the candidate and mentor(s). Once the project has been accepted the trainee will start with the laboratory work.
1. Training goals and anticipated achievements The purpose of having the fellow write a research proposal at the beginning of the training is multifold:
a. The fellow immediately learns the intricacies of writing a research proposal, a necessary skill for his/her future academic career. b. The fellow immediately establishes interactions with the laboratory mentor, since the research proposal will be jointly developed.
25
c. The Training Grant Committee will have scientific input into the proposed research project, and the trainee receives the assurance that the research proposal is well-developed and has the approval of the committee. d. The proposal will serve as a roadmap to monitor progress.
B. Basic laboratory training
Once the fellow has started the laboratory project he/she will be conducting the necessary experiments outlined in the written research proposal. The laboratory mentor will assign a scientific member of his/her laboratory who will be the instructor/advisor for the fellow in the daily scientific tasks. With the help of the laboratory mentor, the members of the laboratory and the research community of the RI, the fellow will learn the techniques and instrumentation required for the research project. Basic laboratory skills will be taught and less technical supervision will be necessary as research training goes on. Supervision by the laboratory mentor will include the development of experimental protocols, the review and interpretation of raw data, discussion of future experiments as proposed by the trainee, communication and analysis of technical (experimental) pitfalls and difficulties, as well as potential solutions to these problems. The fellow shall actively participate at the weekly laboratory meeting and is expected to routinely present his/her data. Six months into the training, the fellow shall develop a preliminary written progress report outlining the progress, scientific achievements as well as potential problems encountered. The fellow’s individual Scholarship Oversight Committee will review this report and recommendations will be given to the fellow and research mentor. The fellow will write an annual research progress report according to established guidelines (see Appendix) at the end of the first year of training. The fellow will orally present his/her annual progress to the members of Scholarship Oversight Committee of the Hematology/Oncology Fellowship as a Hematology/Oncology Grand Rounds presentation and written recommendations will be given to the trainee and research mentor. The fellow will develop a final research report at the end of the second year of research training and he/she will orally present the scientific accomplishments to the members of the Scholarship Oversight Committee of the Hematology/Oncology Fellowship.
1. Training goals and anticipated achievements As part of the laboratory research training, the fellow shall learn to ask important scientific questions related to the project and independently design and execute experiments to get answers to these questions.
a. The fellow will learn to interpret the generated data and develop scientific models supported by the data. b. The fellow will learn to present and explain the research project and the achieved data to different scientific peers, including academic physicians, clinical sub-specialty fellows, PhD fellows and scientists at local, national and international scientific meetings. c. The fellow will learn to develop written documents (annual progress reports) summarizing scientific achievement. d. The fellow will learn to write a research proposal for peer review to be funded by an
extramural/intramural funding agency. e. The fellow will write a first authored manuscript, expected by the end of the training, to be published in a highly respected scientific journal.
26
C. Clinical Research Training Mission: To train a clinical researcher with in-depth knowledge of statistical and analytical skills in populationbased, clinical studies or outcomes research. The candidate will acquire a solid background in the methodological aspects of research, and in statistical thinking as applied to clinical trial development and molecular epidemiology, as well as biostatistical and epidemiological methods. The candidate will be able to independently plan, execute and/or analyze clinical and translational trials.
The guiding principle of the clinical research education is to have fellows of the Hematology/Oncology Fellowship Program to perform a clinical research project under the mentorship of an experienced clinical researcher. Selection of the mentor will be done by the fellow, but must be approved by Scholarship Oversight Committee of the Hematology/Oncology Fellowship. Fellows will have an individual Scholarship Oversight Committee whose membership and function is outlined above. Fellows will have to submit a written research proposal according to the above outlined specifications, which will be reviewed by the Scholarship Oversight Committee of the Hematology/Oncology Fellowship.
1. Curriculum Fellows are assigned a clinical research mentor who has specialized in the fellow’s proposed research area. The research may cover outcome of clinical or translational research trials, or the planning of a trial covering either outcome, or novel prognostic or diagnostic criteria in human subjects. Fellows will learn about population sampling, sample size, analysis and interpretation of data, which will ultimately result in writing a clinical manuscript to be submitted for peer review. The areas of research will be cancer (leukemia, lymphoma, solid tumors including neural tumors, ABMT and BMT, late effects, radiation oncology or pathology) and hematology (sickle cell disease, thalassemia, or hemostasis). Together with the mentor, fellows will participate in local (CHLA) and national) meetings and actively attend CHLA CCI meetings to learn about issues covering research on human subjects. In order to obtain in-depth training in statistical methods, planning of trials, and epidemiology, fellows will take additional training at the Keck School of Medicine, Dept. of Preventive Medicine. The School of Medicine will assign an additional mentor to the fellow to advise regarding research track and courses to be taken either for 1 or 2 years. Tuition fees are covered by the Division.
USC offers three different pathways, which will be tailored to the needs of the fellows:
Masters in Public Health, Dept. of Preventive Medicine at USC, duration of 2 years with the possibility of different tracks.
Masters of Science in Clinical and Biomedical Investigations, Keck School of medicine, Independent Health Professions and School of Pharmacy: administered by the Depts. of Preventive Medicine, Cell and Neurobiology, Family Medicine and the General Clinical Research Center. Duration of 2 years.
Certificate in Clinical and Biomedical Investigations, sponsored as in 2 above, but there is no thesis and duration is 1 year instead of 2 years.
Each curriculum has different program tracks, from which fellows can choose. For example, the Masters of Science in Clinical and Biomedical Investigations offers the following tracks: Patient-oriented translational research; Community based intervention trials; Design, conduct and analysis of clinical studies; Epidemiology and disease etiology; Health outcomes research; Molecular biology, cell biology or alternative options (upon advice of advisor). More detailed information is available at www.usc.edu. under preventive medicine.
27
D. Didactic Research Education
The Division of Hematology/Oncology and the CHLA-Research Institute sponsor and organize various academic
education events and trainees are expected to actively participate.
Hematology/Oncology Grand Rounds: This lecture series intends to cover clinical and research topics relevant to hematology and oncology. The speakers are either from CHLA or local academic institutions. Trainees are expected to attend these lectures and one presentation by the trainee during his/her 2nd and 3rd year of training is required in this lecture series.
Tumor Board: This weekly interdisciplinary colloquium discusses in details one or more clinically challenging cancer cases. Fellows are expected to attend as well as to present. This didactic event is an important teaching tool where cancer therapy is approached by a team of highly specialized physicians.
Hematology/Oncology Journal Club: This weekly Journal Club covers high quality recently published research articles relevant to clinical hematology/oncology and trainees are expected to routinely present such articles to their peers and faculty.
Fellows Lecture: This weekly meeting is organized by the fellows of the Division of Hematology/Oncology to go over required materials for the ABP subspecialty board exam for Pediatric Hematology/Oncology
Hematology Conference: During this weekly meeting, patients with a variety of hematologic disorders will be discussed in depth by faculty and fellows. This is a dedicated time to learn how to approach a patient with a hematologic problem and fellows will be asked to present and discuss patients seen both in the inpatient and outpatient setting.
Pediatric Subspecialty Fellow Education: Core Curriculum Course: This year-long course intends to introduce subspecialty fellows at CHLA to methods in research and the curriculum covers a broad range of topics including teaching, professionalism and ethics, research methods, leadership, team management and business of medicine. Saban Research Seminar Series: These seminars host well established scientists from local, regional and national universities and research institutions, and the invited speakers cover a wide range of biomedical research topics of importance to the research community at CHLA. The speakers generally spend the entire day at CHLA and trainees have an opportunity to meet with the guest speaker.
Journal Club and Chalk Talk: These weekly events are organized by the RI and are attended by CHLA trainees and faculty. Pre-doctoral and postdoctoral trainees (MDs, MD/PhDs and PhDs) present either a scientific paper or their ongoing research work. Trainees in their first year of training are expected to present a Journal Club, whereas trainees in their second or third year are assigned to present a Chalk Talk.
Distinguished Lecturer Series: This lecture series hosts highly selected speakers whose research is related to the research endeavors of specific research programs and initiatives of the RI. A specific time slot is reserved for the lecturer to “Meet the CHLA Trainee” where clinical and laboratory trainees discuss their own research with the distinguished guest.
28
Annual Poster Session: This annual event features laboratory-based research, clinical research and population- based research performed at CHLA. The event offers a unique opportunity for trainees to learn about the broad spectrum of ongoing research at CHLA. Last year, more than 120 posters were presented at this event and trainees of the Hematology/Oncology Fellowship program are expected to present a poster, thus learning how to present a scientific poster. Symposia and Mini-Symposia: Various symposia and other events are organized by research faculty and/or research programs on a yearly basis and trainees have an opportunity to attend these events. Education Series: Several lectures are presented at CHLA that cover important educational aspects of research. These topics cover areas such as “How to write an NIH grant Application”, How to prepare and present a research Presentation”, Ethics in Research” How to prepare your academic career” and “Patents and Intellectual Property”. The trainees are strongly encouraged to attend these lectures.
Presentation at a national meeting: As part of the research training, fellows of the Hematology/Oncology Fellowship Program will be sponsored to attend a national scientific meeting relevant to his/her research and career interests.