Clinical Oncology Version 27 June 2006, College of Radiology

MINIMUM CRITERIA FOR REGISTERING AS A CLINICAL ONCOLOGIST IN THE MALAYSIAN NATIONAL SPECIALIST REGISTER

Definition of a Clinical Oncologist A Clinical Oncologist is a specialist trained in the science and practice of Oncology and the use of non-surgical methods of cancer treatment including radiotherapy, chemotherapy (including hormones and biological therapies) and other non-surgical modalities of cancer treatment, both for curative and palliative purposes. Clinical oncologists work as an integral part of multi disciplinary teams to provide holistic, multi-modality care to patients with cancer.

Eligibility For Registration 1. 1.1 1.2 2. 2.1 Basic Medical Degree Has a basic medical degree recognized by the Malaysian Medical Council (MMC) Is fully registered as a medical doctor with the MMC Post-Graduate Specialist Qualifications List of recognized qualification: Master of Clinical Oncology (Universiti Malaya) Fellow of the Royal College of Radiologists (FRCR) Fellow of the Faculty of Radiologists and Radiotherapists of the Royal College of Surgeons of Ireland (FFRRCSI) Diploma in Medical Radiotherapy (DMRT) United Kingdom, before 1.1.94 Any other equivalent as recommended by the Clinical Oncology Specialty Board on a case to case basis.

3. 3.1

Clinical Experience The Oncology training shall be divided into 2 phases: Basic Specialist Training

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3.2 3.3

Post-Qualification Training

Basic Specialist Training shall be for a period of not less than 4 years in recognized training centres. Post-Qualification Training shall be for a period of not less than 6 months. Government doctors must be gazetted. Equivalent rules will be applicable to university medical lecturers. Any application that does not conform to the above requirement shall be reviewed on a case to case basis by the Clinical Oncology Specialty Board.

3.4

4.0 4.1

Basic Specialist Training Period The period shall not be less than 4 years

4.2

Postings The training must be held in the recognized training centres (see appendix A)

4.3

Training Contents (See details in appendix B)

4.3.1 Basic medical sciences relevant to Clinical Oncology Radiotherapy Physics Radiobiology Pathology and Epidemiology of Malignant Diseases Statistics and Principles of Clinical Research and Clinical Trials Cancer Genetics and Molecular Biology Clinical Pharmacology of Anti-Cancer Agents and Supportive Therapy

4.3.2 Structured Training in the Clinical Management of Cancers and Specific Individual Sites. The training emphasizes on the multidisciplinary approach to the management of the cancer patient. It involves patient evaluation, decision making on the appropriate treatment (or combination of treatment) and the process of treatment delivery. For chemotherapy,

Clinical Oncology Version 27 June 2006, College of Radiology

this includes selection of the appropriate drug(s) regimes and the administration of cytotoxics. For radiation therapy, this involves patient immobilization, treatment planning, dosimetry and the daily care of the patient undergoing radiotherapy. Training should also include on-call commitments and the management of oncological emergencies. 4.3.3 Supportive and Palliative Care 4.3.4 Psycho-social Aspects of Cancer Care 4.3.5 Research Activities 4.3.6 Core Procedural Skills 4.3.6.1 Chemotherapy 4.3.6.2 Familiar with the indications and goals of anti-cancer agents in primary and recurrent malignant diseases. Knowledge of chemotherapy dosages, administration and protocols. Management of short and long term toxicities of chemotherapy.

Radiotherapy Competency in interpreting radiology films e.g plain Xrays, contrast films, CT scans and MRI scans. Simulation and localization procedures of radiation treatment planning Dosimetry and Computer planning Treatment set up of the patient Quality assurance of Radiotherapy Radiation prescription, treatment and care of patients and monitoring patients. Brachytherapy Use of sealed and unsealed sources Radiation protection

4.3.6.3

Supportive and Palliative care procedures including but not exclusively Therapeutic pleural tap Insertion of a chest tube Pleurodesis Paracentesis

Clinical Oncology Version 27 June 2006, College of Radiology

Appendix A

Pain control ( familiar with principles of pain management and understand the various drugs and modalities available for treating pain)

Training Centre Accreditation Checklist

A. Accreditation of the HOSPITAL

1. Total number of beds in the hospital : Minimum 500 beds 2. Occupancy rate of beds in the hospital: Occupancy rate of at least 60% 3. Minimum supporting departments that must be available: Medicine Surgery O&G Orthopaedics A&E Blood bank Pathology lab Microbiology lab Radiology department with ultrasound and contrast study facilities 4. At least one gazetted specialists/consultants in each of the following specialty in the hospital: Internal Medicine Orthopaedics Pathology Otorhinolaryngology O&G General Surgery Radiology

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B. Accreditation of the RADIOTHERAPY/ONCOLOGY DEPARTMENT 1. Total number of oncology beds: Minimum 20 beds 2. Total number of new cancer cases seen per year: Minimum 500 cases/yr 3. Total number of outpatient clinics per week: Minimum 3 clinics, including multidisciplinary clinics 4. Chemotherapy facilities must be available either as in-patient or out-patient. 5. Radiotherapy facilities: a) At least 1 simulator machine b) At least 1 linear accelerator machine c) At least 1 treatment planning system. d) Brachytherapy facilities available at least for gynaecological malignancies 6. Departmental teaching activities a) Number of grand ward round per month: Minimum once/week b) Number of departmental CME programme per month: Minimum once/month

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C. Accreditation of the ONCOLOGY CONSULTANTS 1. Clinical Oncologist(s) with at least 1 year post gazettement (With commitment to teaching/CME and preferably involved in research/publications) 2. Has at least one of the following qualifications: FRCR Clinical Oncology FFRRCSI Clinical Oncology (Ireland) DMRT(UK) before 1.1.1994 MMed in Clinical Oncology (UM)

D. Other facilities (The following are desirable though not mandatory.) a) night duty rooms for doctors b) medical library c) meeting room with audio-visual aids d) internet access

Clinical Oncology Version 27 June 2006, College of Radiology

Appendix B Syllabus PART I BASIC SCIENCES In the first year, candidates will be taught basic sciences relevant to the practices of clinical oncology. This will be in the form of formal lectures, tutorials and practical work. Demonstration, where relevant, will be arranged to show various aspects of basic sciences application in the clinical setting. In House tuition with the clinical oncologists would be ongoing throughout the course. Candidates will also be exposed to the full practices of a clinical oncology department and form an integral part of the team to provide oncological care to patients. The basic sciences subjects are divided into 6 modules : Pathology Molecular biology Radiobiology Chemotherapy Medical Statistics Radiotherapy physics. Pathology The emphasis of this teaching is to understand the natural history of neoplasia. Candidates are expected to be able to discuss the demography, aetiology, clinical presentation, typical macroscopic and microscopic features of common cancers. Candidates should be familiar with general management and prognosis of common tumours. Candidates will be given lectures, tutorials and practicals in the first year amounting to 35 hours on cancers affecting the following major areas: 1. Head and neck 2. Nervous system 3. Respiratory system 4. Gastro-intestinal tract 5. Genito-urinary tract 6. Female genital tract 7. Endocrine system 8. Soft tissue and bone 9. Paediatrics 10. Lympho and Myeloproliferative tumours

Clinical Oncology Version 27 June 2006, College of Radiology

11. Skin Basic Oncological sciences This encompasses 3 modules : molecular biology, chemotherapy and radiobiology. In this module candidates will be taught on carcinogenesis, tumour biology, cancer genetics, radiobiology, chemotherapy and principles of treatment. A basic knowledge of cytology, histology and physiology of normal tissues is assumed. Candidates are expected to have an understanding of the biology of malignancy, and the principles underlying the response of cells and normal and malignant tissues to anti-cancer therapies especially radiation and chemotherapy. There would be some overlap with the pathology module. This module would be covered with lectures and tutorials over 45 hours. The main subject headings would include the following: 1. Introduction to oncology and definition 2. Nomenclature 3. Characteristics of benign and malignant growths 4. Grading and staging of tumours 5. Biology of tumour growth 6. Mechanism of invasion and metastasis 7. Carcinogen and mechanism of oncogenesis 8. Genetic changes predisposing to tumours 9. Oncogene and cancer 10. Tumour suppressor genes 11. Laboratory diagnosis of cancer. 12. Cancer screening 13. Chemotherapy 14. Radiobiology.

Clinical Oncology Version 27 June 2006, College of Radiology

Medical Statistics and Cancer Epidemiology This module aims at imparting working statistics knowledge geared towards understanding basic statistics and demography, clinical trials and critical appraisal of publications. In the first year of Masters of Clinical Oncology, the 25 hours of lectures would include : 1. Introduction to Medical Statistic 2. Data 3. Probability 4. Sampling distribution 5. Significance distribution 6. Types of studies 7. Clinical trials 8. Regression and Correlation 9. Cancer registry 10. Survival data analysis

Clinical Oncology Version 27 June 2006, College of Radiology

Radiotherapy Physics Clinical Oncology includes radiation therapy. Detailed knowledge of radiation physics is required with emphasis on radiotherapy physics and working knowledge of radiotherapy machines. There would be lectures, tutorials and demonstration of relevant equipment and procedures related to radiotherapy practice, amounting to 45 hours. The syllabus would include the following: 1. Introduction to medical physics 2. Production of X - rays 3. Interaction of x and y - rays and other ionising radiation with matter. 3. Measurement of x and -rays 4. Physical basis of radiation teletherapy 5. Beam therapy apparatus. 6. Principles of treatment planning 7. General properties and production of radioactive material 8. Principles and practice of radiation protection 9. Radiation dosimetry 10. Quality assurance in radiotherapy 11. Brachytherapy 12. Nuclear medicine and radionuclides.

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PART II CLINICAL Training for the final examinations will be on going process from the 1st to the 3rd year. There would be emphasis on radiotherapy and chemotherapy but a good knowledge of general medicine, surgery and gynaecology is expected. At the end of the 3rd year the candidates are expected to have in depth knowledge of management of common cancers and the principles of management of rare tumours. Knowledge of tumours at the following sites include : HEAD AND NECK Lip and oral cavity Oropharynx Larynx and Hypopharynx Nasoharynx External and middle ear Nose and paranasal sinuses Salivary gland CENTRAL NERVOUS SYSTEM Brain Meninges Spinal cord and Peripheral nerves CHEST Pleura Trachea Lung Mediastinum and thymus LYMPHO / MYELOPROLIFERATIVE DISORDERS Hodgkins lymphoma Non-Hodgkins lymphomas Plasma cell malignancies Acute and chronic leukaemias GASTROINTESTINAL TRACT Oesophagus Stomach Liver Pancreas Small bowel Colon and rectum Anal canal and perianal region SOFT TISSUE AND BONE Adult soft tissue sarcoma Childhood/adolescent sarcoma Primary bone sarcomas PAEDIATRIC TUMOURS Medulloblastoma Neuroblastoma Nephroblastoma Retinoblastoma SKIN Basal cell carcinoma Squamous cell carcinoma Melanoma Cutaneous lymphoma Kaposis sarcoma

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Clinical Oncology Version 27 June 2006, College of Radiology

GENITO-URINARY TRACT Kidney Ureter & urethra Bladder Prostate Penis Testes ENDOCRINE Breast Thyroid & Parathyroid Pituitary Adrenal Carcinoid

FEMALE GENITAL TRACT Uterine cervix Uterine body Vagina Vulva Ovary

PATHOLOGY For each anatomical site and/or tumour type listed candidates should know: 1. 2. 3. 4. The range of tumours which can occur Their aetiology, incidence and epidemiology A brief morphology of the common turnours The natural history of disease and presenting features. Characteristic growth and metastatic patterns.

MANAGEMENT For each site / tumour type candidates should know: 1. 2. 3. 4. 5. Relevant investigations including imaging and tumour markers Staging classification e.g. TNM, FIGO or AJC where appropriate Prognostic factors Assessment for treatment Plan of management and various options for treatment.

OUTCOMES For each tumour site / type candidates should know the expected outcomes of treatment.

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Clinical Oncology Version 27 June 2006, College of Radiology

Clinical Skills and Experience During the training period the candidates will gain a wide range of expefience in the history taking, investigations, diagnosis, treatment with radiation, chemotherapy, hormonal and biological therapy and in palliative care. During the course, trainees should participate in : Assessment of new patients, including presentation of their history and clinical findings, plus plan of management. Planning and delivery of treatment under supervision. Follow-up and assessment of outcome. Management of complications of cancer treatment. Pathology review meetings. Radiology review meetings. Combined multi-disciplinary clinics. Involvement in discussion of clinical trials, audits and development of treatment protocols. Recording of data for clinical trials, audits plus experience in data management and research methodology.

The candidate will be expected to be able to interpret relevant radiological images, pathology and laboratory results. He should be familiar with the diagnosis and management of conditions which may complicate both the practice of radiotherapy and chemotherapy. Candidates are also expected to have knowledge of : Enviromental causes of cancer and possible strategies for prevention Current screening programmes for early detection of cancer Familial and genetic aspects of cancers and genetic counseling.

Candidates should develop skills and knowledge in : Communication skills Counseling of patients and families. Psychological therapy Medical ethics

The experiences and skill training of the candidates will be recorded in the traineess Log Book. Supervisors are required to provide regular reports of the candidates performance.

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Clinical Oncology Version 27 June 2006, College of Radiology

Candidates are expected to have participated and gained competence in using the following: RADIOTHERAPY For every tumour type and site listed, candidates must know the role of irradiation in radical and palliative treatment. The following details of treatment are expected : 1. A definition of tumour volume and planned target volume 2. An acceptable radiotherapeutic technique, or a range of such techniques 3. The correct treatment position 4. Target volume localization process 5. Verification techniques 6. Dose distribution for the chosen technique 7. Dose / fractionation regimes 8. Relevant dose modifying factors 9. Set-up instructions for Radiotherapy 10. Modifications to changes of patient parameters or interruptions during treatment 11. Acute and late side effects of irradiation Chemotherapy A knowledge of the rationale, mechanism, indication and toxicities of currently used cytotoxics is required. Hormone Therapy A basic knowledge of the rationale, mechanism, therapeutic use and toxicities of currently used hormone therapy is required. Have implemented and evaluated hormone treatment for breast and prostate cancer. Biological Response Modifiers A basic knowledge is required of the clinical uses of currently used biological response modifiers including interferons, colony stimulating factors and other growth factors.

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Others Newer treatment modalities that are currently being investigated and likely to be useful in oncology should be followed with interest. Complications of Treatment Trainees must be familiar with the acute and late complications of oncological treatment and their management. Symptom Control Trainees should know which medical and surgical manouvers are available for the control of symptoms and complications of cancer. This includes treatment of oncologic emergencies. Clinical Trials, Literature and Research Candidates must be familiar with clinical trials. They should have some experience of obtaining informed consent, have followed study protocols and used data foms. Candidates must be aware of major areas of current research and of recent important publications. Communication and Publication The ability to communicate well with patients will be tested throughout the training process. Clear and comprehensive descriptions of disease processes, investigations and treatment will be expected of all candidates who must be capable of expressing themselves clearly in English and producing legible script. Candidates should be encouraged to gain the experience of preparing work for publication. Outpatient and Joint Clinics Candidates must participate in general oncology outpatient clinics as well as combined multi-disciplinary clinics.

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Clinical Oncology Version 27 June 2006, College of Radiology

Quality Assurance Understand the principles of quality control measures that are practiced in their institution. Basic radiotherapy techniques Candidates will need to have a thorough understanding of the following aspects of radiotherapy. Patient positioning Immobilization techique Methods of target Volume Determination Outline techniques Basic field arrangement Tissue compensation Shielding Megavoltage techniques Electrons Dose Calculation Radiotherapy Prescriptions Radiotherapy Machines Quality Assurance in External Ream Therapy Brachytheraphy Radiation safety

Radiotherapy Assessment and the Care of Patients on Treatment Have undertaken regular weekly treatment review clinics. Treatment checks Symptom Control Follow-up Drug Therapy

For every tumour and site candidates should know: The role of cytotoxic, hormonal and biological drugs therapies in radical and palliative management Radical and palliative regiment in common use including dosage, scheduling, toxicities and outcome The techniques of stem cell mobilization, and the procedures for stem cell and bone marrow harvesting.

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Be familiar with the timing of total body irradiation, the reinfusion of bone marrow or stem cells and patient support during the engraftment.

Chemotherapy Cytotoxic Chemotherapy Access Technique for sampling and delivery Drug Delivery Support Techniques Management of Acute Complications

Supportive and Palliative Care Pain Have used the following methods for the relief of pain: 1. Drug treatment 2. Mechanical Methods 3. Radiotherapy Nausea and Vomiting Anorexia and Dysphagia Pleural Effusions and ascites Depression and anxiety Hospice

Radiotherapy for Benign Disease Current Research and Literature Investigational Techniques 1. Laboratory Investigations Be able interpret the results of haematological biochemical and radio- immuno assay investigations. 2. Radiology Have attended regular radiological review sessions involving a consultant radiologist for the interpretation of plain x-rays, CT scans, magnetic resonance imaging and ultrasound covering the whole spectrum of cancer radiology. Be aware of current indications and techniques in interventional procedures.

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3. Pathology Have attended regular pathological review sessions involving a consultant pathologist. 4. Other Procedures Have competently undertaken the following procedures without supervision: - indirect laryngoscopy - lumbar puncture Have competently undertaken the following procedures with supervision: - pelvic EUA and cystoscopy Complications of Treatment Trainees must be familiar with the acute and late complications of oncological treatment and their management.

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