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VCUHS HEMATOLOGY/ONCOLOGY FELLOWSHIP CURRICULUM
MCV and VA Hospitals Continuity of Care Clinics
Description of Rotation or Educational Experience
The VCU Hematology/Oncology Fellowship Program Continuity of Care Clinics at MCVH and the VA Hospitals are designed to
enable fellows to be exposed to a wide variety of patients with oncologic malignancies, hematological malignancies, and
benign hematologic conditions whom the fellows follow throughout the disease process. The fellows are assigned a clinic at
both MCVH and the VA that they maintain through the duration of their training. The continuity clinics consist of one half day
per week at each location, with approximately 6-7 follow up patients and 1-2 new patients.
Location:
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VCUHS Massey Cancer Center Dalton Oncology Clinic
Hunter Holmes McGuire VA Medical Center
Length of Experience:
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All 3 years of fellowship
Educational Goals
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Gain experience, competence and independence in the outpatient evaluation, staging, prognosis, management, and
complications of patients with a wide variety of hematologic and oncologic disorders.
Gain experience, competence and independence in the ordering, administration, monitoring, and identifying
toxicities of chemotherapy
Gain experience, competence, and independence in the management of hematologic and oncologic emergencies in
the outpatient setting, including acute chemotherapy toxicities and reactions.
Gain experience, competence, and independence in performing the procedures essential to the diagnosis and to the
delivery of care of acute hematologic and oncologic disorders, including bone marrow biopsy and aspiration; lumbar
puncture with the intrathecal administration of chemotherapy; and the access and administration of chemotherapy
via an Omaya reservoir.
Gain experience, competence, and independence in identifying, discussing, and arranging home care and hospice as
they pertain to the patient with hematologic and oncologic disease.
Gain experience, competence and independence in the management pain and other symptoms in the outpatient
setting.
Gain experience in communication with and the counseling of patients and families regarding their acute hematologic
and oncologic medical conditions and in providing the necessary support and ancillary services to effectively meet
their medical and psychosocial needs.
Gain experience, competence in effectively, truthfully, and compassionately discussing end of life issues with patients
and their families.
Gain experience in the management of end-of-life issues, including advanced directives, resuscitation status,
surrogate decision-making, and home/inpatient hospice resource utilization.
Gain experience and proficiency in identifying and understanding the specific barriers posed to patients who are
underinsured and/or indigent.
Gain an appreciation of the value of continuity of care in cancer treatment
Gain experience in effective communication with patients, caregivers, and other health care providers necessary to
effective co-management
Gain experience and knowledge in the unique aspects of the role of and effective functioning as a subspecialty
outpatient consultant
Gain experience and proficiency in the effective transferring/returning of subspecialty care back to the primary care
provider
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Obtaining efficiency in the outpatient setting, review literature critically, and to learn how to plan for and manage
clinic days
YEAR 3
YEAR 2
YEAR 1
Progressive Responsibilities by Fellow Year
The first year fellow is expected to focus on primary medical knowledge, communication skill and procedural skill
development. Medical knowledge acquisition should focus on the routine screening, diagnosis, natural history, staging,
prognosis, and first-line management of the hematologic-oncologic conditions. Additionally, the first year fellow should
focus on the pharmacologic mechanism of action, dosing considerations, and common toxicities of the medications
being employed for the treatment of the hematologic-oncologic condition. Consult recommendations and care plans
should be developed independently or in conjunction with attending physician and health care team but reviewed in full
with the attending physician in advance of communication to the patient, family, and consulting providers. Initial
counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling should be
done with direct supervision of the attending physician or only after full review of the goals of care and care plan with
the attending physician. (The PharmD may provide the direct supervision of chemotherapy counseling and consenting
once the care plan has been established with the attending physician).
The second year fellow is expected to refine their medical knowledge by focusing on an understanding of the underlying
pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and treatment
planning; and considerations/options in second-line and beyond. Consult recommendations and care plans should be
developed independently with only moderate need for input from the attending physician though reviewed in full with
the attending physician in advance of communication to the patient, family, and consulting providers. Initial counseling
of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling may be done
independently but only after full review of the goals of care and care plan with the attending physician.
The third year fellow is expected to demonstrate proficiency and independence. The third year fellow is expected to
demonstrate full knowledge of the routine screening, diagnosis, natural history, staging, prognosis, and first-line
management of the hematologic-oncologic conditions. They should demonstrate a proficient understanding of the
underlying pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and
treatment planning; and considerations/options in second-line and beyond. Consult recommendations and care plans
should be developed independently with minimal input from the attending physician though still reviewed with the
attending physician. Initial counseling of the patient and family regarding the goals of care, the care plan, and
chemotherapy counseling should be done independently though reviewed with the attending physician.
Patient Care
Goal
Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health. Please refer to overview of the fellowship curriculum for competencies/objectives for
patient care.
Specifically, fellows will see patients in all of these clinic settings under the supervision of the appropriate subspecialty faculty
member. Fellows will participate in the evaluation and management of acutely and chronically ill oncology outpatients in
order to learn the different approaches to subspecialty cancer treatment.
Competencies
Fellows are expected to:
• Gather appropriate clinical information
• Synthesize information into a care plan
• Partner with patients/families in the implementation of the plan
• Coordinate care plans with referring physicians, social workers, and home health agencies
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Objectives
Fellows are expected to:
• Develop skills in history/physical examination of the patient with cancer
• Develop skills as an outpatient subspecialty consultant
• Integrate clinical data in the formation of a comprehensive care plan
• Document the encounter in the medical record in sufficient detail to communicate to other physicians and meet
billing requirements
• Provide compassionate, appropriate, and comprehensive patient care through:
o Responding to requests for outpatient consultation, evaluation and/or management in a timely and
appropriate fashion,
o Providing appropriate follow-up management
Medical Knowledge
Goal
Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral
sciences, as well as the application of this knowledge to patient care.
Competencies
Fellows are expected to demonstrate skills in:
 Acquisition of knowledge
 Analysis of information
 Application of knowledge
Objectives
All fellows are expected to:
 Demonstrate the ability to perform a comprehensive and accurate physical examination; demonstrate the ability to
arrive at an appropriate differential diagnosis; outline a logical plan for specific and targeted investigations pertaining
to the patient’s complaints; and formulate a plan for management and follow-up treatment of the patient
 Demonstrate their knowledge by presenting the results of a consultation orally and in writing and by defending the
clinical assessment, differential diagnosis, and diagnostic and management plans
ONCOLOGY
Thoracic Oncology
 Demonstrate knowledge of the epidemiology of thoracic cancers including incidence rates and mortality rates
 Demonstrate knowledge of non-small cell histology and biology including adenocarcinoma, bronchoalveolar,
squamous cell, and large-cell carcinoma
 Demonstrate knowledge of small cell histology and biology
 Understand the risk factors for lung cancer including lifestyle, active and passive smoking, asbestos and radon
exposure
 Understand prevention of lung cancer through smoking cessation
 Demonstrate knowledge of clinical signs and symptoms of lung cancer
 Demonstrate knowledge of diagnosis via sputum cytology, imaging, Imaging-guided biopsy, thoracotomy,
bronchoscopy
 Demonstrate knowledge of staging and prognostic factors of non-small cell lung cancer (NSCLC) via the TNM system
and small cell lung cancer via the TNM system and/or limited vs. extensive disease
 Demonstrate knowledge of the treatment of non-small cell lung cancer based on stage of NSCLC
 Understand the first-line, second-line, and third line chemotherapy choices and the pharmacotherapy of the common
agents administered
 Understand the use of immuno-oncology and biologic agents in the management of lung cancers
 Demonstrate knowledge of the treatment of limited stage small cell lung cancer with combined chemotherapy and
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radiation therapy, use of prophylactic brain irradiation, and indication for resection of solitary pulmonary nodule
Demonstrate knowledge of the treatment of extensive disease with first-line chemotherapy, second-line treatment,
use of prophylactic brain irradiation, and treatment of brain metastases
Demonstrate the knowledge of follow-up of Lung cancer according to ASCO and other guidelines
Demonstrate knowledge of treatment of Pancoast tumors
Understand how to identify and manage complications of the treatment of thoracic cancers such as radiation
pneumonitis, infection, dyspnea, and neuropathy
Understand the importance of palliation of symptoms including pain and dyspnea in patients with thoracic
malignancies.
Understand the interventional options in patients with thoracic malignancies and pleural effusions for palliative
purposes such as pleurodesis and pleurovac devices
Understand the importance of clinical trials in thoracic malignancies
Breast Oncology
 Demonstrate knowledge of the epidemiology of breast cancer including incidence rates and mortality rates
 Understand the pathogenesis, pathology, and tumor biology of histiopathic subtypes of breast cancer
 Understand the genetic syndromes and recommendations for genetic counseling and testing
 Understand how to assess the risk of breast cancer in a patient based on family history, lifestyle factors, hormone
replacement therapy, and use the Gail and Claus models
 Demonstrate knowledge on the prevention of breast cancer including chemoprevention and surgical interventions
 Demonstrate knowledge of screening techniques
 Demonstrate knowledge of the diagnosis of breast cancer by fine-needle aspiration, core biopsy, excision, and needle
localization biopsy
 Understand axillary dissection techniques including complete dissection vs. sentinel node dissection
 Understand staging and prognostic factors including TNM system, histologic type, estrogen and progesterone
receptors, HER-2 neu, and other biologic and molecular markers
 Demonstrate knowledge of the treatment recommendations based on stage of lobular and ductal cancer including
surgery, radiation, preoperative vs. post-operative chemotherapy, endocrine therapy, immuno-oncologic and biologic
therapy
 Demonstrate knowledge on estimating the benefits of systemic adjuvant therapy utilizing Oncotype testing and/or
Adjuvant online
 Understand treatment of locally advanced and inflammatory breast cancer using multimodal therapy
 Understand the treatment of locally recurrent breast cancer in the breast or chest wall with surgery or radiation
therapy. Demonstrate knowledge of therapy for metastatic breast cancer.
 Demonstrate knowledge regarding follow-up of breast cancer based on ASCO and NCCN guidelines
 Supportive care of breast cancer including: psychosocial issues and support groups, lymphedema, bisphosphonates
for bone metastases, menopausal symptoms, sexuality and fertility, cognitive dysfunction, surgical reconstruction
 Other/Special issues including male breast cancer, breast cancer in pregnancy, in elderly women, in very young
women and recommendations for oophorectomy
 Demonstrate knowledge of the pharmacology of the common chemotherapies used for the treatment of breast
cancer
 Understand how to identify and manage complications of the treatment of breast cancers
 Understand the importance of palliation of symptoms in patients with breast malignancies.
 Understand the importance of clinical trials in breast malignancies
Hematologic Malignancies
 Demonstrate the knowledge of the WHO classifications of Hematologic malignancies
 Demonstrate an understanding of the pathophysiology of the hematologic malignancies including histologic grade,
role of infectious agents, and genetic factors
 Demonstrate an understanding of the diagnostic modalities used in differentiating hematologic malignancies such as
lymph node biopsy, bone marrow biopsy, flow cytometry, cytogenetics, and molecular diagnostics.
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Demonstrate knowledge of staging and prognostic factors for lymphoma including the Ann Arbor Staging System and
the International Prognostic Index.
Demonstrate knowledge of treatment of Non-Hodgkins lymphoma based on grade (low, intermediate vs. high), as
well as aggressive vs. indolent nature and stage of disease
Demonstrate knowledge of options for treatment of indolent Non-Hodgkins lymphoma including: observation,
chemotherapy, radiation therapy, immunotherapy, stem cell transplant, monoclonal antibodies, and combination of
aforementioned above
Demonstrate knowledge of treatment of aggressive Non-Hodgkins Lymphoma including those mentioned above
except observation
Demonstrate knowledge of referral for stem cell transplant in relapsed or refractory lymphomas
Demonstrate knowledge of the bcr-abl in CML, genetic and molecular abnormalities in CLL
Demonstrate knowledge of the diagnosis of chronic leukemias based on peripheral blood smear review, PCR or FISH
for CML, and flow cytometry for CLL
Demonstrate knowledge of the chronic, accelerated, and blast phase of CML
Demonstrate knowledge of the staging systems in CLL
Demonstrate knowledge of treatment of CML including but not limited to chemotherapy, tyrosine kinase inhibitors,
interferon, treatment of blast phase, and the role of stem cell transplantation
Demonstrate knowledge of treatment options based on stage of CLL including observation, purine analogues,
alkylating agents, combination systemic therapy, monoclonal antibodies, stem cell transplant, radiation therapy,
splenectomy, steroids
Demonstrate knowledge of hypogammoglobinemia, infection risk, and autoimmune hemolytic anemia and
thrombocytopenia in CLL
Demonstrate knowledge of treatment of Hodgkin lymphoma at all stages of disease (initial and relapsed)
distinguishing the role of radiation therapy, chemotherapy, and stem cell transplant.
Demonstrate knowledge of follow up and continued treatment of the acute leukemias after discharge from the
inpatient setting, including the evidence regarding use of maintance therapy in APL and ALL
Demonstrate knowledge of the pathophysiology, staging, prognosis, and therapeutic options for multiple myeloma.
Demonstrate knowledge of the use of supportive therapies for bony disease including neuororadiologic interventions,
radiation therapy, radioactive biologics, medical pain management, and bisphosphonates.
Understand supportive care related to treatment of hematologic malignancies including fertility and sexuality issues,
development of secondary malignancy due to prior chemotherapy +/- radiation exposure, and long term cardiac
complications
Understand the importance of clinical trials in hematologic malignancies
Gastrointestinal Oncology
 Demonstrate knowledge of epidemiology of GI cancers including esophageal, gastric, colorectal, gallbladder,
hepatocellular, and pancreatic cancers
 Understand the pathophysiology of GI cancers
 Understand the treatment of GI malignancy and its relationship to disease stage
 Understand how to identify and manage complications of the treatment of GI cancers such as pain, mucositis,
infection, diarrhea
 Understand the importance of palliation of symptoms in patients with GI malignancies.
 Understand the importance of clinical trials in GI malignancies
Anal Cancer
 Demonstrate knowledge of the epidemiology and incidence rates and mortality rates
 Demonstrate knowledge of the pathology and histology of anal cancer including premalignant lesions and cloacogenic
vs squamous histology
 Demonstrate knowledge of the risk factors associated with anal cancer including HPV infection, sexual activity,
condyloma, HIV infection
 Demonstrate knowledge on diagnosis of anal cancer via physical examination, biopsy, anoscopy/proctoscopy,
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transrectal ultrasound, FNA of palpable inguinal nodes
Demonstrate knowledge of the TMN Staging System and the treatment based on stage for anal cancer
Demonstrate knowledge of follow-up of anal cancer
Biliary Tree Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of the risk factors associated with biliary tree cancer including primary sclerosing cholangitis,
gallstones, choledochalcysts
 Demonstrate knowledge related to the diagnosis including clinical signs and symptoms such as obstructive jaundice,
imaging, ERCP, and endoscopic biopsy
 Demonstrate knowledge of TMN Staging and histologic grade of the cancer and treatment by stage for bilary tree
cancer
 Demonstrate knowledge of supportive care including biliary drainage for biliary tree cancer
Colorectal Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of genetic syndromes, including but not limited to Familial adenomatous polyps and
Hereditary nonpolyposis colorectal cancer.
 Understanding of risk factors such as family history, dietary factors, inflammatory bowel disease
 Demonstrate knowledge of screening of colorectal cancer with rectal examination, fecal occult blood test,
colonoscopy , virtual colonoscopy in both the general population and high-risk populations
 Demonstrate knowledge of the diagnosis including clinical signs and symptoms, imaging, and endoscopic biopsy
 Demonstrate knowledge of staging and prognostic factors based on TNM Staging system, histology and grade, and
genetic and molecular abnormalities
 Demonstrate knowledge of treatment by stage of colorectal cancer
 Demonstrate knowledge of follow-up after curative resection based on ASCO and NCCN guidelines
 Demonstrate knowledge of supportive care of treatment related toxicities such as ostomy care, radiation proctitis,
diarrhea, neuropathy
Esophageal Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of pathology including squamous cell, adenocarcinoma, and mixed histology
 Demonstrate knowledge of risk factors including Barrett's esophagus, gastroesophageal reflux disease, smoking and
alcohol use, genetic and molecular abnormalities
 Demonstrate knowledge of diagnosis of esophageal cancer including as clinical signs and symptoms such as
dysphagia, early satiety, and weight loss; endoscopy and biopsy, imaging
 Demonstrate knowledge of TNM staging and treatment of local-regional disease or recurrent and metastatic disease
with a multimodality approach
 Demonstrate knowledge of supportive care including management of obstruction with endoscopic stenting
Gallbladder Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of the risk factors including inflammatory bowel disease, cholesterol type gallstones, and
chronic inflammation
 Demonstrate knowledge of clinical signs and symptoms of gallbladder cancer
 Demonstrate knowledge of imaging, surgery, bile cytology in making a diagnosis
 Demonstrate knowledge of the TMN staging system for gallbladder cancer
 Demonstrate knowledge of treatment based on the stage of gallbladder cancer
 Demonstrate knowledge of treatment of recurrent or metastatic disease with chemotherapy or radiation therapy
 Demonstrate knowledge of supportive care for gallbladder cancer including use of biliary drainage
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Gastric Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of the genetic and molecular factors involved in the development of gastric cancer including
precursor lesions, adenomatous and gastric polyps
 Demonstrate knowledge of risk factors such as b12 deficiency/pernicious anemia, tobacco use, occupational
exposure, and H pylori infection and its association with gastric cancer
 Understand the role of screening with endoscopy for patients at risk for gastric cancer
 Understand the clinical signs and symptoms, imaging, and use of endoscopy with biopsy in diagnosing gastric cancer
 Demonstrate knowledge of the TMN staging of gastric cancer
 Demonstrate knowledge regarding treatment of local gastric cancer
 Demonstrate knowledge regarding treatment of unresectable and metastatic disease
Hepatocellular cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of the relationship of Hepatitis B, Hepatitis C, and cirrhosis to the development of HCC
 Demonstrate knowledge of the genetic relationship between hemochromatosis, Wilson's disease, alpha1-antitrypsin
deficiency and HCC
 Understand the environmental factors including exposure to alcohol and alphatoxin and HCC
 Understand prevention of HCC with hepatitis B vaccines, alcohol and tobacco cessation
 Demonstrate knowledge of screening of high risk patients with ultrasound and alpha-fetoprotein
 Demonstrate clinical signs and symptoms of HCC including ascites, jaundice, confusion, pain, weight loss
 Demonstrate knowledge of imaging techniques used in diagnosis and staging of HCC including ultrasound, MRI, and
four phase CT scans of the liver
 Understand the role of imaging, alpha-fetoprotein level, and biopsy in diagnosing HCC
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Understand the Barcelona and TMN staging systems of HCC and the impact of cirrhosis on the Barcelona Staging
System
 Demonstrate knowledge of treatment of resectable disease
 Demonstrate knowledge of treatment options for unresectable liver- only disease
 Demostrate knowledge of the treatment of multifocal liver cancer and metastatic disease
 Understand the role of supportive care for patients with HCC including therapeutic paracentesis
Pancreatic Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Demonstrate knowledge of the pathogenesis of pancreatic cancer including progression from ductal epithelial
dysplasia
 Understand risk factors associated with pancreatic cancer including tobacco use, pancreatitis, BRCA2, familial
pancreatic cancer, and MEN
 Demonstrate knowledge of the clinical signs and symptoms of pancreatic cancer including pain, jaundice, and weight
loss
 Understand the role of endoscopy, ERCP, biopsy, laparoscopy, imaging, imaging directed biopsy, and surgery in
diagnosing pancreatic cancer
 Demonstrate knowledge of treatment of resectable disease
 Demonstrate knowledge of treatment of unresectable, locoregional diseaseDemonstrate knowledge of follow up after
curative resection
 Demonstrate knowledge of supportive care for pancreatic cancer including pain control with celiac block, biliary
stenting for obstruction, and treatment of malabsorption
Prostate cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Understand genetic factors such as family history
 Demonstrate knowledge of the benefits and data on finasteride for chemoprevention
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Understand the role of PSA screening and digital rectal exam in prostate cancer
Understand the use of transrectal ultrasound in diagnosis of prostate cancer
Understand the Gleason grading, TNM staging, and PSA use in prognosis
Demonstrate knowledge of treatment options and management of organ confined prostate cancer
Demonstrate knowledge of treatment of metastatic prostate cancer, including the role of bone-directed therapies
Understand the survival benefit of therapy for metastatic prostate cancer
Demonstrate knowledge of supportive care for patients with prostate cancer including sexual dysfunction, hot
flushes, osteoporosis, proctitis, urinary incontinence
Renal Cell Cancer
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Understand genetic factors including Von Hippel-Lindau and Li-Fraumini in relation to renal cell cancer
 Understand the diagnosis of renal cell cancer, signs and symptoms, and imaging techniques used for staging
 Understand the TNM staging system for renal cell cancer, histology, and prognostic factors
 Understand the treatment of local disease
 Understand the treatment of pulmonary metastatic disease
 Understand the treatment of metastatic disease
Bladder and other Urothelial cancers
 Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
 Understand the relation of cigarette smoking, phenacetin, schistosomiasis infection
 Understand screening with urine cytology and imaging
 Understand TNM staging, tumor grading, localized vs. invasive disease in terms of prognosis
 Demonstrate knowledge of treatment of superficial bladder cancer
 Demonstrate knowledge of treatment of early stage and locally advanced disease
 Demonstrate knowledge of treatment of recurrent disease
 Demonstrate knowledge of treatment of metastatic disease
 Understand surveillance of urothelial cancers with cystoscopy, urine cytology, and imaging
Neurologic Cancers
 Demonstrate knowledge of the epidemiology of primary and secondary neoplasms of the central and peripheral
nervous system including incidence rates and mortality rates
 Demonstrate knowledge of diagnosis and cost-effective evaluation of primary and secondary neoplasms of the
central and peripheral nervous system
 Understand the staging of primary and secondary neoplasms of the central and peripheral nervous system
 Demonstrate knowledge of treatment by stage of primary and secondary neoplasms of the central and peripheral
nervous system
 Demonstrate knowledge of risk factors for the development of and cost-effective methods of preventing primary and
secondary neoplasms of the central and peripheral nervous system
 Understand complications primary and secondary neoplasms of the central and peripheral nervous system, including
the toxicities and consequences of the treatments employed in the management of these neoplasms
 Demonstrate knowledge of the appropriate supportive care of patients with primary and secondary neoplasms of the
central and peripheral nervous system
HEMATOLOGY
First year fellows are expected to:
Red Blood Cell Disorders: Anemia
 Categorize anemia on the basis of production vs. post-production etiologies and discuss diagnostic use of laboratory
findings such as the reticulocyte count for so classifying an anemia
 Use a complete blood count with RBC indices to categorize the likely causes of anemia. Likewise, the trainee should
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understand what the RBC indices represent and what leads to their abnormality.
Interpret and recognize common morphologic variations of RBCs (on peripheral blood smear and bone marrow
aspirate) and correlate these with their likely pathophysiological conditions.
Demonstrate a working knowledge and practical competency of the indications and interpretation of a bone marrow
aspirate and biopsy in the evaluation of anemia.
Demonstrate a comprehensive working knowledge of the physiology of iron, vitamin B12 and folate utilization,
storage and transport and determine the appropriate replacement therapy for nutritional deficiency anemia. This
includes demonstrating the ability to calculate the magnitude of the deficit and the proper replacement regimen.
Demonstrate knowledge of the underlying causes, the pathophysiologic basis, the diagnostic criteria, differential
diagnosis, and management of anemia of chronic disease.
Demonstrate a comprehensive working knowledge of the etiologies of autoantibody development. This includes an
understanding of primary autoantibody production and autoantibodies that develop as sequelae of other diseases
(secondary causes).
Demonstrate a comprehensive working knowledge of the different mechanisms by which autoantibodies can lead to
destruction of RBCs. This includes understanding how to distinguish between warm autoantibodies, cold
autoantibodies, cryoglobulins and cold agglutinins in the etiology of hemolytic anemia.
Demonstrate practical competency for evaluating, diagnosing and recognizing the clinical sequelae of the hemolytic
anemia. This should include demonstrating an understanding of the direct and indirect antiglobulin tests and of the
methods used to identify and classify autoantibodies.
The Hematology trainee should demonstrate a comprehensive working knowledge of the pathophysiology of the
different causes of MAHA. This should include demonstrating the ability to differentiate between thrombotic
thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), among others.
The Hematology trainee should demonstrate practical competency for diagnosing and managing TTP, HUS,
disseminated intravascular coagulation (DIC) and the other MAHA.
Red Blood Cell Disorders: Erythrocytosis
 The Hematology trainee should demonstrate a working knowledge and practical competency of the diagnosis of
disorders that cause an increase in RBC number and/or mass. These include polycythemia rubra vera (see Section
IV.C.2.) and secondary causes. The trainee should be able to differentiate between primary (polycythemia rubra vera)
and secondary causes of erythrocytosis.
 Discuss the use of low dose aspirin, hydroxyurea, and phlebotomy in the management of the patient with
polycythemia vera.
 The Hematology trainee should demonstrate a working knowledge of the physiology and role of erythropoietin in
erythropoiesis and of the practical application and interpretation of measured erythropoietin levels. The trainee
should be familiar with the American Society of Clinical Oncology (ASCO)/ASH evidence-based clinical practice
guidelines for the use of erythropoietin in cancer patients.
White Blood Cell Disorders
 Demonstrate a comprehensive working knowledge and practical competency of the pathophysiologic mechanisms
that lead to generation of a differential diagnosis of granulocytopenia and understanding the diagnostic approach to
identifying the etiology of granulocytopenia and agranulocytosis.
 Demonstrate a comprehensive working knowledge of the risks associated with granulocytopenia along with an
understanding of the indication and role of cytokines (e.g. G-CSF, GM-CSF) in management of patients with
granulocytopenia and agranulocytosis.
 Generate a differential diagnosis, develop a diagnostic approach to identifying the etiology, and describe the clinical
consequences of both primary and secondary leukocytosis.
Platelet and Megakaryocyte Disorders
 Demonstrate the ability to identify and interpret the appropriate studies needed to diagnose von Willebrand’s
disease.
 Demonstrate a comprehensive working knowledge and practical competency of the differential diagnosis, approach
to diagnosis, and therapy of diseases that result in qualitative diminishment of platelets due to a decreased
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production of or an increased destruction of platelets.
Recall the International Consensus and ASH guidelines for the diagnosis and management of patients with immune
thrombocytopenic purpura (ITP).
Assess the bleeding risk for a given level of thrombocytopenia.
Generate an approach to diagnosis of the cause and management of thrombocytosis.
Recognize the consequences associated with thrombocytosis that may range from bleeding to thrombosis.
The Hematology trainee should demonstrate an understanding of the anti-platelet function drugs including
mechanism of actions, pharmacokinetics, toxicities, indications, dosages and interactions of all classes of anti-platelet
drugs (i.e. aspirin, ticlopidine/clopidogrel, dipyridamole, GP IIb/IIIa inhibitors, etc).
Bone Marrow Failure States and Stem Cell Disorders
 Demonstrate the ability to provide a differential diagnosis and the acquisition of practical knowledge of the role of
medications, other drugs and environmental pathogens (including chemicals and infectious diseases) in the
development of bone marrow failure states. An understanding of the approach to diagnosis and management of
these disorders should be demonstrated.
 Demonstrate a comprehensive working knowledge and practical competency of the diagnosis and therapy of aplastic
anemia. An understanding of the indications and risks of various treatment approaches (including stem cell
transplantation, anti-thymocyte globulin, cyclosporine, other immune mediators) should be demonstrated by the
trainee.
 Generate a differential diagnosis of and an approach to diagnosis of the etiology of pancytopenia.
 Recall the diagnostic criteria, differential, prognosis, and first-line management of the non-CML myeloproliferative
disorders.
Hemostasis
 Discuss the basic mechanisms and components of normal hemostasis and thrombosis. This should include a practical
knowledge of the function and interactions of procoagulant and anticoagulant proteins, cellular contributions and
interactions between these components as well as with vascular endothelium.
Bleeding Disorders
 Discuss the classification of the different types of von Willebrand disease and recognize the clinical presentation,
diagnose and characterize the different types of von Willebrand disease. The Hematology trainee should have
knowledge of the clinical implications of the different types of von Willebrand disease.
 Demonstrate a working knowledge of the diagnosis and clinical presentation of hemophilia A and B and other
inherited bleeding disorders of coagulation
 Recall the role of vascular abnormalities in the etiology of specific bleeding disorders.
Thrombotic Disorders
 The Hematology trainee should demonstrate a working knowledge and practical competency of the differential
diagnosis of the inherited deficiencies that lead to an increased risk of thrombosis.
 Recall the methods for prophylaxis, diagnosis, and treatment of venous thrombosis, including the proper use of
anticoagulant therapies in both medical and surgical populations.
 Demonstrate a comprehensive working knowledge of the clinical presentation, pathogenic mechanism, diagnosis and
management of heparin-induced thrombocytopenia. The trainee should also demonstrate an understanding of the
risk and consequences of thrombosis in these patients.
 Demonstrate a working knowledge and practical competency for diagnosing and managing the manifestations of
antiphospholipid syndrome.
Pharmacologic Manipulation of Bleeding and Thrombosis
 Demonstrate a practical competency with the use of the various classes of antithrombotics and anticoagulants that
are available including their mechanisms of action, indications, appropriate dosing, monitoring, means of reversal,
and appropriate duration of therapy for various clinical situations.
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HEMATOLOGY
Second and third year fellows are expected to refine their mastery of the first year objectives as well as to:
Red Blood Cell Disorders: Anemias
 Demonstrate a comprehensive working knowledge and practical competency of the basic molecular and
pathophysiologic mechanisms, diagnosis and therapy of anemia.
 Interpret and recognize morphologic variations of RBCs (on peripheral blood smear and bone marrow aspirate) and
correlate these with their likely pathophysiological conditions.
 Demonstrate a comprehensive working knowledge and practical competency of the underlying causes, diagnosis and
management of red cell aplasia and hypoplasia inclusive of understanding the direct toxicity to the bone marrow of
infectious diseases, toxins and metabolic insults and the role and use of immunologic modifier therapy (e.g.
antithymocyte globulin, cyclosporine, glucocorticoids) and stem cell transplantation.
 Demonstrate a comprehensive working knowledge and practical competency in the genetics, pathophysiology,
diagnosis pathophysiology, diagnosis (including interpretation of a bone marrow aspirate iron stain), and
management of the sideroblastic anemias.
 Demonstrate a comprehensive working knowledge of the genetics and pre-natal diagnosis of the thalassemias; the
ability to make a diagnosis of thalassemia with the ability to distinguish between the different “types” of thalassemia
(i.e. , , major, minor, etc.); and the ability to manage the various types of thalassemia along with their clinical
sequelae (iron overload, skeletal abnormalities and organomegalies).
 Demonstrate a comprehensive working knowledge of the genetics and physical properties of hemoglobin S. The
trainee should be capable of establishing the diagnosis of sickle cell disease and the variant sickle cell syndromes (e.g.
S/Thalassemia, SC disease, etc.) along with the recognition, diagnosis, and management of their clinical sequelae
(especially the life-threatening aspects, such as pain, acute chest syndrome, hemolytic and aplastic crises, risk of
infections, sickle cell lung disease, and strokes)
 Demonstrate a comprehensive working knowledge and practical competency for the role and use of fetal hemoglobin
synthesis stimulators (e.g. hydroxyurea, butyrate), transfusion therapy, and stem cell transplantation in the
management of sickle cell disease.
 Demonstrate practical competency in managing autoimmune hemolytic anemia. This should include demonstrating
the ability to recognize indications for treatment, the use of glucocorticoids, IVIg, immunosuppressives, and RBC
transfusions. In addition, the trainee should demonstrate the ability to recognize and manage the sequelae of
autoimmune hemolytic anemia.
 The Hematology trainee should demonstrate a comprehensive working knowledge of RBC metabolic deficiencies that
lead to hemolysis. This includes an understanding of deficiencies of glucose-6-phosphate-dehydrogenase (G6PD) and
pyruvate kinase (PK), among others, and the conditions that aggravate these deficiencies. The trainee should
demonstrate an understanding of the biochemical pathways affected by these enzyme deficiencies.
 The Hematology trainee should demonstrate practical competency in diagnosing and managing the metabolic
enzyme deficiency hemolytic anemias.
 The Hematology trainee should demonstrate a comprehensive working knowledge and practical competency for the
pathophysiology, diagnosis and management of PNH and its associated complications.
 The Hematology trainee should demonstrate a comprehensive working knowledge of the relationship between
structure and function of the RBC membrane and how mutations in the different membrane components lead to
hemolytic syndromes.
 The Hematology trainee should demonstrate practical competency for differentiating between these disorders,
recognizing microscopic morphologic presentations of these disorders, managing these different disorders and their
associated clinical sequelae, and counseling patients about their disease and associated complications.
 The Hematology trainee should demonstrate a working knowledge and practical competency of the pathophysiology,
diagnosis and management of a variety of other acquired etiologies of hemolytic anemia. These etiologies should
include physical (traumatic) fragmentation, infectious diseases, chemicals and toxins, physical agents (e.g. burns), and
the impact of disorders of other organ systems.
Red Blood Cell Disorders: Erythrocytosis
 The Hematology trainee should demonstrate a working knowledge and practical competency of the basic molecular
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and pathophysiologic mechanisms of disorders that cause an increase in RBC number and/or mass. These include
polycythemia rubra vera (see Section IV.C.2.) and secondary causes.
Discuss therapeutic options beyond hydroxyurea for the treatment of polycythemia vera
Red Blood Cell Disorders: Hemochromatosis
 The Hematology trainee should demonstrate a comprehensive working knowledge of the basic molecular and
pathophysiologic mechanisms that lead to the development of hemochromatosis. This should include identifying risk
factors and the common genetic mutations that are associated with an increased risk of a person developing
hemochromatosis.
 The Hematology trainee should demonstrate practical competency for recognizing the presentation and making the
diagnosis of hemochromatosis. This should include the ability to use and interpret molecular diagnosis assays,
including those that identify the C282Y and H63D mutations of the hemochromatosis gene (HFE).
 The Hematology trainee should demonstrate the ability to recognize the clinical sequelae and complications of
hemochromatosis on systemic organ systems.
 The Hematology trainee should demonstrate practical competency for managing patients with hemochromatosis.
This should include understanding the indications for the initiation and choice of therapy and the expected outcome
and toxicities of phlebotomy and iron chelation therapies.
White Blood Cell Disorders
 Demonstrate a comprehensive working knowledge and practical competency of the basic pathophysiologic
mechanisms, diagnosis and therapy of qualitative granulocyte dysfunction disorders, including enzyme deficiencies,
enzyme storage disorders, Chediak Higashi syndrome, chronic granulomatous disease and leukocyte adhesion
deficiency. In order to accomplish this understanding of granulocyte disorders, a basic understanding of normal white
blood cell development, differentiation, migration and trafficking should be acquired by the trainee.
 Discuss normal B and T lymphocyte differentiation and development and demonstrate a basic understanding of the
genetics and pathophysiological mechanisms of B and T lymphocyte functional and numerical deficiencies
 Demonstrate a comprehensive working knowledge and practical competency of recognizing, diagnosing and
managing specific diseases that consist of lymphocyte dysfunction, including common variable immunodeficiency,
severe combined immunodeficiency, adenosine deaminase deficiency, Wiskott-Aldrich syndrome, ataxiatelangiectasia, DiGeorge anomaly, selective immunoglobulin deficiencies, Omenn syndrome, reticular dysgenesis and
others.
 Demonstrate a working knowledge and a practical competency of the basic molecular and pathophysiologic
mechanisms that can lead to leukocytosis (e.g. neutrophilia, lymphocytosis, hypereosinophilia).
 Demonstrate a working knowledge and practical competency of the indications and approaches for interfering with
increased white blood cell production by pharmacologic agents, biologic agents, and mechanical methods (i.e.
leukopheresis) to transiently decrease the elevated leukocyte number. The indications, pharmacologic agents, and
dosages and toxicities of these agents and approaches should be understood.
Platelet and Megakaryocyte Disorders
 Demonstrate an understanding of the pathophysiologic mechanisms, the ability to identify and interpret the
appropriate studies needed to diagnose, and the ability to manage the various inherited disorders of platelet phase
hemostasis, including von Willebrand’s disease, Bernard-Soulier syndrome, platelet collagen receptor deficiency,
Glanzmann thrombasthenia gray platelet syndrome, dense granule deficiency, primary secretion defects and platelet
procoagulant activity disorders.
 Demonstrate a working knowledge of the technical aspects of performing and interpreting platelet aggregation assays
and platelet antigen identification assays.
 Demonstrate a working knowledge and practical competency of the basic pathophysiologic mechanisms, diagnosis
and therapy of acquired platelet function disorders.
 Demonstrate a comprehensive working knowledge and practical competency of the differential diagnosis, basic
molecular and pathophysiologic mechanisms, approach to diagnosis, and therapy of diseases that result in qualitative
diminishment of platelets due to a decreased production of or an increased destruction of platelets.
 Demonstrate a comprehensive working knowledge and practical competency of the basic molecular and
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pathophysiologic mechanisms that lead to primary and secondary thrombocytosis
Discuss management of essential thrombocythemia beyond the use of hydroxurea.
Assess the associated risks of thrombocytosis to individual patients with essential thrombocythemia and
polycythemia vera.
Bone Marrow Failure States and Stem Cell Disorders
 List and describe the clinical characteristics of the inherited and congenital forms of bone marrow failure states. The
trainee should demonstrate a basic working knowledge and practical competency of diagnosing and managing these
disorders.
 Discuss the pathophysiologic basis for the development of aplastic anemia and the therapies employed for the
treatment of the disease.
 Discuss the pathophysiology of the non-CML myeloproliferative disorders and the implications for targeted therapies.
Hemostasis: Bleeding Disorders
 Demonstrate a comprehensive working knowledge and practical competency of the basic molecular and
pathophysiologic mechanisms of genetic and acquired causes of disorders of hemostasis.
 Demonstrate an understanding of the molecular and pathophysiologic abnormalities associated with the different
types of von Willebrand disease/
 Demonstrate a practical competency in the treatment of the various subtypes of von Willebrand disorders.
 Demonstrate a working knowledge of the management of hemophilia A and B, and other inherited factor deficiency
states in the acute bleeding and procedure prophylaxis settings
 Recall the role of vascular abnormalities in the etiology of specific bleeding disorders.
Thrombotic Disorders
 Discuss the indication, approaches to and limitations of genetic testing to assess risk factors for thrombosis.
 Demonstrate a comprehensive working knowledge of the clinical presentation, pathogenic mechanism, diagnosis and
management of heparin-induced thrombocytopenia. The trainee should also demonstrate an understanding of the
risk and consequences of thrombosis in these patients.
 Demonstrate a comprehensive working knowledge and practical competency for diagnosing and managing the
manifestations of antiphospholipid syndrome. This should include a comprehensive working knowledge of the
different antibodies that can be assayed and used in the diagnosis of this syndrome and a practical competency for
the use of prophylaxis for those patients at risk of thrombosis. The trainee should also demonstrate practical
competency for recognizing and managing the clinical manifestations associated with antiphospholipid syndrome,
including the implications and risks associated with pregnancy and surgery.
Pharmacologic Manipulation of Bleeding and Thrombosis
 Demonstrate practical competency with various factor replacement products, inhibitor “bypass” products,
antifibrinolytic agents, and the role of blood products for the management of bleeding disorders. The trainee should
demonstrate a general understanding of the pharmacology dosing and administration of these agents as well as of
their toxicity and potential interactions with other medications and factors.
Practice- Based Learning and Improvement
Goal
Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.
Please refer to overview of the fellowship curriculum for competencies/objectives for practice based learning and improvement.
Systems Based Practice
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Goal
Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the
ability to call effectively on other resources in the system to provide optimal health care.
Please refer to overview of the fellowship curriculum for competencies/objectives for systems based practice.
Professionalism
Goal
Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
Please refer to overview of the fellowship curriculum for competencies/objectives for professionalism.
Interpersonal and Communication Skills
Goal
Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and
teaming with patients, their families, and professional associates.
Effectively discusses and teaches patient and family about their hematological/oncological condition, results of tests, choices,
and goals of treatment, Effectively, honestly and compassionately tells bad news and helps patient and family clarify goals;
facilitate family meetings, explain advance directives and establish code status. Provide courteous, professional and timely
consultation and work effectively with consultants. Communicate effectively, courteously, and professionally with nursing and
clinic staff and peers.
Please refer to overview of the fellowship curriculum for competencies/objectives for interpersonal and communication skills.
Teaching Methods
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Clinical teaching
Role modeling
Patient care/clinical experience
Didactic sessions (division, department, institution)
Performance feedback
Self-directed learning
Pre-clinic conference and in depth discussion of each patient
Nurse Partner mentoring in chemotherapy administration, psychosocial aspects of patient care, interpersonal skill
sets.
Oncology Pharm D teaches short didactics on new chemotherapy and supportive medications, assists in teaching
fellows to write orders one-on-one.
Oncology Social Worker provides mentoring in psychosocial and socioeconomic issues.
Assessment of Fellow Performance
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Quarterly evaluation by the attending of the fellow
Annual 360 assessment by the nursing staff and clinic patients of the fellow
Assessment of Rotation
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Quarterly evaluation by the fellow of the attending
Annual program review
Discussions with fellows during biannual review
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Review in-service and ABIM exam results
Level of Supervision
The level of supervision of the fellows in the continuity clinics is indirect supervision with direct supervision immediately
available by adult trained hematologists/oncologists
 Throughout the week when not in clinic, the attending faculty are available for questions, problems, etc.
Educational Resources
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Devita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology
Hoffman Hematology: Basic Principles and Practice
UpToDate
ASCO University
ASCO Practice and Guidelines
ASCO-SEP
ASH-SEP
NCCN Guidelines (www.nccn.org)
NCI Common Cancer Types and Clinical Trails by Cancer Type/Disease (www.cancer.gov)
The AJCC 7th edition TMN staging of Cancer
Common Toxicity Criteria v4.0 (aka Common Terminology Criteria for Adverse Events)
GAIL model
Claus model
Adjuvant! Online
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