Training in clinical oncology
Authors: Carrie Featherstone, Nicholas S Reed
Publication date: 19 Mar 2005
It can be emotionally draining, but it has sociable on-call commitments, structured training, and huge potential for doing research. Lye Mun Tho, Carrie Featherstone, and Nicholas Reed offer a guide to training in clinical oncology
Over the past few years there has been substantial investment in and reorganisation of cancer services in the United Kingdom along with an expansion in consultant numbers, treatment facilities, and research activity. It's an exciting time to work in clinical oncology. However, many junior doctors are unlikely to have much exposure to this specialty as it is almost exclusively based in cancer centres.
What is clinical oncology?
Non-surgical oncology comprises clinical, medical,  and haematological oncology  . Clinical oncologists treat solid tumours with conventional radiotherapy, brachytherapy, chemotherapy, biological therapy, molecularly targeted agents, and increasingly with a combination of these. Having the skills to deliver all of a patient's treatment is one of the specialty's big attractions.
Historically, clinical oncologists began as radiotherapists and, having common ground with radiologists, belonged to the same faculty.  As cancer chemotherapy developed, clinical oncologists began to incorporate this into their practice, and they still deliver most chemotherapy for solid tumours in the United Kingdom. Medical oncology emerged as a separate specialty in the 1960s, with a greater focus on drug development. Today clinical oncologists remain fellows of the Royal College of Radiologists (within the Faculty of Clinical Oncology), and together with medical oncologists offer their professional views via the Joint Collegiate Council of Oncology.
Entry requirements for training
Clinical oncology is definitely growing in popularity among junior doctors. The prerequisite is membership of the Royal College of Physicians (MRCP), and normally two years of postregistration experience. Most applicants will have oncology experience at senior house officer (SHO) level; a research degree is unusual. Interviewers will not expect candidates to have detailed knowledge of oncology but are looking for a commitment to the specialty and an ability to communicate effectively. It is unclear at this stage how the foundation programme will change this process.
Higher specialist training
Higher specialist training takes five years and trainees obtain fellowship of the Royal College of Radiologists (FRCR) by examinations before a certificate of the completion of specialist training (CCST) is awarded. FRCR part 1 comprises core scientific information (cancer biology/radiobiology, clinical pharmacology, physics, and medical statistics). To the uninitiated, this may seem daunting, but most centres will organise a regional course or provide in-house teaching to cover the syllabus and pass rates are good.
The FRCR part 2 is taken after three years of clinical training and assesses clinical ability by written and clinical examination. The subject matter of both parts relates closely to daily practice, which makes it an interesting and relevant exam to prepare for. An MD or PhD is not essential and most trainees do not undertake one, but research is encouraged where there is interest. Topics can vary from laboratory and basic science projects to clinical work to psychosocial oncology. Unlike in some specialties, because of the close association between scientific and clinical activity in oncology most trainees do feel that their research makes an impact.
Advantages and disadvantages
Multimodality specialty with an interesting and rewarding disease to treat
Sociable on-call commitments for both trainee and consultant
Structured training and good career prospects
Strong support from patient groups and charities
Constantly improving technology and treatments
Huge research potential
Emotionally draining at times
High service demands and limited resources
Working in oncology
Specialist registrars (SpRs) rotate through all cancer types and gain skills and exposure in each. However, with an increase in the number of patient referrals and in treatment complexity, consultant site specialisation has become the norm. This encourages expertise in particular tumour types.
The typical week
The typical working week is varied and is spent doing clinics, ward rounds, prescribing chemotherapy, planning radiotherapy, and attending multidisciplinary team meetings. Working practice in oncology is team oriented and oncologists liaise regularly with many different specialties, so it is a distinct advantage to have good communication and inter-personal skills.
When new patients are discussed at a multidisciplinary team meeting, oncology input usually begins at diagnosis. There is a good balance between outpatient and inpatient work, which consists of looking after patients requiring routine chemotherapy, managing oncological emergencies such as spinal cord compression, and treatment complications such as neutropenic sepsis.
Managing the psychosocial ramifications of the disease is an important and rewarding part of oncology, and most doctors relish the opportunity to make a tangible difference to their patients' quality of life. However, this means that the job can become emotionally stressful; being able to deal with distressed individuals and break bad news sensitively are necessary skills. Clinical trials are an integral part of oncology, and time will also be spent counselling and entering patients into ongoing studies. Despite a hectic working day, on-call commitments are generally light and infrequent compared with general medicine.
Developments in radiotherapy
Radiotherapy has evolved from its humble beginnings as radium treatment at the turn of the last century and now forms a substantial proportion of oncology workload; about half of all cancer patients will receive radiotherapy. It can be used curatively or palliatively and achieves cure for more people than chemotherapy alone.
Routine use of computed tomography (CT), magnetic resonance imaging (MRI), and in some cases positron emission tomography (PET) have improved our ability to localise tumours. Technology is available to fuse these images with radiotherapy CT planning images, to define a target better and even track its position within a moving organ. The challenge of modern radiotherapy is then to deliver tumoricidal radiation precisely to the cancer while sparing surrounding sensitive organs. We can do this by shaping the radiotherapy beam to “conform” to tumour shape and in some cases using complex computer software to vary the intensity of each beam, thus forming the basis of intensity modulated radiotherapy (IMRT) (fig 1). The clinical oncologist needs to foster a close working partnership with the radiation physicist. Improving technique and patient care are steadily reducing the morbidity of radiotherapy, reversing the misconceptions of old.
Developments in systemic therapy
Most cytotoxic chemotherapy and novel treatments are now given in the outpatient clinic. Tolerability of treatment has improved with newer antiemetics, antibiotics, and effective symptom control. Recent efforts in drug development have focused on targeting molecular pathways in cancer cells (so called “smart bombing”) and also combining these agents with conventional radiotherapy and chemotherapy.
There are 1272 consultants and trainees in clinical oncology,  and job prospects are good as new consultant and training posts are still being created. Most consultants will be based in cancer centres (where radiotherapy machines are housed), which means visits to surrounding hospitals to do clinics. You will also need to keep up with developments and sometimes collaborate nationally and internationally; travelling is usually part of an oncologist's life. Academic oncology is alive and funding is provided by cancer charities, the government, and drug companies.
Dr Nicholas Reed has received honorariums for consultancy work and lecturing for the following drug companies during the past 12 months: Hoffman La Roche, Novartis, and Schering Plough Corporation.
- McIllmurray M. Medical oncology. BMJ Career Focus 2000;320: S2.
- Estcourt L, Miflin G. A career in haematology. BMJ Careers 2004;329: 3-4.
- Henk JM. A brief history of British radiotherapy. Int J Radiat Oncol Biol Phys 1996;36(1): 213-8.
- Royal College of Radiologists; www.rcr.ac.uk
Carrie Featherstone consultant in clinical oncology
Nicholas S Reed consultant in clinical oncology
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