Clinical oncologyBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7156.2 (Published 15 August 1998) Cite this as: BMJ 1998;317:S2-7156
Practitioners in this rapidly changing specialty are in high demand. Caroline Brammer, Georgina Gerrard and Rosemary Macdonald discuss prospects, pros, and cons for budding cancer specialists
- Caroline Brammer, specialist registrar,
- Georgina Gerrard, consultant,
- Rosemary Macdonald, Lead dean for clinical oncology
Treatment of cancer patients requires cooperation between members of a multidisciplinary team in cancer centres and units as recommended by the Calman Hine report.(1) In Britain the doctors in the team include clinical oncologists, medical oncologists, surgeons, palliative care physicians, haematologists, chest physicians, radiologists, and histopathologists. Clinical oncologists administer radiotherapy, chemotherapy, endocrine therapy, radioisotopes, and a wide range of medical modalities to treat cancer with both curative and palliative aims. Treating patients with cancer is challenging and rewarding, and far from depressing. In fact, the prognosis and quality of life of a good proportion of cancer patients is better than those with other chronic medical problems such as motor neurone disease, rheumatoid arthritis, or obstructive airways disease. However, improving quality of life for patients with incurable disease remains an important goal for oncologists, equally important as cure.
Pros and cons of a career in clinical oncology
Structured training in preparation towards FRCR
Opportunities for research
Varied, stimulating, and rewarding
Exciting new developments
Less onerous out of hours service requirement than most other
Good job prospects
Further exams after MRCP
Heavy service commitment
Heavy demand for cancer services with limited resources
The specialty is predominantly clinical - that is, assessment of patients by history and examination - rather than technical - physics and big machines -although an understanding of the technical side is essential for the prescription of radiotherapy. Within the specialty clinical oncologists subspecialise by site. The proportion of radiotherapy to chemotherapy given by each consultant depends on their site specialty; consultants treating breast cancer deliver more chemotherapy than radiotherapy, whereas the opposite is true for those specialising in tumours of the head and neck. About half of chemotherapy in Britain is given by clinical oncologists.
Radiotherapy can be given in several ways: external beam radiotherapy given from a short distance, radioactive implants inserted in theatre, and targeted radiotherapy, which includes the “magic bullets” of the future. A clinical oncologist in the role of specialist radiotherapist is half way between surgeon and physician - the radiotherapy beam can be considered analogous to a surgeon's scalpel.
Historically, clinical oncologists were generalists in the management of oncological conditions, treating patients with systemic cytotoxic chemotherapy and radiotherapy, whereas the traditional role of medical oncologists, who administer chemotherapy alone, was mainly research based, operating within university departments or charity funded groups. With the advances in cancer treatments and the publication of the Calman Hine report, however, the position of both specialists has evolved - clinical oncologists becoming increasingly site specialised and medical oncologists expanding their practice to cancer units at district general hospitals.
The Joint Committee for Clinical Oncology, which has representatives from the Faculty of Clinical Oncology of the Royal College of Radiologists and for medical oncology from the Royal College of Physicians, was set up over a decade ago to provide greater links between the two disciplines. The committee has proposed the creation of a joint specialty with a common core training since clinical and medical oncology are inextricably linked as specialties.(2) Currently, most trainees find themselves in one or other specialty by chance, depending on what opportunities arose. A joint training would permit trainees to make an informed choice about the future and would give a greater insight to both specialties.
Four broad categories of oncologist were defined in the recent framework document from a working party of the committee(3):
Visiting oncologist - Based in the cancer centre but serves outreach clinics in the surrounding cancer units. May be a specialist in both chemotherapy and radiotherapy or, less often, chemotherapy alone
Cancer unit based oncologist - Delivers chemotherapy that does not require the back up of a cancer centre but has links with the cancer centre for audit, protocol, and continued education
Specialist radiotherapist - Trained in the delivery of highly technical radiotherapy
Specialist chemotherapist - Practises specialised chemotherapy such as that for rare tumours, high dose chemotherapy, and the investigation of new chemotherapeutic agents.
Most clinical oncologists are based in cancer centres serving outreach clinics at district general hospitals, fulfilling the cancer unit role of the cancer centre and providing specialist expertise in their tumour site of interest within multidisciplinary teams. The specialty is predominantly outpatient based (most radiotherapy and chemotherapy is given to outpatients). This means that being on call out of hours tends to be fairly quiet. The days, however, are busy, with planning and prescribing of radiotherapy and chemotherapy in addition to care of medical, psychosocial, and oncological problems. Not only have patients to cope with the fear of the “big C” but also the fear of the treatments. The specialty can therefore be emotionally demanding but also satisfying in that you can make a real difference to patients' quality of life. The specialty covers all ages and most sites of the body; this is both challenging and stimulating, with the result that we are rarely bored.
Clinical research is important in the day to day practice of oncology. Treatments are continually being updated and improved, with more and more patients being entered into clinical trials. Consequently, this is a valuable component of oncology practice in the outpatient clinic. New developments in technology provide fresh opportunities for improving tumour control and reducing radiation morbidity. These are poised to enter into routine clinical practice, providing further challenges for all those involved in radiotherapy.
Most trainees enter clinical oncology after at least two years of general postgraduate training and the acquisition of MRCP. This is not yet mandatory, but from 1 October 2000 it will be the minimum entry requirement unless the applicant can show equivalent training. Specialist registrar training in clinical oncology lasts at least five years with up to one year of clinical or laboratory based research, with the opportunity for the trainee to take a further two years out of training to gain a research qualification such as MD or PhD.(4)(5)
The training is well structured, with all trainees attending a course of regular lectures leading towards the part 1 examination of the FRCR, covering cancer biology, chemotherapy, radiobiology, physics, statistics, and pathology. Most trainees view physics with some dread, but, although it is not easy, it is certainly not impossible. The emphasis is towards that of clinical practice and how electromagnetic waves and particles pass though tissues rather than a string of equations. Some centres run an oncology MSc course parallel to the FRCR course, and trainees are expected to complete this as well. Part 1 of the FRCR is taken after about one year of training. Part 2 is a clinical exam attempted after at least three years of training, with most trainees again attending a course of lectures in the management of oncology patients in addition to gaining day to day clinical experience.
Many trainees wish to gain experience working in two centres, and to facilitate this a “job match” register has been created on the Royal College of Radiologists website to allow trainees to exchange posts.
The need for expansion
Oncology is an expanding specialty. In 1991 a review of medical manpower and workload by the Royal College of Radiologists recommended that the maximum number of new patients seen each year by each consultant should not exceed 350.(6) At that time the average consultant clinical oncologist in England and Wales saw 560 new patients each year. In 1991 there were 240 consultant clinical oncologists in the United Kingdom. The number of consultants has since expanded to 324. In a revised report published this year the recommended maximum number of new patients a year was dropped to 315 in order to accommodate the increasing complexity of clinical and non-clinical duties.(7)
In the short term it is unlikely that these recommendations will be achieved. The reports from the Royal College of Radiologists and the Calman Hine report has fuelled further expansion in consultant numbers (with corresponding effects on specialist registrar numbers) so job prospects are good.
Exciting new developments are continually moving from the laboratory to clinical practice, perhaps more so than in other specialties. The structured training creates an excellent knowledge base for a rewarding and professionally satisfying career where research is a common component of clinical practice.