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A career built on relationships Find out more about a career in clinical oncology.

Clinical Oncology 32 Building a career on building relationships

This is a rapidly evolving specialty and there have been tremendous advances in the treatment and delivery of systemic agents and radiation techniques over the past decade. Clinical oncology involves working closely as part of a multidisciplinary team, including specialist nurses, radiographers, physicists, dosimetrists, chemotherapy nurses, dieticians, speech and language therapists and members of the palliative care team.

Clinical oncologists are their patients’ advocates through their treatment pathway, whichever form this takes. Good communication skills are necessary to be able to explain the treatment(s) as well as to ensure that patients have a realistic expectation of the outcomes.

Open and honest discussion will empower patients to understand the aims and intent of the treatment and any potential associated risks. Compassion and empathy are crucial in aiding decision making, especially in stopping or starting treatment. General medical knowledge and experience are also vital to support patients during treatment; a combination of this scientific perspective and holistic communication will provide patients with the best care throughout their treatment.

It is important to consider the differences between medical and clinical oncology. Medical oncology focuses on the development and delivery of systemic therapies, whereas clinical oncology involves the development and delivery of both systemic anti-cancer agents and radiotherapy.

Why clinical oncology?Cancer is an incredibly interesting and fulfilling disease to manage, involving chemotherapy and radiotherapy, and the critically important multidisciplinary team. The job incorporates a mix of ward work and clinics, allowing exposure to acute problems as well as continuity of care. After reviewing patients following their initial diagnosis of cancer, clinical oncologists are then able to discuss a patient’s diagnosis

and possible treatment options, and subsequently review the effects of their treatments over time. Throughout these consultations, a close, trusting relationship with patients and their families develops. In addition, the specialty is constantly advancing and offering opportunities to be involved with exciting developments; research is greatly encouraged.

What is clinical oncology?Clinical oncology is an exciting and rewarding field of medicine, focused on the treatment of cancer with systemic therapies (including chemotherapy, targeted agents and immunotherapy) and radiotherapy.

Personally, my ambition to pursue a career in clinical oncology is long held; I undertook a medical school elective with a cancer service in New Zealand. I also worked as an FY2 in oncology in a busy teaching hospital, and thoroughly enjoyed this rotation.

I applied for specialty training in clinical oncology immediately after completing core medical training but was unable to gain a training number in the first round of recruitment.

I therefore worked as a specialty doctor in oncology for six months, gaining further experience and received a training number in the second round that year, commencing formal training in the spring.

Throughout my training I worked in a range of specialties but always had a particular interest in cancer.

How did you get into clinical oncology?Nicola Davis, ST4

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1 You have to be really interested in physics to be a clinical oncologist

Don’t be put off by the physics in clinical oncology. It’s very different to the stuff you might have learnt about at school because it’s applied knowledge (that is, how radiotherapy kills cancer cells) and is therefore a lot more relevant than the laws of momentum. It’s something a lot of people worry about coming into clinical oncology, however, it’s a small part of the job, well taught (from scratch!) and every centre has a team of friendly physicists who deal with the complex calculations. Most clinical oncology trainees would say that the physics aspect of the job is nowhere near as daunting as they may have thought.

2 Clinical oncologists don’t see patients

Clinical oncology is a patient-based specialty. It is a common misconception that clinical oncologists sit in dark rooms planning radiotherapy. This can be true in some countries where this type of oncologist is called a ‘radiation oncologist’. In the UK, clinical oncologists offer very pragmatic and holistic care, involving patient contact in clinics, on the wards and of course during treatments.

3 Clinical oncologists are just radiotherapy technicians

Clinical oncologists don’t only prescribe, plan and aid in the delivery of radiation, they also conduct chemotherapy and are equipped with the skillset to treat all types of cancer, following patients through their whole journey from diagnosis, to recovery or palliative care.

4 Radiotherapy is only a palliative treatment

Radiotherapy can cure cancer. We now live in a world where patients survive many years after successful cancer treatment. There are many cancers in which the combination of early diagnosis and intensive radiation treatment (either alone or in combination with surgery and chemotherapy) has led to excellent survival rates.

5 There is no research in clinical oncology

Clinical oncology is a rapidly advancing area and there are many research avenues available within it. Huge investments are being made in state-of-the-art equipment to be able to offer patients the best and most modern, streamlined treatments. The NHS now funds exploratory research in the most advanced technologies, such as stereotactic radiotherapy and proton beam therapy. But it isn’t just radiotherapy; research in basic sciences, chemotherapy and patient experience also comes in many guises, ranging from one-year fellowships, to lab based or clinical PhD and MD projects.

The truth about clinical oncologyThere are many misconceptions about clinical oncology – this myth-busting section aims to set the record straight.

I am a specialty registrar in clinical oncology currently taking time out of my training programme to spend in research (and complete an MD). I am three and half years through the five-year training programme and work three days a week.

My research projects are clinical, relating to quality of life, decision making and survivorship in urological cancers. The pace of academic work is variable, but mainly I have control over my workload. I’m based in an office with other clinical research fellows (from a number of specialties) and there is a good atmosphere of collaboration. I also work with teams in other hospitals and external companies.

Much of my time is spent designing and setting up studies, including writing protocols, funding applications and obtaining ethics approvals. This is broken up by meetings and clinical work and eventually I will spend more time recruiting patients and conducting studies.

Having time to design and see a project through is such a luxury compared to having a clinical job where six-month attachments make longer term projects difficult.

However, the loss of that immediate gratification of clinical work can be a challenge so I spend one session a week on this.

Taking time out to do research is allowing me time within the training programme to pursue my interests, gain new skills and work more independently. It also enhances my CV as it includes time for me to write papers and attend conferences. I didn’t go into clinical oncology expecting to do research but, with encouragement from colleagues and a realisation that research doesn’t have to take you away from patients, I have been able to pursue this path and gain experience of something new.

Taking time out to do research is allowing me time within the training programme to pursue my interests, gain new skills and work more independently.

My life as a clinical oncologist (in research)Dr Sally Appleyard, ST6

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It might seem pretty scary at the beginning and there is a lot you might not have come across before; by the end of the first week I wasn’t sure that five years would even be long enough!

What do I need to apply?As a clinical oncologist you will work closely with a number of other specialties, so a broad range of experience can really help you as a registrar. Most people will take the route of: undergraduate medical school (5–6 years) (+/-intercalated degree); foundation jobs; core medical training (CMT); then applying for clinical oncology during their CT2 year. Acute care common stem (ACCS) training is an acceptable alternative to CMT and equivalent experience from outside the UK may also be allowed. You must be able to demonstrate achievement of CMT competencies in the three years preceeding the start of a clinical oncology post, which is something to consider if you are planning on taking time out.

The application processTo apply for a training programme you will go through national recruitment. The online application form asks about your experience of clinical oncology and your commitment to the specialty, and you’ll be asked to provide examples of key skills that clinical oncologists have – such as good communication and team working. After that is an interview. Details change from time to time but recently interviews have included three main areas: clinical, ethical and portfolio. To excel in these you have to know a little about oncology, so it might sound obvious but if you have had some relevant exposure and experience this will count for a lot. Once you start thinking about clinical oncology as a career, look for opportunities to build your CV – you can refer to the ‘Top Tips’ section of this booklet for some ideas!

What does training involve?Clinical oncology specialty training takes five years. You are likely to be based in a group of hospitals within your deanery. Attachments are typically for six months, sometimes in a new hospital, sometimes at the hospital where you are already working. Attachments are usually focused on one or two tumour types, allowing you to cover all the different tumour types during your training.

Within each attachment, you will gain exposure to the different areas of clinical oncology, that is, you will spend time in clinic, on the wards, in chemotherapy and in radiotherapy planning. Every year of training is well supported, with dedicated teaching. During your first year there is specific training on physics, cell and radiobiology, pharmacology and medical statistics to prepare you for the First FRCR exam. In addition, clinical oncology is a specialty at the cutting edge of medical research so it is common for trainees to take time out for research, either completing an MD or PhD.

Clinical oncology training pathway

CT1 CT2 ST3

Clinical oncology curriculum

Workplace-based assessments (WPBAs)

ST4 ST5 ST6

Advanced clinical oncology training

Core medical training and MRCP

ST7

Core clinical oncology training

Intermediate clinical oncology training

How do I become a clinical oncologist?

First FRCR Exam Final FRCR Exam

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Systemic (chemo) therapySystemic therapy encompasses chemotherapy and biological therapies, used either in combination with radiotherapy or on their own. Chemotherapy has long been established as an anti-cancer treatment. Some agents are derived from plants (paclitaxel from needles of yew tree), while others originated from antibiotic therapy (doxorubicin). These agents are used because they inhibit the cell cycle, stunting the rapid cell proliferation of cancerous growth. Unfortunately, normal cells with high replication rates suffer a similar fate, translating into toxicities, such as bone marrow suppression and hair loss.

With new advances, biological therapies have been fashioned to target cancer cell pathways and modulate immune systems to produce cancer cell death. Biological therapies range from monoclonal antibodies to small molecule tyrosine kinase inhibitors. Different cell pathways and checkpoints pertinent to cell growth and survival are being manipulated to achieve maximum tumour kill.

New biological agents, along with the increasing ease of treatment administration, a significant improvement in clinical effectiveness and limited toxicities, are opening the door for personalised medicine. There will even be new trials coming soon that will be investigating the scope of individualising treatment based on specific gene mutations.

Radiotherapy Radiotherapy is the use of ionising radiation or high-energy X-ray beams for cancer treatment. Ionising radiation causes DNA damage, in turn causing cancer cell death. It is one of the oldest forms of cancer treatment and has significantly advanced since William Roentgen discovered X-rays in 1895 and Marie Curie discovered the effects of radiation in 1898. It is a hugely technical and scientifically diverse subject, involving in-depth knowledge of physics, cellular biology, radiobiology and pharmacology.

Radiotherapy planning will form an important part of your time in clinical oncology; it is likely to form 1–2 days of your week (often in smaller chunks). Radiotherapy planning is a ‘hands-on’ practical skill which complements the patient facing time.

The patient pathway in radiotherapy delivery starts with an initial consultation with the clinical oncologist. The role of the clinical oncologist will be to explain what radiotherapy entails, encompassing both the practical aspect of treatment delivery, as well as counselling patients on the intended benefits and the potential acute and late toxicities. For patients having radical treatment (aimed at a cure) the individual cases will have been discussed in a multidisciplinary team meeting with radiologists, other oncologists, specialist nurses and other clinicians to ensure that both the patient and their cancer are suitable for radiotherapy treatment.

Radiotherapy is also a very effective palliative treatment and single treatments or short courses can be used to treat symptoms. The planning of this is simpler with the clinical oncologist defining the treatment field directly.

A career in clinical oncology is a unique and holistic blend of all aspects of non-surgical cancer care. The training requires a solid grounding in general medicine, but provides trainees with the opportunity to treat cancer patients at all stages of their disease. There are excellent opportunities to get involved in clinical trials and academia, and taking time out of programme to undertake cancer research or a clinical fellowship is encouraged.

Trainees will gain experience of: multidisciplinary team meetings; assessing new and follow-up patients in outpatient clinics; managing inpatients and acute oncology care; understanding palliative care; systemic chemotherapy; endocrine and biological therapies; and training in palliative and curative radiotherapy planning and treatment. In addition, the knowledge of general medicine obtained during core medical training helps with the management of medical comorbidities that are often seen alongside cancer diagnoses.

As a clinical oncology trainee, you are required to pass the FRCR examinations during the course of your training. The learning for these exams is well-structured with attendance on appropriate courses being not only encouraged but compulsory. Study leave is therefore well protected in clinical oncology training. There is also dedicated time built into your weekly rota for you to be away from the wards and clinics for radiotherapy planning so that you get to experience every aspect of the job.

Compared to other specialities there are a relatively small number of clinical oncology registrars and so courses and conferences can be a friendly sociable occasion. This can be a useful way to network and share experiences.

What is it like to be a trainee in clinical oncology?Dr Michael Kosmin, ST5

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What will clinical oncology look like in 2050?In over thirty years as a clinical oncologist, I have seen overall cancer cure rates soar from 25% to 50%. In the next thirty years they will surely reach 75%. This won’t be the result of a single breakthrough, but a product of being able to take patients through clinical trials, developing and proving dramatic new therapies. We expect that the role of surgery in curing cancer will diminish, with many patients no longer requiring the ordeal of surgery and instead relying upon modern radiotherapy to achieve the cure.

We will see the development of personalised medicine, where the DNA mutations in a tumour will be seen as targets for novel therapies. Based on those data, a cocktail of targeted drugs uniquely matched to a patient’s tumour can be prescribed. For example, oncologists are likely to be using a concoction of different therapies including immunotherapy and inhibitors of cancer pathways, possibly together with radiotherapy, to produce a specific treatment for the patient’s tumour.

Treatment of cancer will have evolved and you will be part of a multidisciplinary team in a brave new world, contributing to the development of brand new treatments to improve the life of all cancer patients.

8:00 amArrive at the district general hospital (DGH) for the urology multidisciplinary team meeting. Discuss cases with the surgeons, nurse specialists, radiologist, histopathologist and palliative care, deciding the appropriate treatment for each patient.

9:00 amTelephone the on-call oncology registrar to hand over the admissions from overnight as I was on-call from home. The resident senior house officer (SHO) had assessed the patients during the night and both were stable so I did not have to go in. Join the rest of the team in the canteen for a bacon buttie before clinic starts!

9:30 amClinic in main outpatient department at the DGH starts. I see three gentlemen on long-term hormone therapy for prostate cancer, a new patient with prostate cancer who wishes to discuss radical radiotherapy versus surgery, and consent another man for palliative radiotherapy to treat his symptomatic haematuria from bladder cancer. The next patient is a newly diagnosed metastatic prostate cancer patient who we’re starting on hormone therapy. He reports a two-day history of leg weakness and back pain. I arrange for his admission to the oncology centre for an emergency spine magnetic resonance imaging (MRI) scan to rule out cord compression.

1:15 pmClinic finishes and I accompany the consultant to the ward to review a patient who was admitted two days ago with fever post chemotherapy. She doesn’t have neutropenia but is being treated by the medical team for a chest infection. I make a note of her details to document this event in the computerised oncology notes as we may need to review the dose of chemotherapy for the next cycle of treatment. Time for a quick sandwich.

2:15 pmCheck in with the secretary to sign off some letters. Answer emails and return a call to a general practitioner (GP) who has a query.

3:00 pmAttend the registrars’ teaching session – the management of uterine cancer. We review the current guidelines, discuss how we’d manage some example cases, assess the ‘mock’ radiotherapy plans and have a catch-up.

4:30 pmChase up the result of the spinal MRI from this morning’s case. It didn’t show cord compression but there are some metastases that would account for the patient’s pain. I book the patient into the radiotherapy clinic tomorrow and arrange some palliative treatment to help with his pain.

5:15 pmHome time!

In over thirty years as a clinical oncologist, I have seen overall cancer cure rates soar from 25% to 50%. In the next thirty years they will surely reach 75%.

Typical day in the life of a clinical oncology registrarDr Sam Cox, ST6

The future of clinical oncologySeamus McAleer, Senior Lecturer and Consultant in Clinical Oncology; Medical Director, Education and Training, The Royal College of Radiologists

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Medical students:

� Enhance your CV

� Apply for undergraduate bursaries and prizes (see the RCR website [www.rcr.ac.uk] for more info)

� Choose a special study module or elective in clinical oncology

� Develop your portfolio to demonstrate a commitment to specialty – conduct clinical or medical audits

� Join an oncology society, or found your own

� SPEAK to clinical oncologists!

� Attend regional and national careers events

� Spend some time finding out about how the cancer services work in the UK

� Investigate the resources available on the RCR website (www.rcr.ac.uk): the careers pages, public lectures and other informative videos (especially the one on radiotherapy!).

Junior doctors:

� Gain a good grounding in general medicine

� Take or create any opportunity for cancer related research

� Do some clinical or medical audits

� Foster links with the oncology departments and get to know the oncologists and the rest of the team

� Follow a patient through the radiotherapy process

� Attend a taster week or taster evening promoting the specialty

� Investigate the resources available on the RCR website (www.rcr.ac.uk) especially the careers pages, public lectures and other informative videos (especially the one on radiotherapy!).

Top tips: how to get into clinical oncology

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August 2016

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