University of Washington Medical Center (UWMC)

Clinical rotations for first-year fellows

The first year is devoted to 12 months of clinical training in "classical" medical oncology but with substantial exposure to clinical hematopoietic cell transplantation (HCT) and to general clinical research. The first year rotations are divided between several institutions: The University of Washington Medical Center (UWMC); the Seattle Cancer Care Alliance (SCCA); and the Veteran's Administration of Puget Sound Health Care System (VAPS). A combination of patient types and treatment modalities are offered to provide fellows with a solid foundation in medical oncology care.

Core rotations are divided among the sites of practice, as follows:

1. University of Washington Medical Center (2 months inpatient general hematology/oncology; 1 month inpatient HCT)
2. Seattle Cancer Care Alliance (3-4 months ambulatory care general hematology/oncology; 1 month ambulatory care HCT)
3. Veterans Administration Puget Sound (4-5 months inpatient/ambulatory care and general hematology/oncology and HCT)

Two inpatient rotation blocks occur at the UWMC for a total of four months. The general Hematology/Oncology Inpatient Service (Heme/Onc Inpatient Service) is headed by Dr. Stephen Petersdorf. The Hematopoietic Cell Transplantation Inpatient Unit (HCT Inpatient Unit) is headed by Dr. Marc Stewart. (Note: Although the HCT Inpatient Unit is located at UWMC, the SCCA is responsible for the overall HCT program [both inpatient activities located at UWMC and outpatient activities which are located at the SCCA]).

UWMC Heme/Onc Inpatient Service (also referred to as "Green Medicine")

This is a 2-month inpatient rotation providing care for general medical oncology patients, including initial evaluation, treatment with chemotherapy and/or radiotherapy, management of disease and/or treatment-related complications and disposition. In addition to conventional treatment, other modalities of therapy such as stem cell transplantation (autologous or syngeneic) and biological treatments with growth factors and immune response modifiers are employed. The Heme/Onc Inpatient Service is divided into two teams designated A and B. Each of two medical teams consists of two R-1 residents, an R-3 resident, and one fellow. There is one attending for each of the two teams. In conjunction with the attending, the fellow will plan the evaluation and treatment of patients including protocol enrollment, bone marrow biopsies and aspirations, chemotherapy orders (if not already written by an attending), antiemetic orders and appropriate follow-up at discharge. Admissions to Teams A and B alternate without respect to diagnosis, with admissions being assigned to the "on-call" team. The daily patient census for each team averages from 10 to 15 patients. There is a fairly even distribution of hematologic malignancies and solid tumors. Many of the oncology patients are hospitalized on a multidisciplinary 32-bed oncology ward (7 SE). The fellow makes work rounds every morning with his/her team. While providing direction in oncologic treatment, the fellow interacts with the R-1 and attending to provide direction in regular medical care. The fellow supervises the R-1 in bone marrow procedures when possible. The fellow is responsible for providing references and articles relevant to particular patient problems.

Additional responsibilities include management and evaluation of certain short-stay chemotherapy patients who are not seen by the medical team. The fellows are also responsible for inpatient hematology consultations. Night call occurs from home on an alternating basis. The fellows attend bone marrow rounds four afternoons a week. Every other Thursday afternoon they attend hematology clinic at the SCCA.

UWMC HCT Inpatient Unit

This is a 2-month inpatient rotation at the UWMC. Fellows have the opportunity to develop skills and knowledge from some of the foremost experts in the HCT field. There are two units at UWMC (7NE and 8NE floors) devoted to the care of HCT patients for a variety of conditions. Ninety percent of patients are referred from outside the state of Washington. The 7NE inpatient unit consists of 30 beds; the 8NE inpatient units has 22 beds for transplant patients and 6 ICU beds for all oncology patients. Primary care for these units is provided by oncology and hematology fellows and residents from the UWMC, physician assistants, and visitors from many centers throughout the world who wish to gain clinical training in the area of HCT. Patients are intensive care cases with a broad spectrum of problems in internal medicine. The HCT Inpatient Unit provides in-depth experience in HCT, including supportive care (platelet and granulocyte transfusions, reverse-isolation techniques, Hickman catheters, nutrition research, plasma exchanges, ex vivo immunoabsorption), infection prevention and treatment in granulocytopenic and immunosuppressed patients. Basic principles of intensive chemoradiotherapy are emphasized. Supporting activities include pathology, immunology, microbiology, cytogenetics, cryobiology, pulmonary, gastroenterology, nephrology, pediatrics, virology, hematology and blood cell separation laboratories.

Seattle Cancer Care Alliance (SCCA)

The ambulatory care facilities for UWMC general hematology/oncology outpatients and HCT outpatient patients are located at the SCCA adjacent to the Fred Hutchinson Cancer Research Center (FHCRC) campus. Two ambulatory care rotation blocks occur at the SCCA, a 2-month general hematology/oncology rotation and a 1-month HCT rotation. In 2001 the SCCA was formed to take advantage of the strengths of the local medical institutions, the UWMC, FHCRC and Seattle Children's. Transplant patients formerly treated at the FHCRC are now seen under the auspices of the SCCA. Seattle Children's patients are seen by Pediatric Oncology Training Program fellows.

Patients presenting to the SCCA clinic include newly diagnosed patients as well as patients with more advanced disease. Patients will be seen in general oncology clinics, multidisciplinary clinics, and the HCT clinics. During these ambulatory rotations, fellows learn how to deliver chemotherapy and will perform procedures such as bone marrow aspiration and biopsy and delivery of intrathecal chemotherapy. Fellows will also have as part of the ambulatory care experience the opportunity to participate in ongoing clinical research protocols.

SCCA General/Hematology Ambulatory Care

Under the direction of Dr. Stephen Petersdorf, this is a 2-month ambulatory care rotation on the 4th Floor of the SCCA. The goal of this rotation is to provide experience in ambulatory care oncology where fellows see a breadth of patients. Under the guidance of an attending physician, the fellow may evaluate from two to four new patients per day, order appropriate staging and diagnostic studies, perform bone marrow biopsies and aspirates, and formulate a plan of treatment based on history, physical, and test results. Patients are evaluated for eligibility for clinical research protocols. This may involve an explanation of the study and alternative treatment, patient enrollment on the study, and coordination of the treatment program. Cases requiring interdisciplinary management may be seen in one of several specialty clinics. Fellows currently attend multidisciplinary clinics in breast cancer, melanoma and sarcoma tumor clinics where patients are evaluated in conjunction with medical, radiation and surgical oncologists. In addition, there are general medical oncology clinics where patients are evaluated for hematologic malignancies, lung cancer, gastrointestinal malignancies, and other solid tumors. Opportunities are also available for rotation through the gynecologic oncology clinic. Fellows are offered the opportunity to participate in continuity clinics for general hematology/oncology at the SCCA during the second and subsequent years.

SCCA HCT Ambulatory Care

Dr. Marc Stewart heads the HCT ambulatory care activities at the SCCA. This is 1-month ambulatory care rotation following the 2-month inpatient HCT rotation. Planned admissions are scheduled based on the dates and types of preparative regimen as coordinated by the Clinical Coordinator's office. Fellows will also see patients who are admitted for stem cell infusion in preparation for non-myeloablative transplants and unrelated "mini" transplants. HCT patients are followed pre- and post-transplant for a period of approximately 100 days, after which they are referred back to their referring physician.

The HCT ambulatory clinic is staffed with one attending for pediatric patients (Green Team), one attending for autologous patients (Violet and Aqua Teams), and two attendings for allogeneic patients (Blue, Yellow, Lime Team and Red, Orange, Tan Teams). Each attending manages the pre-transplant and post-transplant phases of the patients under their care. Attendings make every effort to see their patients at the time the fellow sees the patient for a follow-up visit. Rounds are held daily in designated conference rooms for each of the four teams starting at 8am on Mon, Wed and Thurs and at 9am on Tues and Fri.

SCCA Clinical Trials

Clinical trials are often performed under the auspices of SCCA protocols, national protocols from the Southwest Oncology Group (SWOG), and in-house protocols. New agents in cancer treatment are being investigated through pharmaceutical company studies and SWOG. The continuing focus of clinical research is an attempt to improve therapy studying new approaches to chemotherapy, improving supportive care or through biochemical modulation. The University of Washington-based faculty with clinics at the SCCA are active participants in SCCA and SWOG protocols. Active representation by faculty members are included in the leukemia, lymphoma, lung, breast, GU, brain tumor, and melanoma committees. Clinical trials are underway using dose dense therapy for breast cancer, high dose therapy for non-Hodgkin's Lymphoma with marrow-ablative or non-marrow-ablative antibody approaches. As the largest sarcoma and melanoma programs in the Northwest, clinical investigation is particularly active in these areas. In particular, the use of biologic-response modifiers with IL-2, in renal cell cancer and melanoma is pursued on the inpatient service. Continued expansion of the clinical research protocols is anticipated as programs are integrated in the SCCA.

Veterans Administration Puget Sound (VAPS)

The Oncology Service at the VAPS is under the directorship of Dr. William Schubach. Fellows are trained in general oncology, with emphasis on the treatment of patients with lung, genitourinary, and head and neck cancer as well as hematologic malignancies. There is an 8-bed transplant unit that performs 40 to 50 HCT transplants per year for patients with hematologic malignancies and aplastic anemia. The VAPS is a 428-bed acute care facility that includes all medical and surgical disciplines. On the average, 650 new cancer cases are diagnosed annually and 550 new cancer patients receive treatment. The general oncology service follows from 12 to 20 inpatients on a daily basis and there is an average of 4,500 visits to the outpatient clinics each year. Referrals are from the entire country through the VAPS systems and the system of military hospitals. This is one of only three such units in the country. The Oncology Service operates an interdisciplinary tumor board, a daily chemotherapy clinic and two weekly clinics, including a prostate clinic for patients on protocol with these diseases. Both general oncology rounds and hematology rounds are conducted five times each week. Transplant rounds are held daily and there is a twice weekly post-clinic conference. Other weekly activities include the oncology X-ray conference, tumor board and bone marrow pathology conference. Fellows are offered the opportunity to participate in continuity clinics at the VAPS during the second and subsequent years.

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	First-year Clinical Rotations
	Research Years