REVISED: January 7, 2015

A Guide to MEDICAL ONCOLOGY

Tom Baker Cancer Centre University of Calgary

2017-2018 For Undergraduate and Postgraduate Medical Trainees

Version: July 2017

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Introduction to Medical Oncology Welcome to the Tom Baker Cancer Centre! This handbook was designed to answer the most commonly asked questions by residents during their Medical Oncology rotation. If you have any questions that are not answered here or need clarification, please do not hesitate to ask me, Mary Lee, or anyone else at the TBCC (we’re a friendly bunch!). In this rotation, You will be assigned to one of 6 “Education Teams” which are made up of 3-4 Medical Oncologists and covering at

least 3 of the 4 major tumor sites (Breast, Lung, GU, GI), plus some minor sites. You should communicate with a preceptor (team coordinator) prior to starting your rotation (emails and pagers can

be found in this handbook). You may be assigned to do inpatient consultations during one of your weeks on this rotation. During that week, you

should not be assigned to clinics at the Holy Cross Centre. While you may be assigned clinics to attend at the Tom Baker Site, you may not always be able to attend if you are doing the consult or are reviewing with the appropriate attending for that tumor site. There is a schedule for Medical Oncologists for urgent/inpatient consultations for each tumor site, and this is with whom you would review the consultation. Please ensure that the preceptor in an assigned clinic is aware that you will be late/have to leave early/not attending the clinic because of consults.

We have 2 sites for our Outpatient Clinics, so please make sure you check where you are scheduled to attend clinic:

1. Tom Baker Cancer Centre (TBCC) – next to Foothills Medical Centre at 1331 – 29 St NW 2. Holy Cross Centre (HXH) – located at 2202 – 2 Street SW (see map at back)

There are a variety of educational rounds that are held at the TBCC: tumor boards, grand rounds, Medical Oncology core curriculum. You are welcome to attend (please refer to your schedule for times and locations). You should attend Friday Morning Handover rounds, particularly if you are on call over the weekend (which start promptly at 8:00) on Unit 57. Along with this handbook, you will have also received other education resources that you should review before starting your rotation. I hope that you enjoy your experience in Medical Oncology, and I look forward to meeting/working with you. Kindest regards Dr. Cynthia Card Director of Medical Oncology Rotations

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Table of Contents

A Few Resources 2 Staff at the Tom Baker Cancer Centre 3 Education Teams – Clinic Schedules 4-6

Medical Oncology – Rotation Objectives 7 Dictations in Clinic 8

Inpatient Service 9 On Call: Responsibilities and Procedures 10

Consensus Statement on Oncology Patients in the ER 11 Holy Cross Centre - Map 12

Tom Baker Cancer Centre Maps 13-14

A Few Resources: Alberta Cancer Guidelines: http://www.albertahealthservices.ca/info/cancerguidelines.aspx BC Cancer Agency Drug Manual: http://www.bccancer.bc.ca/health-professionals/professional-resources/cancer-drug-manual/drug-index

National Cancer Institute - PDQ® Cancer Information Summaries: Adult Treatment: https://www.cancer.gov/publications/pdq/information-summaries/adult-treatment Oncology Education (a Canadian resource for oncology information): https://www.oncologyeducation.com/ Palliative Care – Fast Facts (a quick resource for managing cancer symptoms/treatment side-effects): https://www.mypcnow.org/fast-facts

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Staff at the TBCC Education Coordinator Mary Lee Pedora 403-521-3810 marylee.pedora@ahs.ca Director of Medical Oncology Training Experiences: Dr. Cynthia Card Pager 01684

403-521-3446 cynthia.card@ahs.ca

Faculty Pager Tumor Site Alimohamed, Nimira Bebb, Gwyn Card, Cynthia (Cindy) Cheng, Tina Dowden, Scot Hao, Desiree Heng, Daniel (Danny) Henning, Jan-Willem Krause, Vanessa Lee-Ying, Richard Lupichuk, Sasha Nixon, Nancy Monzon, Jose Morris, Don Roldan-Urgoiti, Gloria Ruether, Dean Stewart, Doug Tang, Patricia Tam, Vincent Tsang, Roger Webster, Marc

02650

01528 01684

05626 05613 01685 08908 02652

00557 08234 00334 02338 11664 00588 10784 03313 00082 07466 10783 00292 01530

GU and Breast Deputy Program Director Medical Oncology Residency Lung and GI Lung and Endocrine/Neuroendocrine Director of Medical Oncology Rotations GU and Cutaneous GI and Unknown Primary Lung and Head & Neck GU and Breast Breast and Sarcoma Program Director Medical Oncology Residency Breast and GI GI and GU Breast and GI Breast GI and Cutaneous Lung and Sarcoma Neuro-Oncology and Breast GU and Endocrine/Neuroendocrine Breast, Lymphoma and BMT GI and Breast GI Breast and Neuro-Oncology Breast and Head & Neck

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Medical Oncology – Rotation Objectives Medical expert:

1. Perform a focused and complete history/physical examination as pertaining to an oncology patient, a. examination of lymph nodes, liver and spleen, breast b. neurological exam to assess of spinal cord compression and brain metastases c. physical findings associated with pleural and pericardial effusions

2. Demonstrate general knowledge of the roles of chemotherapy, hormonal therapy, targeted therapy, radiation and surgery in managing cancer patients at various stages of disease

3. Recognize the differences between adjuvant, curative and palliative therapies and demonstrate general knowledge regarding the indications for these in the common solid tumors

4. Recognize, anticipate and manage general medical problems experienced by cancer patients appropriately 5. Recognize and manage common oncologic emergencies 6. Recognize and describe common acute and chronic toxicities associated with common antineoplastic agents and

the prevention and management of these toxicities 7. Demonstrate proficiency in the following as available: thoracentesis, paracentesis, bone marrow aspiration and

biopsy and lumbar puncture. Communicator:

1. Elicit relevant information from the patients/families to assist in patient care 2. Convey information to patients/families regarding diagnosis, prognosis and treatment options in a compassionate

and effective manner 3. Communicate effectively with other health care providers to ensure consistency and continuity of patient care,

including dictation of clinic notes. Collaborator:

1. consult other physicians/health care professionals in patient care when appropriate 2. participate in multidisciplinary team activities, including patient oriented and educational rounds

Manager:

1. understand the limitations of health care resources and incorporate the principles of evidence based medicine to make management decisions that maintain the best interest of the patient

2. work effectively and efficiently in a cancer care setting Health Advocate:

1. identify risk factors important in the development of malignancies and provide appropriate counseling to patients and families

2. identify where the role of cancer screening is established and promote preventative strategies 3. recognize and respond to issues in which advocacy on behalf of cancer patients is appropriate

Scholar:

1. review and critically appraise medical information and incorporate the use of evidence into daily clinical decision making

2. develop skills necessary in medical education of patients, students, residents and other health professionals 3. gain exposure to clinical trials and recognize their importance and contribution to the evolution of medical oncology

as a subspecialty Professional:

1. deliver quality care with integrity, honest and compassion 2. exhibit personal and interpersonal professional behaviors

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Dictations in Clinic We currently use the DST dictation system. • If you are from the UofC, you should already have your own “Speaker Code”. • If you are a visiting trainee, you will have requested a “Speaker Code” when completing your paperwork to do an

elective as a non-UofC trainee. Dial 77778 (or 1-855-648-3117) Speaker Code Enter: _ _ _ _ _ # (5 digits followed by #) Facility Code 213 # ( Tom Baker Cancer Centre)

201 # (Holy Cross Site) Work Type 11# (Initial Consultation)

90# (Progress Note) Patient Medical Record Number

_ _ _ _ _ _# (6 digit ACB patient number – drop the ‘letter’ at the beginning for eg. ACB# C999999 would be entered as 999999#)

Initiate Dictation Enter: 2 Then if dictation is a priority, Enter: 1

Start Dictating • This is “____” (spell name) dictating for “Dr. _____” (spell name) • Dictating from

o “Tom Baker Cancer Centre” or o “Holy Cross Cancer Clinic”

• “Initial Consult Note” or “Progress Note” • On “_______ ” (state patient name and spell name) • Date of birth ____-____-____ • Patient Number _ _ _ _ _ _ _ (ACB# for example “C999999”) • Date of visit ____- _____-____ • Please send copies to:_____ _____ … (full name and location of those you wish to send

copies to) Dictate Note using Section Headings

Examples: Diagnosis Treatments to Date Past Medical History Medications Summary and Plan (you may want use your preceptor’s dictations as a guide)

State punctuation; Spell ‘difficult’ words

• Say “Period”, “Comma”, “Colon”, “new paragraph” • When making lists say “Number 1”, “Next Number”, “Next…”

Other Keypad Prompts 3 = Short rewind 4 = rewind to beginning 54 = fast forward 55 = fast forward to the end 7 = abandon dictation

Ending the dictation 9 = end dictation

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Inpatient Service Medical Oncology inpatients are admitted to one of 2 teams. I know it will be confusing but this system was needed because we have 4 AIMG clinical associates working with the inpatient service. Team A (mostly Lung and GI): One to two clinical associate is assigned to this team at all times There is one attending physician for this team, covering one week at a time

o Schedule available (but can change so ask) Patients are admitted to team A if their TBCC physician is:

o Dr. G. Bebb o Dr. C. Card o Dr. S. Dowden o Dr. G. Roldan-Urgoiti o Dr. D. Hao o Dr. R. Lee-Ying o Dr. S. Lupichuk o Dr. J. Monzon o Dr. P. Tang

Team B (mostly Breast and GU): One clinical associate is assigned to this team at most times Multiple attending physicians, each covers their own patients Patients are admitted to team B if their TBCC physician is:

o Dr. P. DeRobles (Neuro-oncology only) o Dr. T. Cheng o Dr. D. Heng o Dr. J-W Henning o Dr. V. Krause o Dr. D. Morris o Dr. N. Nixon o Dr. D. Ruether o Dr. D. Stewart (Breast only – Lymphoma goes to Hematology)) o Dr. V. Tam o Dr. R. Tsang o Dr. M. Webster

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On-Call: Responsibilities and Procedures You will be provided with an on-call schedule prior to starting the rotation. This schedule is set out by the Chief Resident in Medical Oncology, and any questions pertaining to this should be directed to the Chief Resident. It is “Home Call. There will be a Medical Oncologist on-call with you. Responsibilities Weeknight coverage of inpatients starts ~ 4:30 pm and ends at 8am

o You may be asked to admit a patient directly to the hospital o You are not expected to round on patients, only to see those patients having issues/problems o Speak to the clinical associates for handover at 4:45pm

Weekend coverage of inpatient, you will be expected to round on the Medical Oncology inpatients during the day; this is often shared with the Medical Oncologist on-call

Emergency room consultations/admissions (see next page for CHR guidelines): Questions to ask before agreeing to see a consult for admission: 1. Who is this patient’s Medical Oncologist?

a. Not all cancer patients are followed by Medical Oncologist it is common for a patient to be more appropriate for Hematology, Radiation Oncology, Gyne-oncology, and Surgical Oncology.

b. If the patient has never been seen at the TBCC, contact the MedOnc On-call and ask his/her opinion on the consult

2. What is the diagnosis? (Should be a solid tumor) 2. What is the reason for admission?

a. Admissions should be for cancer-related problems or chemotherapy-related complications i. Eg if patient is having an MI or stroke, should not be admitted to MedOnc

b. If brain mets or spinal cord compression, should go to Radiation Oncology (if in doubt, ask the MedOnc on-call)

Foothills Inpatient Consultations o You are not responsible for inpatient consultations, unless the MO has asked you to do a consult o It is common for the resident on-call to be paged for consults; if this occurs, take the information on the consult,

and then call the Medical Oncologist on-call to find out who to send the consult to Procedures Handover on Weeknights

o You should be contacted by Clinical Assistants before they leave for the day o If you are not getting handover, please contact Dr. Card so she can look into this

Handover for Weekends There are formal handover rounds, starting promptly at 8:00 on Unit 57 Resident Handover post-call please contact the Clinical Assistants or Attending MO if there are any admissions

while you are on-call, or if there were problems with particular patients Weekend – Rounding on patients discuss with the MO you are on call with about how he/she wants to do rounds

over the weekend If in doubt or in need of assistance, do not hesitate to contact the Medical Oncologist On-call, as they are ultimately

responsible for patients

POST-CALL: As per the PARA contract, you may leave early on your post-call day. PLEASE inform the physicians in the clinics that you will miss

that you will not be attending, and do so ASAP.

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Consensus Statement: Recommended Admission and Disposition of Oncology Patients presenting to CHR Emergency Departments

Clinical Scenario Examples Recommended Disposition

Patient with proven oncology diagnosis, requiring or receiving active chemotherapy

- Delivery of multiple days of chemotherapy - Chemotherapy not well tolerated as

outpatient - Symptomatic liver metastasis

Medical Oncology admission

Patient with proven diagnosis, requiring or receiving active radiation therapy

- Spinal cord compression - Brain metastases - Emergent radiation therapy for pain crisis

or severe dyspnea - Elective radiotherapy patients who are too

frail to travel from home

Radiation Oncology admission

Toxicity of acute radiation therapy or chemotherapy requiring admission, or delayed toxicity of recent therapy

- GI inflammation - Head&Neck soft tissue inflammation

related to radiation therapy - Febrile neutropenia - Opportunistic infection

Medical or Radiation Oncology admission, based on treating service

Active treatment completed, possible complication of therapy

- See above Seek consultation/advice from primary oncologist before making disposition decision

Palliation of symptoms after completion of active chemotherapy and radiation therapy

- Progressive symptoms - Patient requiring higher level of care than

can be provided at home (eg hospice)

Non-oncology service, likely hospitalist Immediate (ER) involvement of palliative care service for complex symptom mgmt only, or if specifically requested by outpatient palliative care-givers

New medical problem unrelated to oncology diagnosis, regardless of current active radiation or chemotherapy

- Many examples Non-oncology service, MTU or hospitalist (refer to scope of practice documents)

Oncology patient in ER at RGH or PLC (no on-site oncology service)

- Any patient Not necessary to admit directly to FMC oncology, unless urgent radiation or chemotherapy required, and patient not fit for daily transfer between sites

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Holy Cross Centre (HXH) 2202 – 2nd St SW

HXH

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