ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology Edition 2023

Tanja Cufer; Michael P Kosty; Curriculum Development Subgroup—ESMO/ASCO Global Curriculum Working Group

doi:10.1016/j.esmoop.2023.101631

. 2023 Oct 23;8(6):101631. doi: 10.1016/j.esmoop.2023.101631

ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology Edition 2023

Tanja Cufer ^1,^∗,^∗, Michael P Kosty ²; Curriculum Development Subgroup—ESMO/ASCO Global Curriculum Working Group, on behalf of the

PMCID: PMC10774906 PMID: 38158226

Abstract

The European Society for Medical Oncology (ESMO) and ASCO are publishing a new edition of the ESMO/ASCO Global Curriculum (GC) with contributions from more than 150 authors. The purpose of the GC is to provide recommendations for the training of physicians in medical oncology and to establish a set of educational standards for trainees to qualify as medical oncologists. This edition builds on prior ones in 2004, 2010, and 2016 and incorporates scientific advances and input from an ESMO/ASCO survey on GC adoption conducted in 2019, which revealed that GC has been adopted or adapted in as many as two thirds of the countries surveyed. To make GC even more useful and applicable, certain subchapters were rearranged into stand-alone chapters, that is, cancer epidemiology, diagnostics, and research. In line with recent progress in the field of multidisciplinary cancer care new (sub)chapters, such as image-guided therapy, cell-based therapy, and nutritional support, were added. Moreover, this edition includes an entirely new chapter dedicated to cancer control principles, aiming to ensure that medical oncologists are able to identify and implement sustainable and equitable cancer care, tailored to local needs and resources. Besides content renewal, modern didactic principles were introduced. GC content is presented using two chapter templates (cancer-specific and non–cancer-specific), with three didactic points (objectives, key concepts, and skills). The next step is promoting GC as a contemporary and comprehensive document applicable all over the world, particularly due to its capacity to harmonize education in medical oncology and, in so doing, help to reduce global disparities in cancer care.

Keywords: Global curriculum, medical oncology, training requirements, learning objectives, didactic principles

1. Introduction

Tanja Cufer

Michael P. Kosty

Cancer remains one of the major global health care issues.¹ Despite increasing incidence rates, the trend of mortality rates is decreasing in some regions of the world, mainly due to improved cancer care. Over the past few decades, medical oncology gained an important and independent role in multidisciplinary cancer care. With the increasing internationalisation of health care as well as the increased exchange of specialists and knowledge across borders, the European Society for Medical Oncology (ESMO) and ASCO identified the need for a set of international recommendations for the clinical training of physicians to qualify them as medical oncologist. Patients, wherever they live, should have a chance of receiving the best possible, evidence-based treatment from well-educated physicians.

In 2004, a joint ESMO/ASCO Task Force produced the first outline for a Global Core Curriculum (GCC) for training in medical oncology. This outline was subsequently distributed to universities as well as medical oncology societies and was simultaneously published in the Annals of Oncology and the Journal of Clinical Oncology.^2,3 The GCC was updated in 2010 with the change in the title from “Global Core Curriculum” to “Global Curriculum.”^4,5 This was based on the observations that all curriculum recommendations might not be implementable in some countries, due to different priorities, needs, and resources around the globe. In 2016, the third edition of Global Curriculum (GC) was developed and published by the Global Curriculum Working Group (GC WG) which evolved from the GC Task Force.⁶ Each of the GC editions introduced updated information and skills that medical oncologists need to know and master, to be able to implement them in their everyday clinical practice.

The GC Task Force also produced a Log Book as a support tool for medical oncologists in training and their supervisors with the purpose of keeping a record of oncology trainees' educational programmes and their progress, at the same time providing mentors a tool to assess the mentees' performance. Each edition of the GC was accompanied by a corresponding Log Book. The third Log Book (edition 2017) corresponds to the 2016 GC and is available on the ESMO and ASCO websites.^7,8

Interest in using the ESMO/ASCO GC outline has increased considerably since its inception, as evidenced by translations in 11 languages. It is also used as a model for the development of the speciality of medical oncology in several countries around the world. In 2011, the European Commission based its formal recognition of medical oncology as a medical speciality on the recommendations of the ESMO/ASCO GC.⁹

A global survey conducted by ESMO/ASCO GC WG in 2019 identified a high rate of medical oncology recognition and GC adoption worldwide.¹⁰ Based on this survey, medical oncology has been recognised as a standalone speciality or sub-speciality in 75% of responding countries, without major differences observed around the globe. GC has been adopted, either fully or partly, into training programmes of two thirds of countries with recognised medical oncology specialisation. In addition, GC has also been adapted in some countries with mixed training in haemato-oncology or clinical oncology. It is encouraging that despite being ambitious and complex, GC remains highly applicable at global level. One of the main reasons for this is that it has been updated in close collaboration with the colleagues working on medical oncology training programmes worldwide. Many of them provided significant contributions to all ESMO/ASCO GC editions as co-authors and editorial board members.

Significant advances in medical oncology continue to occur at a very rapid pace. Since publication of the 2016 edition of the GC, there has been an explosion of new therapies: new targeted agents, increasing indications for immunotherapy, advances in cellular therapy, as well as continuing refinements in molecular pathology and imaging. The increased personalisation of cancer therapy, introduction of multidisciplinary treatment approaches, and widespread adoption of digital technology, as well as recognition of the need to reduce barriers to cancer care delivery, have necessitated changes in how we train future generations of oncology specialists. The standard and special requirements for training in medical oncology stemmed on previous GC editions^2-6 have been updated. While many of the disease state chapters required only minor revision, others needed significant revisions reflecting a substantial shift in the way patients are diagnosed, treated, and followed.

In order to simplify and standardise each disease chapter, the format was reorganised based on three didactic principles (objectives, key concepts, and skills) and separated templates for cancer-specific or non–cancer-specific chapters were used. It is anticipated that this new format will provide clarity for both the faculty and trainees regarding topics that are important to understand and master. For cancer-specific chapters, a common objective on ability to perform specialist assessment, guide systemic therapy in the context of multidisciplinary treatment, and counsel patients with particular cancer will be outlined in the preface. Each chapter will provide updated key concepts with the references to supplement the key concepts and skills. At the completion of their training, it is expected that the trainee will be able to perform specialist assessment and guide systemic therapy in the context of multidisciplinary treatment and counselling of patients with each type of cancer along the disease continuum.

With regard to content, multiple changes and innovations have been incorporated in the GC 2023, including:

•
updating the sections on educational programme to reflect the techniques and teaching environment used by users of the GC;
•
updating and expanding sections on cancer epidemiology and prevention;
•
expanding the therapy sections to include options which have only recently became available;
•
significantly revising sections on pathology, molecular pathology, laboratory medicine, imaging, translational research, and principles of personalised cancer medicine, which acknowledges the substantial advances in each of these areas;
•
combining and expanding the sections in prior versions dealing with unique populations of patients into one unified chapter discussing the management and treatment of specific populations;
•
adding a section on emergencies in oncology;
•
adding a section on patient education to the standalone chapter on psychosocial aspects of cancer, which acknowledges the important role patients play in the management of their cancer;
•
adding an entirely new section on cancer research with subsections on translational and clinical research, research ethics, and statistics;
•
adding a new section on cancer control which broadly covers health care systems, technology, team-based care, access to health care, equity principles, and global cancer control;
•
cancer care in low resource environments was deleted as a stand-alone chapter—aspects of this content were included in other existing chapters, such as cancer control, cancer prevention, and cancer epidemiology.

Several basic skills exist that are of importance to all clinicians and patients; therefore, separate chapters/sections have been revised and enhanced:

•
integration of palliative or supportive care measures;
•
consideration of psychosocial aspects of care including communication skills;
•
survivorship issues.

Core references provided for each chapter in the GC 2023 will be basic or review articles and are not intended to be all encompassing. Faculty and trainees are encouraged to take full advantage of the extensive medical literature available from many sources, including ASCO and ESMO. In addition to the chapter-specific references, a link to ESMO, ASCO, or NCCN guidelines and some other online ESMO and ASCO educational materials will be provided.

Although the GC 2023 is very comprehensive, it does not claim to be a textbook. Moreover, it is the intention of the GC to represent a meticulously structured collection of requirements to be fulfilled in order to qualify as medical oncologist. A corresponding Log Book for the documentation of the assessment of the learning progress according to the GC 2023 will follow.

References

1.
Sung H, Ferlay J, Siegal RL, et al: Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71:209-249, 2021
2.
Hansen HH, Bajorin DF, Muss HB, et al: Recommendations for a global Core curriculum in medical oncology. Ann Oncol 15:1603-1612, 2004
3.
Hansen HH, Bajorin DF, Muss HB, et al: Recommendations for a global core curriculum in medical oncology. J Clin Oncol 22:4616-4625, 2004
4.
ESMO/ASCO recommendations for a Global Curriculum in medical oncology, 2010 update. https://www.esmo.org/content/download/8171/168764/file/ESMO-ASCO-Revised-Recommendations-for-aGlobal-Curriculum-in-Medical-Oncology.pdf
5.
ESMO/ASCO recommendations for a Global Curriculum in medical oncology, 2010 update. http://www.asco.org/sites/default/files/esmoasco_revised_recommendations.pdf
6.
Dittrich C, Kosty M, Jezdic S, et al: ESMO/ASCO recommendations for a global curriculum in medical oncology edition 2016. ESMO Open 1:e000097, 2016
7.
ESMO/ASCO Global Curriculum for training in medical oncology, Log Book, second edition, 2016. http://www.esmo.org/content/download/81967/1487517/file/The-ESMO-ASCO-Global-Curriculum-for-Training-in-Medical-Oncology-Log-Book-2016.pdf
8.
ESMO/ASCO Global Curriculum for training in medical oncology, Log Book, second edition, 2016. https://www.asco.org/sites/newwww.asco.org/files/content-files/international-programs/documents/2016-ESMO-ASCO-Log-Book-interactive.pdf
9.
The European Parliament and the Council of the European Union: Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications (text with EEA relevance). OJ EU L255:22-142, 2005
10.
Cufer T, Kosty M, Osterlund P, et al: Current landscape of ESMO/ASCO global curriculum adoption and medical oncology recognition: A global survey. ESMO Open 6:100219, 2021

2. Standard requirements for training in medical oncology

Tanja Cufer

Michael P. Kosty

Florian Lordick

on behalf of the ESMO/ASCO GC Working Group

The training requirement to specialise in medical oncology encompasses a minimum of 5 years of clinical and didactic activities, beginning with training in internal medicine for 2-3 years, followed by a training programme in medical oncology for an additional 2-3 years. Structured rotations within different internal medicine disciplines allow trainees to acquire basic knowledge and skills in internal medicine, which is an essential foundation for speciality training. The subsequent medical oncology training programme should be conducted with a well-defined curriculum in medical oncology and committed faculty.

The training programme in medical oncology must include full-time clinical activities in the diagnosis and management of a broad spectrum of neoplastic diseases comprising solid tumours and haematologic malignancies. Trainees should have access to a wide variety of disciplines in oncology, including general surgery and surgical subspecialities, radiation oncology, pathology, laboratory medicine, diagnostic radiology, psycho-oncology, palliative and supportive care, as well as epidemiology, molecular biology, and rehabilitation.

Full-time clinical training means that the trainee's professional time and effort during a standard working week is dedicated to clinical activities, defined as patient care and education. These may include the primary care of patients with cancer on the general medical or on designated medical oncology inpatient units, oncology outpatient clinics and day care units, regular oncology rounds, oncology consultations, and performance of interventional procedures as well as a review of imaging, pathology, molecular pathology, and other diagnostic materials. Trainees should actively take part in multidisciplinary tumour board meetings on a regular basis. Attendance of national and international meetings and exchange of evidence-based knowledge between peers should be encouraged. Reading relevant literature and active participation in journal clubs should be part of the curriculum. Sufficient access to all these activities should be provided.

Clinical activities should also include care for patients enrolled on clinical trials. To ensure adequate understanding of medical evidence, active involvement in clinical and translational research activities should be included, whenever possible. Dedicated time for clinical research activities of a maximum of 6 months may be counted toward the total training period of at least 5 years. Research experience of longer duration, including international training, is strongly recommended, especially for oncologists who wish to pursue an academic career.

3. Special requirements

Ahmad Awada

Kathryn Bollin

Jill Gilbert

on behalf of the ESMO/ASCO GC Working Group

3.1. Programme Leader/Director of Medical Oncology Training Programme

The medical oncology programme leader (or director of medical oncology training programme) must be qualified to supervise and educate trainees in medical oncology. Thus, the leader must be certified in medical oncology or possess equivalent qualifications. The leader will have a major commitment to the training programme and related activities, and must be based at the primary training site of the medical oncology programme.

The programme leader will document completion of medical oncology training by the trainee. The trainee will maintain a record of his/her training that the programme leader will countersign, as appropriate, to confirm the satisfactory fulfilment of the required training experience and the acquisition of the competencies that are gained in the speciality curriculum. The record will remain the property of the trainee and must be signed at the annual reviews by the responsible programme leader/director of the medical oncology training programme.

3.2. Faculty

3.2.1. Faculty Members

The medical oncology programme faculty must include a minimum of three full-time, qualified teaching faculty members, including the programme leader. All faculty members must be certified in medical oncology or possess equivalent qualifications. Each of the faculty members must devote a minimum of 10 hours per week to teaching, clinical work, or other scholastic activities. Faculty must actively participate in the critical evaluation of performance, progress, and competence of the trainees.

3.2.2. Faculty Standards

The teaching staff must demonstrate an interest in teaching and set an example for trainees by documented engagement in the following pursuits: actively sharing the personal experience of working in a medical oncology clinical practice and multidisciplinary team; continuing his/her own medical education; active membership in regional, national, and international scientific societies; ideally active participation in scholarly activities; and presentation and publication of scientific studies.

3.3. Educational Programme

The educational programme in medical oncology must be organised to provide training and experience at a level high enough for the trainee to acquire the competency of an independent specialist in the field. The programme must emphasise scholarship, self-instruction, development of critical analysis of clinical problems and the ability to make appropriate decisions, in addition to active involvement in regularly scheduled conferences and multidisciplinary clinics and/or tumour boards. The educational goals set by the programme should be formalised into a curriculum which is routinely updated and provided to trainees by the programme leader.

The curriculum should at least cover all aspects of cancer care, from basic oncology science, epidemiology, diagnostics, multimodality treatment, supportive and palliative care to genetic counselling, psycho-oncology, cancer research, and cancer control principles.

The programme should foster all aspects of the roles required of an oncologist, including being an effective communicator with patients, a collaborator in the treatment team, a manager of the health care system, a health advocate not just for the patient but for the community, and a scholar with lifelong commitment and high professional ethics and standards. Appropriate supervision of the trainees must be provided for the duration of their educational experience. Evaluation of trainees, in addition to evaluation of faculty, the training programme, and training facilities is strongly recommended.

The following principles require special emphasis:

3.3.1. Educational Environment

Medical oncology training programmes must provide an intellectual environment for acquisition of the knowledge, skills, clinical judgement, and attitudes essential to the practice of medical oncology in the context of multidisciplinary care. This objective can only be achieved when appropriate resources and facilities are available. Service commitments must not compromise the achievement of educational goals and objectives.

3.3.2. Professionalism

Professionalism must be fostered during medical oncology training. In addition to mastering the comprehensive clinical and technical skills of the consultant medical oncologist, trainees are encouraged to participate in the educational activities of professional organisations, community programmes, and institutional committees. By the end of training, trainees should be able to intervene and use appropriate resources to prevent and manage professionalism lapses and dilemmas in self and others. The program should foster accountability and conscientiousness. This includes the ability to perform tasks in a timely manner with appropriate attention to detail. Professionalism training should also include the ability to develop a plan to optimise personal and professional well-being.

3.3.3. Responsibility

Lines of responsibility must be clearly delineated for the trainees in medical oncology. Specifically, the programme must delineate trainee responsibility for patient care, progressive responsibility for patient management and graded supervision. This encourages the transition from an early to an advanced learner.

3.3.4. Update of Skills and Knowledge

Having obtained certification in medical oncology, the specialist is expected to update the acquired skills and knowledge by participating in continuing medical education programmes such as courses, symposia, or self-learning processes on a regular basis.

3.3.5. Interdisciplinary Teamwork

It is also essential to have the support of oncology nursing, pharmacy, emergency medicine, intensive care, rehabilitation medicine, palliative care medicine, and dietetic and psychosocial services so that the trainee can perceive the role of other specialities in the total care of the patient with cancer. Specifically, the trainee should be able to coordinate care of patients in complex clinical situations effectively using the roles of their interprofessional teams.

3.3.6. Institutional Requirements

3.3.6.a. Clinical setting

The clinical setting must include opportunities to observe and manage patients with a wide variety of neoplastic diseases on an inpatient and outpatient basis. The trainee must be given the opportunity to assume the continuing responsibility for acute and chronically ill patients in order to learn the natural history of cancer, the extent of the effectiveness of the various therapeutic programmes and how to impart information to the patient, including bad news. The scenario should include everything from prevention, treatment, to the long-term follow-up of patients with cancer and survivorship.

3.3.6.b. Hospital facilities

Modern inpatient, ambulatory care and laboratory facilities necessary for the overall educational programme must be available and functioning. Specifically, at the primary site, there must be adequate pathology services, modern diagnostic radiology services, resources for nuclear medicine imaging, blood banking and blood therapy facilities, and facilities for clinical pharmacology and tumour immunology/biology. A general surgical service and its support must be available, in addition to access to radiation therapy. The programme must also include a set-up for multidisciplinary tumour conferences and preferably participation in clinical trials according to guidelines on good clinical practice.

3.3.7. Facilities

It is the responsibility of the teaching institute to oversee that these facilities are available before a graduate medical education programme is initiated.

References

1.
Hansen HH, Bajorin DF, Muss HB, et al: Recommendations for a global Core curriculum in medical oncology. Ann Oncol 15:1603-1612, 2004
2.
Hansen HH, Bajorin DF, Muss HB, et al: Recommendations for a global Core curriculum in medical oncology. J Clin Oncol 22:4616-4625, 2004
3.
ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology, 2010 Update. https://www.esmo.org/content/download/8171/168764/file/ESMO-ASCO-Revised-Recommendations-for-aGlobal-Curriculum-in-Medical-Oncology.pdf
4.
ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology, 2010 Update. http://www.asco.org/sites/default/files/esmoasco_revised_recommendations.pdf
5.
Dittrich C, Kosty M, Jezdic S, et al: ESMO/ASCO recommendations for a global curriculum in medical oncology edition 2016. ESMO Open 1:e000097, 2016

4. Competencies required in the curriculum

4.1. Basic Science

4.1.1. Cancer Biology

Bently Doonan

Julia Lee Close

Joan Seoane

Objectives	To describe the cellular components, molecular mechanisms, and alterations in basic cell biology involved in the development of cancer and apply these concepts as they relate to disease, modes of action of specific drugs, significance of biomarkers, and the basis for adverse effects and acquired resistance to treatment
Key Concepts	Describe the process of cell division and tissue regeneration starting from the precursor stem cell to progenitor cell and finally to differentiated cells and how this process is under tight intracellular control Summarise the concept of a cancer stem cell/cancer-initiating cell and how a cell capable of regeneration, resistance to cell death, and endless replication leads to tumour development, relapse, and metastasis and how this poses difficulty in tumour eradication Recognise the importance of increased and unchecked cell division in tumours as it relates to available anti-cancer therapeutics which target various aspects of this process Explain that each tissue is comprised of a heterogenous amalgam of cells undergoing cell division or apoptosis at various stages depending on innate cellular mechanisms and environmental stressors Determine that these environmental stressors can lead to aberrations in cell division oversight, resistance to apoptosis, and loss of function in tumour suppressor genes that provide an evolutionary advantage for clonal selection of tumour cells over normal cells Recognise that response to therapy, likelihood and pattern of metastasis, and aggressiveness of disease are related to both site of origin and tumour histology, among other factors Demonstrate an understanding that the tissue of origin of tumours is also important to pathologic identification of cancer and that there is overlap between shared normal cell surface and intracellular proteins between cancer cells and normal cells Determine that interactions between tumour cells and the surrounding tumour stroma (extracellular matrix, fibroblasts, fatty tissue, vasculature, and immune cells) are vital to tumour survival, resistance to treatment, and development of metastasis Distinguish that cell-cell interaction between tumour tissue and surrounding microenvironment (including immune cells) utilize natural existing mechanisms for cell survival, communication, and metabolism which makes targeting these features difficult and results in off target toxicity to treatment Recognise that epithelial to mesenchymal, as well as other trans-differentiation changes related to changes in cell surface receptor and cell adhesion expression can lead to tumour migration and metastasis and that the reverse of this process leads to tumour establishment in new locations Explain that selective pressure induced by tumour targeted strategies (chemotherapy, radiation therapy, immunotherapy) leads to selection of resistant clones within the heterogenous tumour leading to resistance and treatment failure
Skills	Demonstrate the ability to: Use information technology and data sets to understand the landscape of disease and patients' care Critically discuss mechanisms of pharmacologic interactions within the cell and the potential adverse effects based on intracellular pathways of signalling and metabolism Critically discuss the heterogeneous nature of tumours and selective environmental stress that results in tumour evolution, metastases, and therapy resistance

Objectives	To be able to: Critically interpret the process of transformation of a normal cell into a malignant cell through a series of genomic alterations and epigenetic modifications of oncogenes and tumour suppressor genes Recognise interactions between oncogenes and tumour suppressor genes and the processes they control, and the impact on tumour biology, epidemiology, and molecularly targeted therapies
Key Concepts	Recognise oncogenes and tumour suppressor genes and their association with hereditary cancer and that the same genes can be responsible for malignant development of sporadic cancers Determine that proto-oncogenes are normally functioning genes that when subjected to genomic alterations or epigenetic modifications are converted to oncogenes altering their normal function or expression levels Recognise that alteration of a single oncogene works in a dominant fashion and can result in malignant transformation, whereas tumour suppressor genes work in a recessive fashion, so they require loss of two copies of gene for malignant transformation Demonstrate an understanding of Knudson's hypothesis of two-step loss of tumour suppressor function in retinoblastoma as a model for cancerogenesis Recognise that the tumour suppressor TP53 is the gatekeeper of the normal cell function and interacts with more than 500 intracellular proteins and that activation in normal cells results in apoptosis and that loss of function is seen in multiple malignancies and is correlated with aggressiveness and resistance to therapy Identify the common tumour suppressor genes associated with familial cancer syndromes, retinoblastoma (RB), Li-Fraumeni syndrome (TP53), Cowden syndrome (PTEN), and breast and ovarian cancer syndrome (BRCA1, BRCA2) Recognise retroviral infections and DNA transfections as classical models of identifying common tumour oncogenes, c-MYC, RAS, ALK, and the NTRK family, which are becoming actionable targets in treatment Identify the potential for chromosomal translocation and gene fusions that result in malignancy and the BCR-ABL fusion gene generated from translocation of chromosome 9 and 22 as a model for cancerogenesis Explain that there are multiple translocations that result in oncogene activation which are critical to tumour development, can be used for tumour identification, and are increasingly the targets of therapy Demonstrate an understanding of the well described pathway of colorectal cancer development where multiple sequential mutations and epigenetic modifications result in mutations in APC, resulting in polyp formation followed by oncogenic activation in KRAS leading to proliferation and finally loss of TP53 function Determine there are additional alterations in resistance to apoptosis genes, genes involved in cell cycle, DNA damage and repair mechanisms, and mitogenic signal transduction pathways that play a role in cancerogenesis and that a major focus of tumour identification and treatment relies on identification and targeting of these changes Identify the common environmental stresses and exposures that result in mutations leading to malignancy, including cigarette smoke, UV radiation, gamma radiation, heavy metals, radon, asbestos, and benzene among others Distinguish that common viruses can also lead to cancer development when paired with additional cellular alterations, most importantly is the relationship between human papillomavirus and cervical and squamous cell head and neck cancers Identify escape of the immune system as an important aspect of tumour survival Determine that genomic alterations are random and sequential and that lead to intratumour heterogeneity that can evolve under environmental pressure such as therapies
Skills	Demonstrate the ability to: Discuss familial cancer syndromes and risks of subsequent malignancies based on genetic mutations Discuss and interpret environmental risk factors for malignancy development including common carcinogens and their respective cancers Counsel patients with this knowledge as a mechanism for appropriate risk reduction and appropriate population screening Understand the complexity of cancer and its evolving heterogeneity Understand the interaction of the immune system with cancer

Objectives	To describe: The basic components of the immune system and the interrelationships between the host immune system and the tumour The immune surveillance postulate of anti-tumour immunity and mechanisms of immune evasion and commonly utilised immunotherapy strategies
Key Concepts	Identify the components of the cellular and humoural immune system and their differences Identify the difference between innate and adaptive immunity and the different components of each system and their interplay Distinguish the different classes of immunoglobulin molecules, their primary roles and location within the immune system, and the mechanism of class switching Express the components of immunoglobulins (Fab/Fc fragment, heavy/light chains, variable/constant domains, hypervariable region) Recognise the primary immunoglobulin manipulated for anti-cancer therapy is IgG and the mechanisms by which this molecule has effect (receptor blocking, opsonisation, ADCC) Explain the role of co-inhibitory and co-stimulatory immune checkpoint molecules, their function in prevention of host autoimmunity, how this is manipulated by tumours for immune evasion and how these are targeted Identify the components of the T-cell receptor complex, the homology with this structure and immunoglobulins, and the role of co-stimulatory molecules in T-cell activation Recognise the main differences between the human leucocyte antigen complex classes (HLA A, B, C v HLA DM, DO, DP, DQ, DR) and their animal counterparts MHC Class I/Class II Identify the role and function of cytokines and chemokines and specifically those related to tumour growth, immune evasion, and those with anti-cancer properties Give examples of the major classes of immunotherapeutics for cancer: monoclonal antibodies targeting growth factor receptors, checkpoint inhibitors, cytokine therapy, tumour-infiltrating lymphocyte therapy, T-cell receptor therapy, CAR-T cell therapy, bi-specific antibodies and cancer vaccines Describe the innate immune system and its components and how tumours evade immune detection and the burgeoning role for targeting/manipulating these cells in anti-cancer therapy Identify the general use and efficacy of immune checkpoint inhibitor therapy across disease types and the difference between immune responsive (hot) tumour types and nonresponsive (cold) tumours Recognise the potential and promise of immunotherapy but the issues with broad application and general total population response rates of roughly 20%
Skills	Demonstrate the ability to: Apply the proper use of immunotherapy in management of disease and where these therapies fall in the stage of cancer treatment Predict common immune-mediated side effects to checkpoint inhibition therapy and the common side effects associated with cell-based strategies including CAR-T cell therapy and be able to differentiate the type of management needed based on symptom severity Discuss the complicated interactions of the immune system and tumour to patients and how immunotherapy works for their given cancer Differentiate between tumour progression, pseudo progression, and hyper progression to immunotherapy agents

Objectives	To describe: The central role of molecular alterations in cancer biology and evolution that play a role at all stages of tumorigenesis and are one of the largest areas of interest in pharmacologic targeting in cancer The increasing role for targeting tumour characteristics and molecular alterations that are shared among different cancer types and understand how these pathways relate to the mechanisms of action of certain anti-cancer drugs
Key Concepts	Distinguish commonly mutated tumour suppressor and oncogenes involved in tumour development and progression Explain the basis for therapeutic targeting of molecular mutations in tumours and the various mechanisms of pharmacologic intervention Define the importance of molecular oncology in the diagnosis, prognosis, and selection of therapeutic options in solid and haematologic malignancies Describe the concept of tumour molecular heterogeneity and how tumour evolution results in molecular differences in different areas within the same tumour lesion or between different tumour lesions of a same patient Demonstrate an understanding that some molecular alterations will be present from the onset of the tumour cell, whereas others will emerge over time as a result of selective pressure Recognise there are shared molecular alterations across tumour types of different origin and that these mutations may result in common therapeutic targets across classes Demonstrate an understanding of the downstream signalling cascade of intracellular kinase transcription factors as this relates to therapeutic targets, treatment failure, and development of resistance Determine the concepts of pathway up/down regulation and molecular pathways cross-talk or co-regulation Recognise that beyond gene mutations, the activity of a relevant pathway may be modified by transcriptional or epigenetic regulation Interpret the secondary mutational mechanisms and epigenetic modifications tumours make in response to therapy that lead to treatment resistance Give examples of certain pathognomonic chromosomal translocations that define various lymphoid malignancies and how this can be used for diagnosis Determine the importance of tumour suppressor gene functional deficiency in terms of DNA repair mechanisms as a marker for sensitivity to poly (ADP-ribose) polymerase inhibition and DNA damaging agents Interpret advanced molecular testing through FISH, cytogenetic, and next generation sequencing as it relates to appropriate diagnosis and treatment planning Determine that mutation in TP53 is the most common molecular alteration in cancer and conveys a worst prognosis than tumours with normal expression Recognise that though increasing in importance and frequency, the number of patients with targetable mutational changes with available therapeutic agents is very limited and most mutations are not currently targetable Identify that globally, infectious diseases are a major contribution to molecular alterations that lead to cancer with EBV, Hepatitis B and C, and HIV as major contributors to malignancy globally
Skills	Demonstrate the ability to: Apply the knowledge of biologic pathways to understand the drivers of cancer progression upon the presence of different molecular alterations Apply selection of advanced molecular testing of tumours for precise diagnosis and identification of therapeutic options Select molecular alterations associated with common familial cancer syndromes as a means for risk reduction in patients and their relatives

Objectives	To be able to identify major resources for assessing the global cancer burden To describe and differentiate cancer incidence, mortality, and survival
Key Concepts	Define a cancer incidence rate as the number of persons diagnosed with a registrable malignancy in a given country or region (state, province, etc) in a given calendar year, typically expressed per 100,000 population per year (see also Cancer Registries) Define a cancer mortality rate as the number of persons certified as having died with cancer as the underlying cause of death (a specific cancer, or all cancers combined) in a given country/region, again per 100,000 population per year (see also Cancer Registries) Distinguish between crude and age-adjusted incidence and mortality rates and understand when each metric should be used Demonstrate an understanding of the role of high-quality national or state-wide population-based cancer registries for producing reliable national and global statistics on cancer incidence, survival and mortality Demonstrate an understanding that cancer survival is a probability (not a rate) in the range 0-1, usually expressed as a percentage in the range 0%-100% for convenience (see also Cancer Registries) Recognise that survival estimates are only meaningful if the period when the patients were diagnosed and the duration of survival is stated (eg, the estimated 5-year survival of patients diagnosed during 2015-2019 was 75%; see also Cancer Registries) Demonstrate an understanding of why the mortality-to-incidence ratio (M/I ratio) is not a case-fatality ratio, and why its complement (1-M/I) is not a valid proxy for survival Demonstrate an understanding of the importance of age-standardisation for comparing incidence, mortality, and survival estimates over time, or between countries or population sub-groups Define and understand the interpretation of cumulative risk estimates Define the annual percentage change in incidence and mortality rates, and understand its interpretation for cancer trends Define age effects as variations in biologic and social changes in individuals over time, including physiologic changes, external exposure and social experiences accumulated over the lifespan Define period effects as the result of exposures that affect all age groups equally at a particular point in calendar time. These could include local, regional or global changes in environment, economics or social behaviours that are age-independent, as well as changes in how cancer data are coded, defined and collected that change at a fixed point or period in time Define cohort effects as the result of a unique exposure or experience to a group of subjects (eg, a birth cohort) as they move through time (eg, early life exposure to radiation effects of the atomic bomb in Japan)
Skills	Demonstrate the ability to: Use GLOBOCAN publications for estimates of cancer incidence and mortality worldwide Use CONCORD publications for estimates of cancer survival worldwide Perform calculation of age-adjusted incidence and mortality rates Use crude incidence and mortality rates as estimates of disease burden for resource allocation and planning Use age-adjusted incidence and mortality rates to compare cancer burden between populations Use trends and inequalities in population-based survival estimates to evaluate the overall effectiveness of health systems Use the average annual percentage change to evaluate impact of population or policy changes on the cancer burden over time Evaluate age-specific cancer rates and trends with an understanding of age-period-cohort effects to identify the root causes of change in cancer burden over time

Objectives	To describe: A population-based cancer registry and its key functions The relevance of cancer registry data in cancer control
Key Concepts	Recognise that population-based cancer registries capture a standardised minimum data set about the person, the malignancy, the treatment and the outcome Demonstrate an understanding that population-based registries with high completeness and good data quality provide an unbiased picture of cancer epidemiology in their territory Demonstrate an understanding that population-based registries combine data about each patient from many health care facilities to create a unique database of all residents in their territory who are diagnosed with a registrable malignancy Demonstrate an understanding that most registries follow up with all registered patients to establish their vital status (alive, dead, lost to follow-up, emigrated) on a regular basis, and that these data are used to estimate population-based cancer survival Demonstrate an understanding that cancer registration is a statutory requirement in many countries, and be aware of the position in your own country Explain why hospital-based registries provide valuable information about the patients managed in that hospital (eg, caseload, investigations, follow-up, case-fatality ratios), but cannot usually provide a representative profile of cancer in the country or region where they are located Define a cancer incidence rate as the number of persons diagnosed with a registrable malignancy in a given country or region (state, province, etc) in a given calendar year, typically expressed per 100,000 population per year Define a cancer mortality rate as the number of persons certified as having died with cancer as the underlying cause of death (a specific cancer or all cancers combined) in a given country or region, again per 100,000 population per year Demonstrate an understanding that cancer survival is estimated as a probability (in the range 0-1) from population-based data. Understand that survival estimates are usually expressed as percentage in the range 0%-100%, for convenience Recognise that survival estimates are only meaningful if the period when the patients were diagnosed and the duration of survival is stated (eg, the estimated 5-year survival of patients diagnosed during 2015-2019 was 75%) Demonstrate an understanding that net survival is a population-based metric that reflects the survival of all patients in a country or territory, after correction for the risk of death from other causes, given that this competing risk of death is higher in elderly persons Demonstrate an understanding that registries routinely publish cancer incidence and survival statistics for their territory by age, sex and calendar year, often by other variables such as stage at diagnosis, race/ethnicity, and socio-economic status Define a case-fatality ratio as the proportion of persons diagnosed with a cancer who die within a specified period of time, usually a few weeks or months Demonstrate an understanding why the mortality-to-incidence ratio (M/I ratio) is not a case-fatality ratio, and why the complement of the M/I ratio (1-M/I) is not a valid proxy for survival Recognise that registries maintain the confidentiality and security of their data with electronic, physical, and managerial arrangements designed to reduce the risk of inadvertent disclosure to the absolute minimum Demonstrate an understanding that population-based registries are a unique resource for research into the causes, incidence, management, and survival of patients with cancer, and into the quality of life of survivors (survivorship research) Recognise why ethical or statutory approval is usually required for observational research using registry data without patient consent Demonstrate an understanding why cancer registry data are an essential component of rational cancer control policy Give examples of how cancer registry data have been deployed to formulate cancer control policies (eg, early diagnosis, screening, access to health care), and subsequently to evaluate the impact of those policies
Skills	Demonstrate the ability to: Use cancer registry data to describe current patterns and past trends of incidence and survival in your country or region, or in a sub-group of the population Interpret graphs and tables from registry data appropriately, to gain insight into the adequacy of cancer control plans and intervention programmes Report information derived from cancer registry data accurately and in appropriate language to policy-makers, to advocate for relevant policy initiatives

Objectives	To describe modifiable and non-modifiable risk factors for cancer and understand the underlying behavioural, biologic, and genetic mechanisms associated with risk To be able to discuss clinical and non-clinical strategies through which cancer risks can be modified
Key Concepts	Recognise family history patterns indicative of hereditary cancer syndromes Define modifiable cancer risk factors (eg, obesity, alcohol use, tobacco use, sun exposure, viral infections, air pollution) and discuss prevalence and trends worldwide Explain burden of cancer attributable to genetic risk and recognise appropriate screening and prevention measures for individuals identified with genetic predisposition to cancer Explain the burden of cancer attributable to modifiable risk factors overall and at specific anatomical sites (eg, breast, oesophagus, pancreas, kidney, intestine, uterus, ovary, gallbladder, stomach, brain, liver, blood, and thyroid), including prevalence and strength of association for each site Explain behavioural, biologic, environmental and genetic factors associated with weight gain, excess fat accumulation and obesity, and their societal, communal and individual consequences Recognise disparities in cancer risk between and within individuals with obesity Explain pathways, mechanisms, and alterations through which obesity, alcohol, and tobacco use support tumour growth Explain lifestyle modifications and preventive interventions (eg, medications, surgeries, diet, physical activity) and their impact on cancer incidence Define metabolically healthy obese phenotype and its risk for developing cancer Describe new areas of research and emerging hypotheses exploring lifestyle and environmental factors associated with cancer risk
Skills	Demonstrate the ability to: Communicate cancer population-wide and regional statistics appropriate to individual patients Evaluate a family history and refer for cancer genetic testing as appropriate Distinguish modifiable and non-modifiable risk factors associated with cancer, and explain burden of disease attributable to modifiable risk factors Apply and integrate scientific knowledge regarding modifiable cancer risk factors into clinical practice and patient counselling Explain and advise behaviour modification and other cancer prevention measures, including chemoprevention and risk-reducing surgery, where appropriate Counsel patients at genetic risk regarding appropriate screening and prevention measures

Objectives	To be able to: Define programme for cancer prevention in average and high-risk populations for cancers that are preventable Define and describe types of preventive therapies, behavioural interventions, and surgical strategies, and list specific populations they are used in
Key Concepts	Identify existing behavioural interventions and local resources to address modifiable cancer risk factors Determine existing preventive therapies, eg, aspirin and endocrine agents, and human papillomavirus (HPV) vaccines and their indications for use Summarise existing tobacco cessation strategies Demonstrate an understanding of the management of high-risk dysplastic and proliferative lesions to interrupt the initiation or progression to invasive cancers Describe local and national public health efforts to promote community awareness of cancer prevention Recognise the impact of social determinants of health on disparities in cancer incidence Interpret direct to consumer genetic testing
Skills	Demonstrate the ability to: Define primary prevention and to explain relative risk, absolute risks and benefit/risk balance Participate in multidisciplinary care discussions in order to identify healthy individuals who should undergo risk assessment, genetic counselling and gene mutation testing and prevention counselling Discuss evidence-based cancer prevention guidelines, such as smoking cessation, improvement of dietary habits, maintenance of a healthy body mass index, that may alter an individual's risk for developing cancer Discuss and educate about preventive agents (when, how, whom to prescribe, and, most importantly, when to stop it), eg, aspirin use, endocrine therapies, and HPV vaccines that may alter an individual's risk for developing cancer Discuss and educate the public, decision makers and health care providers about evidence-based prevention approaches

Objectives	To describe: The role of secondary prevention in cancer control and prevention and the scientific basis for screening and case finding Regional, resource, and cultural factors that may affect cancer screening and prevention practises and the model of an Integrated Cancer Prevention Centre
Key Concepts	Demonstrate an understanding that screening is the testing and evaluation of a population of asymptomatic persons to distinguish between those who may have a disease and those who likely do not Demonstrate an understanding of the key characteristics of effective screening tests and strategies: Screening must for a serious condition for which detection in asymptomatic individuals may reduce the morbidity of the disease and its treatment and reduce long-term mortality from the condition The condition must be common enough to warrant screening the general population or of a defined at-risk group The screening test must have acceptable sensitivity and specificity The screening programme and test must be reasonable in terms of cost, be acceptable to people and safe Demonstrate an understanding of the concepts of risk-based screening and active case finding (ACF) and how the benefits and risk of ACF must be carefully balanced in developing and implementing ACF policies Give examples of state-of-the-art cancer screening tests and recognise that screening guidelines vary between organisations with varied perspectives and data interpretation Demonstrate an understanding of the most common cancer types in local/regional area that affect the population and the effective screening strategies for those cancer types Evaluate the direct and indirect costs of screening and the potential cost savings of an integrated prevention and early detection model Identify the resources and levels of access to cancer prevention and screening services in the region and community you serve Determine the key factors in implementation of one-stop prevention and early detection models, including scientific issues, personal, familial, and societal risk factors, and cultural issues to tailor appropriate diagnostic testing Demonstrate an understanding of the role of inherited susceptibility in cancer risk and the impact of inherited risk on cancer screening recommendations for affected persons Recognise the potential for precision medicine in future cancer screening and prevention
Skills	Demonstrate the ability to: Understand principles and criteria for implementation of screening tests (simple, safe, reliable, affordable, sensitivity, and specificity) Identify the value of screening and the relevant guidelines and the symptoms, specific markers, and epidemiologic factors important to consider in defining screening and diagnostic recommendations for specific cancer types based on the prevalence in the population, evidence of value, and resource availability

Objectives	To describe the general methodologies of laboratory testing in order to judiciously order appropriate tests To be able to appropriately use laboratory diagnostic testing for the diagnosis and follow-up of patients with cancer, as well as understand the limitations of testing
Key Concepts	Interpret laboratory testing in patients with cancer and those being evaluated for cancer Demonstrate an understanding of the role of laboratory testing for the diagnosis and management of patients including establishing disease prognosis and response to therapy Recognise the availability of relevant laboratory diagnostic tests and the application of those tests for specific clinical scenarios Describe the components and relevance of common laboratory tests, such as the complete blood count, comprehensive metabolic panel, and microbiology cultures Recognise the balance between utility and costs of diagnostic and prognostic laboratory testing, including biomarkers Recognise the balance among testing sensitivity, specificity, positive predictive value, and negative predictive value for different testing populations for diagnostic testing Recognise the importance of laboratory quality practises, including controls (positive, negative), assessment of data quality, and limitations of techniques Describe pertinent uses of relevant biomarkers in an appropriate clinical context Demonstrate an understanding of the appropriate sample type for various laboratory tests Recognise the importance of sample handling and processing Define adequate frequencies of repeat laboratory diagnostic analyses in different clinical settings Demonstrate an understanding of general microbial identification techniques and other infectious disease-related testing modalities Distinguish current technologies, including molecular methodologies with emerging diagnostic applicability, such as polymerase chain reaction (PCR) and quantitative reverse transcription-PCR, interference with gene expression (small interfering ribonucleic acids, short hairpin ribonucleic acids, overexpression), the Clustered Regularly Interspaced Short Palindromic Repeats system, fluorescence-activated cell sorting, mass spectrometry, high-performance liquid chromatography, basic cytogenetic techniques (fluorescence in situ hybridisation and karyotype), immunohistochemistry, immunofluorescence, Sanger sequencing and next-generation sequencing, single-cell technologies, liquid biopsies: circulating tumour cells, circulating cell-free DNA
Skills	Demonstrate the ability to: Assess critically, interpret, and discuss specific laboratory parameters Evaluate costs of laboratory tests in relation to their clinical relevance Use laboratory findings and other diagnostic procedures in clinical decision making Discuss complex laboratory results with laboratory physician colleagues Discuss and interpret laboratory findings with regard to clinical consequences Explain the results of laboratory tests to patients and colleagues Understand the limitations of laboratory testing

Objectives	To describe the pathologic diagnosis and report, and be able to explain the information and its associated management implications to the patient To describe the reasons behind, the basis and the implications of immunohistochemical and molecular analysis
Key Concepts	Demonstrate an understanding of the different tasks in pathology, including gross sampling, frozen section, histology, immunohistochemistry and molecular analyses Recognise the indications for and limitations of frozen section diagnostics and of the importance to wait for the definitive diagnosis before starting a clinical action Evaluate pertinent history (including familial history of cancers), clinical findings and radiographic findings needed to make adequate pathologic diagnoses Demonstrate an understanding of the nomenclature of neoplasia (eg, adenoma v carcinoma, benign v malignant, low-grade v high-grade, dysplasia, in situ v invasive disease, carcinoma v sarcoma, etc) and knowledge of the local growth or metastatic potential of these different types of neoplasms Distinguish grading schemes in different types of tumours Interpret the current WHO classification of tumours and the importance of keeping up to date Interpret the current TNM staging system, and other staging systems used in particular tumours (eg, Ann Arbor for lymphoid malignancies) Describe metastasis and the different mechanisms of spread (eg, haematogenous, lymphatic, perineural, perivascular, and peritoneal) Determine particular microscopic features that have clinical relevance (eg, tumour budding in different cancer types, extranodal extension of nodal metastasis in different cancer types, etc) Define the indications for requesting a biopsy of a new lesion, and selection of the best site to perform the biopsy Determine the different procedures and the types of specimens that are obtained Determine the role of genetic and epigenetic alterations in malignant tumour formation and dissemination Determine the role of infectious agents in the development of some cancers and their potential influence of staging (eg, human papillomavirus in head and neck carcinoma) Determine predictive and prognostic factors—such as oestrogen receptor, progesterone receptor and human epidermal growth factor receptor-2—and how to interpret and use the results in forming a treatment plan Explain the use of immunohistochemistry (IHC) and next-generation sequencing (NGS) and particular markers in establishing diagnoses Describe the applications of IHC or NGS on whole sections of tumours, on microdissected areas or on tissue microarrays Identify the limitations of interpretation of IHC and NGS including the importance of internal and external controls and the importance of preanalytical variables such as fixation Classify molecular alterations in different classes of pathogenicity according to current guidelines of the American College of Medical Genetics and Genomics and the Association of Molecular Pathology Describe ethical, consenting, and storage procedures involved in biobanking, and the various techniques offered in association with them Recognise that many pathology departments have associated biobanks, which enable the collection of surplus diagnostic tissue/fluids from consenting patients
Skills	Demonstrate the ability to: Interpret the pathology report (including histopathology, IHC and molecular reports) and explain it to the patient Discuss the pathology report (including histopathology, IHC, and molecular reports) with the pathologist and the other members of the multidisciplinary team Incorporate the information contained in the Cancer Checklist (Synoptic Summary) into the current pathologic stage (eg, American Joint Committee on Cancer TNM) staging system Use the additional prognostic and predictive information contained in the Cancer Checklist to help formulate the best treatment plan for the patient Recognise a discrepancy or discordance in the pathologic diagnosis with the clinical findings and to discuss with the pathologist Use the information in the pathology report to develop the best treatment plan for the patient Use the information within the pathology report to formulate research projects to help answer gaps in our understanding of cancer and to propose improved therapeutic options

Objectives	To describe the role of genomic alterations in the pathogenesis of various neoplasms and to differentiate various types of genomic alterations and their impact in carcinogenesis and management of the disease To be able to acquire a basic technical knowledge of various genomic tests, used in patients with cancer and their specimen requirements
Key Concepts	Demonstrate an understanding of molecular biology (eg, properties of nucleic acid, structure of chromosome, DNA repair process, epigenetic changes, and omics) and basic pathways and signalling networks Recognise genomic findings that impact classification, prognostication and the treatment of various neoplasms Recognise that the role of genomic findings in classification of most neoplasms is in combination with morphologic and immunophenotypic findings Classify tiers of genomic variants, based on the available clinical evidence Give examples of various publicly available databases for annotation of variants Distinguish various types of pathogenic variants, including point mutations, rearrangements, and copy number alterations Demonstrate an understanding of the difference between an oncogene and a tumour suppressor and types of variants, considered pathogenic in each group (activating mutations versus truncating mutations) Explain how specimens are managed and how pre-analytical variables (eg, fixation, decalcification, contamination) may affect the performance of a molecular assay Define adequacy of tumour tissue sample for downstream molecular assays Evaluate critically new genomic technologies considering the downstream costs secondary to genomic analysis for the laboratory and the patient, including the costs associated with new technologies Evaluate basic tests characteristics, such as analytical sensitivity and specificity, and distinguish them from clinical sensitivity and specificity Determine the advantage and limitation of the clinical diagnostic test modalities, including cytogenetics, flow cytometry, immunohistochemistry (IHC), fluorescence in situ hybridisation (FISH), reverse transcriptase polymerase chain reaction (RT-PCR), Sanger sequencing, next-generation sequencing (NGS), and gene expression panels Recognise internal and external quality control parameters of a molecular assay Recognise that within NGS there is a conceptual distinction between panel sequencing, exome sequencing and genome-wide sequencing Recognise that there are different types of assays that can be used in a laboratory, namely regulatory-approved assays, laboratory-developed assays with internal evidence for analytical validity and purely research assays Interpret guidelines/recommendation to refer to for biomarker evaluation
Skills	Demonstrate the ability to: Define genome, exome, metabolome and proteome Select the appropriate molecular test based on patients' needs Distinguish various genomic alterations (eg, point mutations, rearrangements, copy number alterations) and their pathogenicity as it relates to specific type of gene and neoplasm Select appropriate molecular tests based on tumour histology Recognise the circumstances when germline testing and genetic counselling is required and the appropriate tests Identify whether an assay requires DNA, RNA, or protein and how that impacts tissue requirements Predict the analytical sensitivity of an assay and suitability for minimal residual disease testing Recognise the scope and limitation of an assay (eg, single analyte, versus targeted multiple analyte panel, versus genome-wide assay) Interpret molecular pathology reports in conjunction with active discussion with pathologists and clinical geneticists whenever needed Report and contextualise a clinical case within a molecular tumour board

Objectives	To describe and communicate basic test performance, including knowledge of the underlying technology and methodology and appropriate fields of application To be able to accurately assess the clinical validity and clinical utility of genetic test results, appropriately discuss results with patients, and effectively communicate as part of a multidisciplinary team (eg, pathologists, clinical geneticists, and other stakeholders in a molecular tumour board)
Key Concepts	Recognise that there are legal, ethical, and social implications of genetic testing Demonstrate an understanding for the patient's perspective (including preferences for testing, costs of the assay for the patient, and the potential need for additional follow-up testing or counselling) Distinguish among the different types of genomic assays that can be used in a laboratory: regulatory-approved assays, laboratory-developed assays, and research use only tests Distinguish among the diagnostic, prognostic, and/or predictive information that genomic tests may contain Determine the best approach for obtaining genetic data (eg, tissue and body fluids including blood such as liquid biopsy) Distinguish each test method and genomic test including test parameters (eg, sensitivity, specificity, accuracy, precision, and positive and negative predictive value) Classify genomic tests into next-generation sequencing (NGS) v non-NGS assays (non-NGS include in situ assays and single gene testing, such as different types of polymerase chain reaction [PCR]-based assays and Sanger sequencing) Recognise that NGS-based test can be differentiated according to their genomic coverage, ranging from small gene panels (usually covering hotspot regions of 20-50 major cancer genes) to large gene panels (around ≥1 Megabase genomic footprint) and whole exome (WES) as well as whole genome sequencing (WGS) Describe the approaches to NGS testing. With the exception of whole genome sequencing, target enrichment methods are used. Main methods are: hybrid capture, AmpliSeq, anchored multiplex PCR, and single primer extension Classify tissue-based genomic tests as tumour-only sequencing v parallel sequencing of the tumour and germline DNA (usually obtained from lymphocytic DNA in a blood draw) Recognise that tumour-only sequencing harbours genetic information from both somatic and germline DNA. Further work-up may be required if there are possible germline variants detected (eg, confirmatory germline testing and genetic counselling). For whole exome and whole genome sequencing (WES/WGS), parallel germline sequencing is critical Recognise that using NGS, gene fusions can be interrogated at both the DNA (break points) and RNA (transcripts) level. Parallel analysis is ideal. For formalin-fixed and paraffin embedded (FFPE), RNA sequencing is preferred over DNA sequencing Recognise that in contrast to fresh tissue, FFPE material harbours deamination artifacts (C>T transitions) that need to be accounted for in the analysis and influence sensitivity of test results Recognise that liquid biopsies are based on the analysis of the tumour DNA containing fraction of cell-free DNA. Sensitivity is particularly influenced by the number of nucleic acid molecules per locus and the sequencing depth/sensitivity per locus Explain the common pre-analytic variables that may influence test results and include age of archival material, tumour cellularity, quality and quantity of nucleic acids, as well as conditions for collection, preparation, transport, and storage of sample and analyte types Recognise that post-analytic variables in NGS-based testing primarily include bioinformatic tools and filters used for data processing including variant calling, annotation, functional, and clinical variant interpretation
Skills	Demonstrate the ability to: Present core definitions and terms of genomic testing Present core knowledge of genetic testing technology and methodology Identify whether an assay is directed to DNA, RNA, or protein (eg, methylation analysis, whole exome sequencing, transcriptome sequencing, proteome analysis including IHC) Identify the concept the assay is based on, namely either testing for a specific analyte, a panel test, ie, used for multiple analytes or an open, so-called, unbiased, genome-wide assay Recognise different genomic aberrations and methods of detection: missense, nonsense, frameshift mutations, indels, copy number aberrations, translocations/gene fusions, gene expression/transcript levels, and protein levels Classify and interpret genomic variants according to established classification systems and interpret variants in their proper clinical contexts Discuss the clinical indications for molecular testing in oncology, including applications in screening, diagnosis, prognosis, response prediction, disease and treatment monitoring, identification of resistance mechanisms, and evaluation for inherited conditions Apply genetic counselling principles, including communicating to family members in need of further testing, and preparing patients for the potential for incidental and secondary germline information before conducting somatic mutation profiling

Objectives	To describe the state-of-the-art diagnostic imaging strategies for different tumour types To be able to communicate imaging findings with patients and to discuss imaging differentials with imaging experts
Key Concepts	Distinguish existing imaging modalities, in particular, cross-sectional techniques (computed tomography [CT], magnetic resonance imaging [MRI] and hybrid imaging combined with positron emission tomography [PET]), their principles and technical or diagnostic limitations Demonstrate an understanding of image-guided diagnostic and therapeutic interventions, their principles, technical or diagnostic limitations, and complications Recognise the contraindications and safety issues related to CT, including radiation exposure related to patient age, cancer during pregnancy, and contrast media-related risks and side effects Recognise the contraindications and safety issues related to MRI, including implanted medical devices, pregnancy, claustrophobia, gadolinium-based contrast media-related risks, and side effects Identify the influence of pre-test probabilities of disease, to estimate the potential impact of imaging exams on patient management, and to be aware of the costs and cost-effectiveness of different imaging exams Recognise the impact of novel imaging modalities on stage migration, in particular hybrid imaging with tumour-specific tracers compared with conventional imaging Distinguish imaging-based staging systems and the role of different imaging tests, eg, for TNM, Ann Arbor, Barcelona Clinic Liver Cancer, International Federation of Gynecology and Obstetrics (see chapter 4.5.3) Interpret the breast imaging reporting and data system and prostate imaging reporting and data system Demonstrate an understanding of the RECIST (see chapter 4.5.4) Express familiarity with cancer-specific methods of response assessment, eg, the Lugano Classification of the International Conference on Malignant Lymphoma, the modified RECIST criteria for hepatocellular carcinoma, the Choi Response Criteria for gastrointestinal stromal tumours Recognise treatment-specific response patterns on imaging, in particular for immunotherapy, including specific criteria for response assessment, eg, the immune-adapted RECIST criteria Evaluate the imaging appearance of local or systemic treatment-specific toxicities
Skills	Demonstrate the ability to: Report a comprehensive imaging referral form, including current and former treatment history and timeline, and all clinical data relevant to the examination Discuss the basics and the process of any ordered imaging exam or image-guided intervention with patients, including providing information on preparation where appropriate Discuss with patients about complications, side effects, contraindications, as well as radiation exposure related to imaging exams and image-guided interventions Select the appropriate imaging modality based on tumour type, treatment, specific question, and safety profile for individual patients Select the appropriate mode of biopsy, eg, surgical v image-guided, based on patient factors, anatomic location, size of the lesion Discuss the results of imaging exams with patients and put the findings into the context of the individual patient's disease course Apply staging systems based on information provided in imaging reports or in multidisciplinary tumour boards Discuss the results of imaging exams or diagnostic strategies for validation with radiologists and nuclear medicine physicians in multidisciplinary tumour boards Evaluate an image-guided local response in multidisciplinary tumour boards in the context of the patient's overall response to systemic treatment Discuss the use of image-guided interventions in combination with or as an alternative to surgical, radiation, or systemic treatment in multidisciplinary tumour boards

Objectives	To be able to use nuclear medicine and molecular imaging correctly in daily practice To describe the emerging role of therapeutic radiopharmaceuticals (theranostics) in oncologic practice
Key Concepts	Describe different molecular imaging techniques, and in particular nuclear medicine procedures and different diagnostic radiopharmaceuticals for both positron emission tomography (PET) and single-photon imaging, including single-photon computed tomography (SPECT) Describe the basic principles of nuclear medicine including planar scintigraphy, SPECT and PET imaging, pharmacokinetic evaluation of radiotracers, and radionuclide dosimetry Describe the relevant imaging instrumentation, including hybrid imaging systems that use computed tomography (CT, PET/CT, SPECT/CT) or magnetic resonance imaging (MRI, PET/MRI) and evolving whole-body PET systems Demonstrate an understanding of the geographical variation in the availability of specialised nuclear medicine instrumentation and supply of different molecular imaging techniques and tracers, especially short-lived PET tracers Describe the therapeutic application of radiopharmaceuticals to cancer, the principles of the theranostic approach, and of different radionuclide therapies including emerging agents Identify relevant newer radiopharmaceuticals, including approved agents for imaging new targets, such as prostate-specific membrane antigen (PSMA) for prostate cancer, somatostatin receptors for neuroendocrine tumours, oestrogen receptors for breast cancer, and amino acid transport and metabolism for imaging brain and other cancer, and investigational targets including fibroblast activating protein, human epidermal growth factor receptor 2 (HER2), immunotherapy targets, poly (ADP-ribose) polymerase, and others that can be used for either diagnosis or therapy Describe the normal biodistribution and abnormal patterns associated with cancer used to interpret images for commonly used oncologic nuclear imaging tracers, such as (¹⁸F-fluorodeoxyglucose ¹⁸F-FDG), ^99mTc-diphosphonates Describe the diagnostic indications for scintigraphy, SPECT and PET scans for the different tumour types, with particular reference to clinical guidelines, including the role of ¹⁸F-FDG-PET in lymphoma and other haematologic malignancies (myeloma), in non–small-cell lung cancer, breast and ovarian cancers, in melanoma, in GI tumours and in other malignancies Describe the use of radiopharmaceuticals to guide tissue sampling, including use in sentinel lymph node biopsy Describe the roles of other more specific tracers, such as somatostatin receptor tracers for neuroendocrine tumours and PSMA for prostate cancer Describe the role of molecular imaging (and in particular ¹⁸F-FDG-PET) in evaluating response to therapy and criteria for response assessment (RECIST, EORTC, PERCIST, Deauville/Lugano [lymphoma], and others) Identify existing/approved radionuclide therapies, including Na1³¹I for thyroid cancer, ¹⁷⁷Lu-DOTATATE and ¹³¹I-mIBG for neuroendocrine tumours, ¹⁷⁷Lu-PSMA, and ²²³RaCl₂ for bone metastases, and other emerging agents and applications, including novel isotopes such as alpha-emitters Describe the radiation doses and toxicities associated with radionuclide therapy agents Describe patient preparation requirements for diagnostic scans and radionuclide therapy and radiation safety precautions, particularly for radionuclide therapy Describe the complementary role of molecular imaging versus anatomic imaging and non-imaging molecular diagnostics in diagnosis, staging, response assessment, and image guidance Describe the use of diagnostic nuclear medicine/molecular imaging to guide therapeutic decisions and the impact of molecular imaging over patient management and treatment decision making Distinguish the role of radionuclide therapy vis-à-vis external beam radiotherapy and standard systemic oncologic agents
Skills	Demonstrate the ability to: Select the right indications for nuclear medicine/molecular imaging, considering anatomic imaging and other diagnostics, in line with clinical guidelines Use nuclear medicine/molecular imaging to guide patient treatment and assess treatment efficacy Identify patients who may benefit from radiopharmaceutical therapy and discuss benefits and risk versus other therapeutic choices Identify, at a basic level, the physiologic biodistribution, pathologic uptake and pitfalls of molecular imaging techniques, and recognise obvious artifacts of molecular imaging techniques Identify major radiopharmaceutical therapy toxicities and possible interactions with other oncologic treatments

Objectives	To describe the principles and general rules of staging systems, mainly the TNM staging system To be able to do appropriate and accurate staging
Key Concepts	Describe the principles and general rules of the TNM system Recognise: The TNM classification The relationship between the TNM system and contemporary practice in order to assign each stage The difference between clinical and pathologic staging Post-therapy or post-neoadjuvant therapy staging and restaging Stage migration by use of more sensitive methods Stage shift after introduction of screening Different systems of staging in each tumour type: the Union for International Cancer Control and American Joint Committee on Cancer classification for the majority of tumours, also the Lugano Classification for lymphoma, and International Federation of Gynecology and Obstetrics stages for gynaecologic tumours The relationship between stage, prognosis, and additional prognostic factors The differences in treatment choice based on staging
Skills	Demonstrate the ability to: Perform the appropriate procedures such as physical examinations, imaging studies, laboratory tests, and pathologic or cytologic examinations for individual carcinomas

Objectives	To be able to use RECIST for assessment of tumour response as (part of) an end point in the context of clinical trials
Key Concepts	Demonstrate an understanding that RECIST is the result of an initiative to harmonise the definition of tumour response to establish a credible end point that can be used uniformly across centres in a multicentre trial, but also to compare results across clinical trials on different tumour types and treatment modalities Recognise that RECIST applies to solid tumours only, in the locally advanced or metastatic setting. Other response criteria have been developed for haematologic malignancies Describe the difference between the original RECIST criteria and the RECIST v1.1 Demonstrate an understanding that measurement error is an issue for response assessment, so the choice of imaging modality at baseline and during follow-up is important. Be able to give examples of imaging types which are recommended according to RECIST and which are not, including the reason why not Distinguish between measurable and non-measurable disease and how they are taken into account in the assessment of overall response Define the different categories of response: complete response, partial response, stable disease, progressive disease (PD), early death and non-evaluable Describe how to select target lesions (maximum 5 lesions, max 2 per organ) and how the evolution of the sum of their longest diameter contributes to the response assessment Demonstrate an understanding of how to evaluate non-target disease, eg, the non-measurable lesions or measurable non-target lesions, for integration in the overall response assessment Describe the role of new lesions in the response assessment Recognise that lymph nodes deserve special attention as nodes <10 mm are considered benign; specific rules apply to lymph nodes that disappear and then re-appear Recognise that response (complete and/or partial) needs to be confirmed in single arm trials where it serves as a primary end point; this is to ensure that a response is not merely the result of measurement error only Recognise that once a PD is observed as per RECIST, the outcome of the patients stays PD for RECIST, regardless of what happens afterwards Demonstrate an understanding that specific guidelines, named iRECIST, have been published to collect data in the context of trials testing immunotherapeutics Describe the difference between a confirmed and an unconfirmed progression; more specifically a number of rules are to be applied to confirm a progression at the next assessment Recognise a pseudo-progression and demonstrate an understanding on how to reset such a progression Recognise that RECIST was developed for clinical trials; for the individual patient, treatment benefit should be based on medical judgement that results from a synthesis of clinical, imaging, and laboratory data
Skills	Demonstrate the ability to: Perform an assessment of response to treatment according to the rules specified in RECIST or iRECIST Discuss at tumour board reviews with imaging specialists Present the limitations of the RECIST assessment in the context of the treatment for an individual patient outside of a clinical trial

Objectives	To describe: The indications and contraindications of oncologic surgery by interacting and collaborating with surgeons The role of oncologic surgery in the staging, cure, and palliation of patients with malignant diseases
Key Concepts	Recognise the availability of different diagnostic procedures in various cancer types including indications and different types of diagnostic biopsy Recognise the importance of the multidisciplinary approach for treatment of patients with solid tumours to achieve a better outcome Recognise the existence of different prognostic factors (including patient, tumour, and treatment characteristics) in oncologic entities Determine how to assess a patient for suitability for surgery, including appropriate tests and their interpretation Recognise the importance of value-based health care delivery regarding new surgical techniques and technical devices Recognise the indications for organ preservation, reconstructive surgery, extent of definitive surgery, principles of radical surgical dissection (including regional lymph nodes) and sequencing of surgery with other treatment modalities Recognise the risks and benefits of surgery as a definitive treatment and as an adjunct to radiotherapy and/or systemic therapy, and how the risks and benefits differ based on whether neoadjuvant or adjuvant therapy is used Explain postoperative complications and the expected length of recovery, and its impact on planned postoperative therapy Demonstrate an understanding of the role of surgery in the metastatic and palliative setting Demonstrate an understanding of the importance of prospective trials and differences in planning of surgical trials from planning of medical oncology and radiotherapy trials Demonstrate an understanding of the importance of prospective data and tissue collection for translational research
Skills	Demonstrate the ability to: Present the patient cases during multidisciplinary team meetings and to promote this systematic multidisciplinary strategy Critically discuss the treatment options/recommendations Discuss with colleagues and patients on general management strategies in the neoadjuvant and the adjuvant setting, as well as at advanced stage

Objectives	To describe the impact of radiation in oncology To be able to expand access to radiotherapy for improvement of outcomes in patients with cancer
Key Concepts	Demonstrate an understanding of the basic biology of radiation induced cell killing and normal tissue injury Demonstrate an understanding of the role of radiotherapy in multidisciplinary management of patients with cancer Recognise that indications of radiotherapy are based on cancer staging and goal of care Recognise that timing of radiotherapy should be integrated with the whole course of cancer treatment and can be neoadjuvant, concurrent, definitive, adjuvant, palliative, and consolidative Recognise that the stereotactic body radiation therapy (SBRT) is considered as one of the standards of care for early-stage non–small-cell lung cancer Determine the role of local consolidation radiotherapy combined with systemic therapy (cytotoxic chemotherapy, immunotherapy, targeted therapy, etc) in advanced cancers Recognise the important role of radiation in immune modulation and cell therapy Recognise the role of palliative radiotherapy Recognise that there are different types of radiotherapy, including external beam radiation, intracavitary radiation, plaque, and interstitial radiation Recognise that there are multiple effective radiation technologies include 3-dimensional conformal radiation, intensity modulated, image-guided radiation, techniques considering respiratory motion Recognise the different radiation beams including photons, protons, heavy ions, electrons Recognise acute side effect and long-term complication of radiation therapy
Skills	Demonstrate the ability to: Participate in multidisciplinary tumour board discussions and appreciate the considerations that go into deciding the most appropriate combination, timing of treatments (systemic therapy, surgery, radiation) Present the evidence supporting indications for radiotherapy and the risks and benefits of different radiation treatment options Select those patients who are suitable for SBRT as a curative treatment Select those patients who are suitable for concurrent chemoradiation as a curative treatment Report that in selected malignancies adjuvant immunotherapy is standard of care after concurrent chemoradiation Discuss the role of radiation in patients with stage IV cancer Discuss diagnosis and effective management of radiotherapy-related acute and long-term toxicities Identify conditions that palliative radiation may improve patient quality of life in terms of pain control and symptomatic relief Advocate for safety and improvement in process Practise patient centric cancer care by discussing use of radiotherapy via transparent and timely communication with the team involved in the episode of care, caregiver, and patient

Objectives	To describe: The fundamentals of image-guided therapy (IGT) and guide therapy selection and educate oncologists in fundamentals of image-guided interventions The role of imaging in IGT, specifically the key contributions to tumour characterisation
Key Concepts	Recognise that cancer imaging methods provide tumour phenotype, size/volume, locations, staging, whole body tumour burden, marker for treatment response and prognostication Demonstrate an understanding that cancer radiologists preforming diagnostic image interpretations now commonly use standardised approaches such as the American College of Radiology RADS, eg, breast cancer imaging BI-RADS or prostate cancer magnetic resonance imaging (MRI) PI-RADS Identify that cancer diagnostic biopsies of suspicious lesion/target are almost exclusively defined and guided by imaging Define tumour margins and access/trajectory planning with imaging for interventional radiologists, surgeons, and radiation oncologists using IGT Recognise imaging as predictive marker and patient selector for theranostics (eg, peptide receptor radionuclide therapy in neuroendocrine tumours) Recognise that as ultrasound, computed tomography scan, angiography, MRI or positron emission tomography (PET) scans, can all be integrated into modern operating/procedure rooms Demonstrate an understanding that image-guided therapies use minimally invasive or non-invasive techniques, such a percutaneous thermal (hot/cold) ablation or magnetic resonance (MR) guided focused ultrasound (FUS) or high intensity FUS (HiFU) Determine IGT as an intervention which can lower morbidity and its usefulness in patients with surgical comorbidities Demonstrate an understanding that the goal of IGT thermal ablations is to achieve cell kill temperatures of the image-based 3D volume with an ablative margin of normal tissue. Hence, ablation volumes are generally greater than image-based volumes Recognise that IGT can also serve as selection method for targeted therapies (eg, Fluoroestradiol-PET in patients with breast cancer and prostate-specific membrane antigen [PSMA] PET before PSMA radioligand therapy in prostate cancer) Explain that MR guided FUS uniquely provides near real-time thermometry allowing for intra-procedural thermal dosimetry to ensure full thermal coagulative necrosis of the target and spare proximal structures Identify that focal image guided rather than whole gland therapies are gaining credibility for prostate cancers which can be safe and effective
Skills	Demonstrate the ability to: Discuss the newest developments in IGT Select patients who may benefit from IGT Discuss different tumour thermal ablation methods (eg, microwave, cryotherapy, FUS, or chemo-embolisation) and theranostics Participate in multidisciplinary team discussions integrating imaging findings and identify patients suitable for theranostics Predict conditions (such as performance status, response to therapy and side effects, comorbidities, prior therapy) that are important to consider when deciding whether to advise surgery or less invasive IGT methods

Objectives	To describe: The indications, mechanisms of action, the relevant mechanisms of resistance, the pharmacogenomics, and the pharmacology of cytotoxic agents The common toxicities, and their frequency of occurrence, the safety parameters to be monitored, and the ways of administration of cytotoxic therapy
Key Concepts	Describe cytotoxic agents and their respective drug classes Classify cytotoxic agents based on their effect on the cell cycle—cell cycle–specific or non-specific Describe mechanisms of action and relevant mechanisms of resistance for specific cytotoxic agents, the pharmacokinetic, pharmacodynamic, and the pharmacogenetic features relevant for each cytotoxic agent Summarise differences between cytotoxic therapy and other types of therapy, such as targeted therapy and immunotherapy Define indications of specific cytotoxic agents Summarise important pharmacologic factors (metabolism, clearance) of specific cytotoxic agents and how they translate into patient treatment Recognise the work-up necessary before initiation of cytotoxic therapy Recognise the role in therapy for cytotoxic therapy as part of multimodality therapy Define the dosing, schedule, and dose adjustments of cytotoxic therapy for specific indications as a single agent and in combination Demonstrate an understanding of side effect profiles of cytotoxic therapy and their management strategies, like modification of the dose, when needed, in case of renal or hepatic dysfunction Summarise the expected treatment outcome of cytotoxic therapy in patients with malignancies Describe drug-drug, drug-herb, and drug-food interactions for specific cytotoxic agents and their management in clinical practice Describe aim, safety profile, and indications for combining of cytotoxics with radiation therapy Describe aim, safety profile, and indications for combining cytotoxics with immunotherapy
Skills	Demonstrate the ability to: Discuss the expected response of cytotoxic therapy alone or in combination with other agents for specific indications Discuss the role of cytotoxic therapy as part of multimodality therapy Use patient-specific factors when prescribing the appropriate cytotoxic therapy for individuals Manage adverse effects from cytotoxic therapy and adjust treatment accordingly Discuss with patients pros and cons of cytotoxic therapy treatment in comparison with other therapeutic options

PERMALINK

ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology Edition 2023

Tanja Cufer, MD

Michael P Kosty, MD, FACP, FASCO

Abstract

1. Introduction

References

2. Standard requirements for training in medical oncology

3. Special requirements

3.1. Programme Leader/Director of Medical Oncology Training Programme

3.2. Faculty

3.2.1. Faculty Members

3.2.2. Faculty Standards

3.3. Educational Programme

3.3.1. Educational Environment

3.3.2. Professionalism

3.3.3. Responsibility

3.3.4. Update of Skills and Knowledge

3.3.5. Interdisciplinary Teamwork

3.3.6. Institutional Requirements

3.3.6.a. Clinical setting

3.3.6.b. Hospital facilities

3.3.7. Facilities

References

4. Competencies required in the curriculum

4.1. Basic Science

4.1.1. Cancer Biology

References

4.1.2. Cancerogenesis

References

4.1.3. Tumour Immunology

References

4.1.4. Molecular Oncology

References

4.2. Cancer Epidemiology

4.2.1. Global Cancer Statistics

References

4.2.2. Cancer Registries

References

4.3. Cancer Prevention

4.3.1. Population Risk Factor

References

4.3.2. Primary Prevention

References

4.3.3. Secondary Prevention/Screening

References

4.4. Cancer Diagnostics

4.4.1. Laboratory Diagnostics

References

4.4.2. Pathology

References

4.4.3. Molecular Biology/Pathology

References

4.4.4. Genetic and Genomic Testing

References

4.5. Imaging in Oncology

4.5.1. Radiologic Imaging

References

4.5.2. Nuclear Medicine and Clinical Molecular Imaging

References

4.5.3. Staging Procedures

References

4.5.4. Response Evaluation (RECIST Criteria)

References

4.6. Therapy

4.6.1. Surgical Oncology

References

4.6.2. Radiation Oncology

References

4.6.3. Image-Guided Therapy

References

4.6.4. Cytotoxic Therapy

References

4.6.5. Endocrine Therapy

References

4.6.6. Targeted Therapy

References

4.6.7. Immunotherapy

References

4.6.8. Cell-Based Therapy

Objectives	To describe the rationale for and mechanism of action of endocrine therapy in the management of some cancer types, including breast, prostate, and ovarian cancers To be able to effectively manage endocrine treatment-related adverse events To describe mechanisms of resistance to endocrine therapies and to use them in combination with other treatments where appropriate
Key Concepts	Demonstrate an understanding: Of tumour biology and the interplay between cancer and hormone receptors Of the mechanisms of action of different endocrine therapies When to use endocrine therapy Of the magnitude of clinical benefit from endocrine therapy Of the multidisciplinary approach to management of patients with endocrine-sensitive tumours Of the prevention and management of acute and chronic treatment-related toxicities of endocrine therapies Of mechanisms of resistance to endocrine therapies in patients with solid tumours including somatic mutations Of the rationale for use of combination endocrine treatments and/or use of endocrine treatments in combination with other agents (eg, luteinizing hormone-releasing hormone agonists, CDK 4/6 inhibitors, PI3KCA inhibitors, etc) in the management of solid malignancies Of the clinical benefit and toxicity profile of commonly used endocrine and targeted agent combinations How to monitor response to endocrine treatments in patients with early stage and advanced cancer Of the rationale for sequencing endocrine therapies approaches in some type of cancers
Skills	Demonstrate the ability to: Participate actively in presenting patient cases during the multidisciplinary team meetings and promote a systematic multidisciplinary approach Select appropriately, present to patients, and prescribe appropriate endocrine therapies Manage acute and chronic side effects of endocrine therapies and/or endocrine treatment combinations across different tumour types

Objectives	To be able to perform assessment, including ordering and interpreting predictive biomarkers of response and treatment and counselling of patients with cancer who will be receiving targeted therapy (small molecule signal transduction or kinase inhibitors, hormonal agents, antibodies or antibody drug conjugates) To describe the common toxicities seen with these agents when used as a single agent or in combination with other targeted agents or chemotherapy
Key Concepts	Recognise that the basic principles of oncogenesis provide the biologic rationale for the classification of different types of targeted therapy in cancer, eg, small molecules, antibodies, anti-hormonal agents, or antibody drug conjugates Define a targeted agent in the context of DNA damaging agent or a drug harnessing the immune system for its activation Explain the differences between molecularly agents and non-targeted agents, such as DNA damaging or tubulin binding agents Describe the basic principle of the use of a predictive biomarker which could be gene mutation, eg, BRAF, gene rearrangement eg, TRK, gene amplification such as human epidermal growth factor receptor 2 (HER2) or protein expression, such as oestrogen receptor Demonstrate an understanding of basic principles of pharmacokinetics such as role of loading dose for drugs with a long half-life, eg, bevacizumab Recognise the importance of pharmacodynamics in determining the dose and schedule of targeted agents eg, difference from determining only maximally tolerated dose in chemotherapeutic agents Evaluate the use of targeted agents alone or in combination with other classes of drugs eg, other targeted agents (eg, BRAF inhibitor + MEK inhibitor) or in combination with chemotherapy (eg, cetuximab + folinic acid, fluorouracil and irinotecan chemotherapy) Summarise different classes of common toxicities associated with targeted agents, like skin rash or diarrhoea, and specific targeted therapy–based toxicities such as cardiotoxicity with HER2 targeting agents Recognise the importance of clonal evolution and emergence of resistance mutations eg, detection of epidermal growth factor receptor (EGFR) T790M mutation in patients with EGFR mutated non–small-cell lung cancer treated with first generation EGFR inhibitors such as gefitinib or erlotinib
Skills	Demonstrate the ability to: Contribute actively to a variety of targeted therapy clinical scenarios Discuss targeted therapy treatment options Select the correct patient for targeted therapy, based on histology, staging, mutations, and performance status Interpret biomarker data eg, protein expression on immunohistochemistry, like oestrogen receptor positivity, HER2, or interpretation of mutations in tumour eg, EGFR mutations or germline mutations such as BRCA1 Optimally sequence targeted therapies based on an understanding of resistance mechanisms and biomarker-based response assessment Prescribe targeted agents as flat dose for small molecules, such as osimertinib or as mg/m² as with cetuximab and mg/kg for bevacizumab Recognise and manage targeted therapy adverse events Perform a risk-benefit assessment for patients considering adjuvant targeted therapy

Objectives	To be able to perform specialist counselling and treatment of patients with cancer who will be receiving immunotherapy, and to monitor and manage emerging immune-related toxicities of such therapies. This summary relates to immune checkpoint-targeted therapies and does not cover cell-based therapies and cytokines/haematopoietic growth factors
Key Concepts	Demonstrate an understanding that the basic principles of tumour immunology provide the biologic basis for the use of different types of immunotherapies for cancer Recognise the different types of immune response that can be utilised for immunotherapy, especially the differences between innate and adaptive immune responses Distinguish the differences between immunotherapy and targeted therapy or chemotherapy Demonstrate an understanding that antibody-based immune checkpoint inhibitors interact with endogenous immune cells, different from cellular therapy Recognise unconventional patterns of response with immunotherapies, including late responses or regression after progression, and the need to verify progression in selected patients who may have pseudo-progression or a mixed response Recognise the phenomenon of hyperprogression, its identification, and appropriate management Demonstrate an understanding that immunotherapy has the potential to induce durable responses in some patients, and improves overall survival Recognise mechanisms of immune-mediated cytotoxicity and the concept of immunogenic cell death Recognise that immunotherapies have a unique spectrum of toxicities different from chemotherapy or targeted therapy Determine the signs and symptoms of immune-related adverse events and their management, including the management of long-term steroid therapy and the use of steroid-sparing immune-suppressive therapies Evaluate approaches seeking to introduce immunotherapy into curative treatment settings, including their use in neoadjuvant, concomitant (with radiation) and adjuvant treatment protocols Recognise potential benefits and unique side effects of combining immunotherapy with conventional therapeutics, such as radiation therapy, targeted therapy, and chemotherapy Recognise specific mechanisms of primary and acquired resistance to immunotherapies, the principles of combination strategies to overcome resistance, and their unique toxicity profiles
Skills	Demonstrate the ability to: Perform a history and physical examination in patients receiving immunotherapy, and recognise patient presentations unique to immunotherapy Contribute to clinical scenarios and discuss the reasoning behind selection of immunotherapy options/recommendations, based on histology, staging, tumour burden, performance status, comorbidities, and tolerance of toxicity Select, communicate, and prescribe the optimal immunotherapy regimen for an individual patient Discuss the choice of the optimal sequence of immunotherapy versus other standard-of-care anti-cancer therapies Recognise the unique response patterns to immunotherapy, including pseudoprogression, late response, and hyperprogression Recognise and manage immune-related adverse events seen with immune checkpoint inhibition, most commonly involving skin, endocrine, gastrointestinal, pulmonary, and hepatic systems Assemble a multidisciplinary group of consultants to facilitate the care of patients suffering from immune-related adverse events Distinguish immune-related toxicity from non–immune-related toxicity and progression of disease Perform a risk-benefit assessment for patients considering immunotherapy, especially in patients with earlier stage disease. Select the optimal duration of immunotherapy, including checkpoint inhibitors based on their toxicity profile and the likelihood of having an unconventional response

Objectives	To describe the application of cell-based therapies in the treatment of various malignancies and to manage the most common toxicities associated with cell-based therapies, including cytokine release syndrome (CRS), immune effector cell-associated neurologic syndrome (ICANS), infections, disorders of coagulation, and other immune complications
Key Concepts	Demonstrate an understanding of the different types of cell-based therapies used to treat malignancy Describe the structure and function of approved cell-based therapies including dendritic cells and chimeric antigen receptor (CAR) T cells Distinguish the different types of cell-based therapy used to treat malignancies including, but not limited to, CAR T-cell therapy Demonstrate an understanding of the different generations of CAR T cells and the rationale and mechanistic underpinnings for the modifications made to the structure of the chimeric antigen receptors they bear Evaluate candidates for cell-based therapies based on type of malignancy as well as number of previous lines of therapy Identify disease characteristics or risk factors that would make a candidate ineligible for treatment with cell-based therapies Describe the process of manufacture of various cell-based therapies including the process of cell mobilisation and aphaeresis Demonstrate an understanding of the process of genetic modification used to produce cell-based therapies Demonstrate an understanding of the different approaches that can be used to effect genetic modifications in cell-based therapies and be aware of their relative merits and weaknesses Explain the purpose and risks of using lymphodepleting chemotherapy before cell therapy infusion Summarise the efficacy and toxicity profiles of available cell-based therapies in various malignancies by explaining the response rates, overall survival, and rate of common toxicities observed in pivotal clinical trials for each cell-based therapy Demonstrate an understanding of currently available methodologies for studying the persistence of cell-based therapies after administration to patients Demonstrate an understanding of the grading and management of common toxicities of cell-based therapies, such as CRS and ICANS, and the requirements for use of anti-cytokine therapies, such as anti–IL-6 therapies and corticosteroids
Skills	Demonstrate the ability to: Identify patients who are eligible for cell-based therapies based on type of malignancy, prior lines of therapy, disease burden, performance status, comorbidities, and organ function Discuss with patients the risks and benefits of the process of aphaeresis or any other process used to harvest cells Select the appropriate cell-based therapy based on the patient's malignancy, presence or absence of the cell-based therapy target, and the predicted toxicity and efficacy profiles of the cell-based therapy Select and administer lymphodepleting chemotherapy as needed before cell-based therapy infusion and manage any subsequent side effects Monitor clinical efficacy of cell-based therapy, including an understanding of the kinetics of persistence/disappearance of any administered cell product Identify, monitor, grade, and manage common toxicities of cell-based therapies including CRS and ICANS with the assistance of a multidisciplinary team Report other potential toxicities associated with various cell-based therapies including other possible immune side effects as well as common infections

Objectives	To be able to: Assess, diagnose, and guide treatment of symptoms to the disease from time of diagnosis and throughout the cancer trajectory Assess patients' and caregivers' supportive care needs and perform counselling from the time of diagnosis and throughout the cancer trajectory
Key Concepts	Recognise that supportive care needs are present from the time of diagnosis and throughout the cancer trajectory, including pre-habilitation, during treatment, survivorship and rehabilitation, or end of life Classify the following as symptoms/signs/complications of the disease or supportive care needs (listed in alphabetical order): anxiety, anaemia, bleeding, breathlessness, cachexia, cancer associated thrombosis, comorbidities, constipation, depression, diarrhoea, hormonal effects, infections, fertility preservation, fatigue, fistula, lymphoedema, malignant effusions, nausea, nutritional support, oral complications, pain, paraneoplastic syndromes, psycho-social effects, sexual effects, tumour-related fever Demonstrate an understanding that the supportive care needs varies throughout the cancer trajectory Recognise that clinical and individual assessment for correct management of symptoms is essential to the overall outcome Determine the common disorders induced by the cancer disease, ie, physical and psycho-social disorders Recognise the overlap between symptoms of the cancer disease and treatment toxicities Demonstrate an understanding of the pathophysiology of the symptoms of the cancer disease and how to tailor supportive strategies accordingly Demonstrate an understanding of the importance of educating patients and caregivers regarding the symptoms of the cancer disease Recognise that supportive care measures and symptom management is often multidisciplinary, including physicians, nurses, pharmacists, and allied health professionals Recognise that active patient and caregiver involvement, including education and use of patient-reported outcomes, is critical for the success of management of the symptoms, including strengths and limitations Interpret available evidence-based supportive care guidelines, and recognise that their routine implementation can reduce the severity of cancer-related symptoms Recognise that optimal supportive care can impact the relative dose intensity of subsequent anti-cancer treatment
Skills	Demonstrate the ability to: Recognise presentations of symptoms of the disease and care needs for patients and caregivers during the various phases of the cancer trajectory Perform a thorough history and relevant clinical examination to determine the likely aetiology of the symptoms as origin of the disease Perform a thorough family and psychosocial history to reveal potential care needs to address Apply evidence-based supportive management strategies for the most common disease-related symptoms and complications including pharmacologic and non-pharmacologic approaches Discuss the principles and benefits of pre-habilitation and rehabilitation Discuss the principles and benefits of advance care planning Discuss the principles and benefits of early integration of palliative care Discuss potential diagnostic tools/surveys and tests, including the merits and limitations of the these Discuss and interpret patient-reported outcomes in clinical practice for supportive care issues Discuss the role and integration of multidisciplinary clinicians for the diagnosis and management of supportive care issues Discuss the importance of supportive care measures in relation to optimal overall cancer care and treatment outcome

Objectives	To be able to: Assess, diagnose, and treat patients experiencing toxicities induced by systemic anti-cancer therapies Counsel patients on preventive measures
Key Concepts	Recognise the unique and overlapping toxicities of different classes of cancer treatments (eg, cytotoxic, hormonal, targeted, and immunotherapy) Evaluate the pathogenesis (if known) of therapy-related toxicities and how to tailor supportive strategies accordingly Demonstrate an understanding of the importance of educating patients and caregivers regarding the signs and symptoms of treatment-related toxicity Recognise that treatment-related toxicities can be acute or chronic Recognise that a toxicity's severity and chronicity impact its clinical management Demonstrate an understanding that patients experience toxicities with variable individual risk (risk factors eg, performance status, comorbidities, age, concurrent irradiation), frequency, and severity Determine the relationship between pharmacology and toxicity, including drug-drug and food-drug interactions, and its implications on clinical presentation of treatment-related toxicities Recognise that clinical assessment is critical in the evaluation of treatment-related adverse events Translate available diagnostic tests in assessing toxicity, including strengths and limitations Recognise the differences between patient-reported versus clinician-reported toxicity and quality of life Recognise that active patient involvement, eg, patient education and regular patient-reported outcomes, can improve symptom management Summarise toxicity grading systems (eg, Common Terminology Criteria for Adverse Events), interpret and apply the toxicity grading on cancer treatment Recognise that toxicity management is often multidisciplinary, including physicians, nurses, pharmacists, and allied health professionals Recognise that evidence-based prophylactic strategies exist and their routine implementation can reduce the frequency and severity of treatment-related toxicities Recognise that toxicities can impact the relative-dose intensity of subsequent anti-cancer treatment Recognise that treatment-related toxicities have physical and psychologic impacts on a patient's well-being
Skills	Demonstrate the ability to: Recognise characteristic presentations of systemic treatment toxicities of different classes of anti-cancer therapies Perform a thorough history and relevant clinical examination to determine the likely aetiology of the treatment-related toxicity Use toxicity grading to discuss further relevant investigations and treatment modifications Discuss potential diagnostic studies, including the merits and limitations of the tests Apply optimal supportive management strategies for the most common treatment toxicities, including pharmacologic and non-pharmacologic approaches Discuss the role and integration of other multidisciplinary clinicians for the diagnosis and management of treatment-related toxicities Apply evidence-based prophylactic strategies to prevent systemic treatment toxicities Discuss the relevance of dose delay, dose modification or treatment cessation in case of unacceptable treatment toxicity

Objectives	To be able to support and maintain normal body composition and function To describe the limitations of artificial nutrition and hydration at the end of life
Key Concepts	Demonstrate an understanding of the differences and similarities between nutrition-associated terms, including malnutrition, starvation, weight loss, frailty, sarcopenia, and cachexia Explain to patients and caregivers the differences between cancer cachexia and starvation Interpret existing evidence-based nutritional guidelines for patients with cancer Identify effectively and treat any reversible causes or symptoms impacting a patient's nutrition Identify and collaborate with key local multidisciplinary experts to optimise nutrition in patients with cancer Distinguish different causes for weight loss, including psychosocial, local tumour-associated, and metabolic factors, especially systemic inflammation Describe the pathophysiology of cancer cachexia and the interaction of resulting derangements on the patient's clinical status Describe the relevance of maintaining body weight and especially skeletal muscle mass Recognise the importance of routine screening for nutritional risk and give examples of different evidence-based screening tools Describe global concepts of defining malnutrition and cachexia, especially as recommended by the Global Leadership Initiative for Malnutrition Describe the importance of an individually targeted and multiprofessional treatment approach in patients with cancer at risk of or diagnosed with malnutrition Describe the escalation of nutritional care, including dietary counselling and indications for offering oral nutritional supplements and different forms of artificial nutrition Recognise the decreasing effectivity, while risks and burdens are maintained, of nutritional interventions at the end of life Describe the relevance of combining nutritional interventions with muscle training Identify settings for supporting body resources before aggressive anti-cancer treatments (pre-habilitation) Summarise the components of a healthy lifestyle to be recommended for cancer survivors
Skills	Demonstrate the ability to: Select and discuss the routine use of a malnutrition screening tool for clinical practice Discuss the interpretation of nutritional assessment Predict energy and nutrient requirements for individual patients Select members of a multidisciplinary group to cooperate in providing best nutritional and metabolic support Present details of a patient report on nutritional and metabolic status and required multimodal interventions

Objectives	To describe the fundamentals of end-of-life care and recognize when a patient is actually dying To be able to provide sensitive and effective care to patients dying of advanced cancer and support their family members throughout the dying process and into their acute bereavement period
Key Concepts	Demonstrate an understanding: That there is no one best way to die and that the care of dying patients must be individualised to incorporate specific cultural, religious, or other considerations relevant to each patient and their family Of the major ethical issues surrounding end-of-life care, including documentation of advance care planning, requests for euthanasia, assisted suicide, and withholding/withdrawal of treatments Of the need for interdisciplinary care at the end of life, including early referral and close cooperation with palliative care services Of the need for effective continuity of compassionate care for both the patient and their family throughout the cancer experience, including end-of-life care and family bereavement (without abandonment when treatment to control the cancer is no longer effective) When patients are approaching the end of their lives and palliative interventions focused on completing important life goals and comfort will be the most effective approaches to caring for the patient Of the signs of the dying process when patients are entering the last hours of their lives and provide a safe and comfortable dying process for the patient and the family How to manage effectively the dying process for the patient and family Provide bereaved family members with referrals to counselling services that will help them address their grieving and rebuild their lives
Skills	Demonstrate the ability to: Effectively use the available tools to guide prognostication as patients are approaching the end of their lives and sensitively discuss prognosis with the patient and family Describe the signs of the dying process and identify when a patient is in the last hours of life Identify when death has occurred and communicate this effectively to family members Discuss and effectively evaluate the needs of the patient and family at each stage of end-of-life care Discuss shared goals of life and goals of care with each patient, their family members and health care professionals that includes the physical and emotional, social, cultural, and spiritual dimensions of care and establishes the optimal place for end-of-life care acceptable to everyone Design plan of care, incorporate family members into that plan, and ensure they have the skills they need to care for the patient Design an effective plan of care with the patient, family, and members of the health care team that focuses on the patient’s capacity to complete important life goals, ensures comfort, and provides effective support for family members when patients have a limited life expectancy Design an effective plan of care to ensure safe and comfortable dying for the patient and manage the distress of the family when patients are actively dying (with signs of the dying process) Assess effectively, prevent, and manage the common symptoms experienced during the dying process, including dyspnoea, dysphagia, excessive secretions, pain, both hyperactive and hypoactive terminal delirium, dry mouth nares and eyes, and skin breakdown Schedule early referral to palliative care and counselling services that can assist with the management of the dying process, and support the family throughout the last hours of the patient’s life and into bereavement Apply the concept of refractory symptoms and the judicious use of palliative sedation to manage them at the end of life Perform end-of-life care in a variety of settings including the patient’s home

Objective	To be able to perform specialist assessment, guide systemic therapy in the context of multidisciplinary treatment and counselling of patients with small-cell lung cancer along the cancer continuum
Key Concepts	Describe the different molecular subtypes of small-cell lung cancer (SCLC) Recognise that tobacco use is the single most important cause of SCLC and tobacco cessation reduces lung cancer risk Explain why lung cancer screening is of limited value in detecting early-stage SCLC Recognise the aggressive nature of SCLC requiring no delays in diagnostic procedures, rapid initiation of treatment, and close monitoring during follow-up Describe the role of [¹⁸F]Fluorodeoxyglucose-positron emission tomography scan and magnetic resonance imaging brain at diagnosis and during follow-up Recognise, evaluate, and give examples of common neurologic and endocrine paraneoplastic syndromes that are associated with SCLC Explain that optimal treatment of SCLC cancer involves a multidisciplinary team, including pulmonologist, thoracic surgeons, medical oncologist, radiation oncologist, neurologist, and palliative care specialist Describe the limitations and potential role of surgical resection in (very) limited SCLC Summarise the role of systemic therapy, including immunotherapy, in adjuvant, curative, and palliative settings Distinguish patients who will benefit from radiation therapy in the definitive, consolidative, and prophylactic settings Distinguish patients with platinum-refractory and platinum-sensitive recurrence Recognise that early palliative intervention has been shown to improve survival and quality of life
Skills	Demonstrate the ability to: Discuss the relevance of Veterans Administration and TNM staging systems for SCLC Practise to select and interpret staging modalities Practise to contribute to discussions on general management strategies, including limited and extensive stage in order to understand the rationale for selecting and sequencing treatments in a multidisciplinary setting Select systemic treatments, including cytotoxic chemotherapy and immunotherapy to optimise patient treatment for response and tolerance Discuss situations where initiating systemic treatment is urgently required Discuss with patients the risk-benefit ration of several treatment strategies as concurrent chemoradiotherapy and prophylactic cranial irradiation (PCI) Apply personalised treatment and follow-up taking into account patient-related characteristics Predict and treat short- and long-term side effects of PCI

Objectives	To describe the epidemiology, clinical characteristics, and treatment of cancers in adolescents and young adults (AYA)s and the specialised multidisciplinary care of these patients To be able to guide systemic therapy in the context of multidisciplinary care
Key Concepts	Describe the age range and epidemiology of cancer in AYA Recognise the modest improvement in survival gains compared with childhood and adult cancers Demonstrate an understanding of the complex psychologic, social, and financial impact of a cancer diagnosis during a period of rapid physiologic, personal and psychologic growth that affects well-being in significant ways Recognise that haematologic malignancies (predominantly lymphoma and leukaemia) and central nervous system tumours are more common in young AYAs, but as age increases, carcinomas become more common. Other cancers include melanoma, germ cell tumours, thyroid cancer, and sarcomas Explain the inequitable access to services which provide expert cancer care and consider the unique needs of AYA Describe the many histotypes for which tumour genomics, biology and clinical behaviour may differ in AYAs compared with children and older adults Explain the diagnosis often made at an advanced stage due to insufficient awareness that cancer may occur in this age group, the complex evaluation process and pathway to diagnosis Give examples of the multidisciplinary care in an age-appropriate setting, ie, crucial to support a healthy and productive life during and after cancer therapy Demonstrate an understanding why lack of compliance is a considerable issue and long-term follow-up is necessary Determine the need to immunise AYAs with and without cancer for human papillomavirus through age 26 years
Skills	Demonstrate the ability to: Provide age-appropriate information and adapt to communication challenges Select, communicate and provide the most appropriate evidence-based therapy within the relevant cancer-specific multidisciplinary team To participate in the comprehensive multidisciplinary care that AYAs with cancer need or refer to a cancer centre specialised in AYA cancers Discuss the patient needs related to psychosocial status, fertility, genetic predisposition, and survivorship Design the shared decision-making process and enforce compliance and treatment adherence Discuss peer support Discuss fertility risk and preservation options before initiation of treatment Practise the inclusion in age-specific clinical trials Perform transition to cancer survivorship care and management of treatment side effects Discuss prevention strategies and healthy lifestyle behaviours