*Note: This post is based on my (limited) experience as a trainee in medical school and residency at one institution (University of Toronto). If you have had a different experience please share in the comments or on Twitter
On the weekend I wrote “Diagnosing cancer is hard” and said I would later write about what can be changed on the physicians’ side to improve diagnostic skills, and well…I lied. I don’t have any great insights into that. What I would like to discuss is the lack of general oncology teaching for non-oncologists.
Cancer is responsible for 30% of all deaths in Canada; two in five Canadians will develop cancer in their lifetime and one in four will die of it (Canadian Cancer society). Survival rates are increasing, and patients even with advanced or metastatic disease are living longer due to new treatments, turning cancer in many patients into more of a chronic disease. Yet many doctors on the front lines (family physicians, internists, other specialists) are much less comfortable treating the issues that surround active cancer (or side effects from treatment) than they should be. And I believe that it all stems from a lack of education, starting in medical school, and continuing throughout residency.
The first two years of my medical school were lectures on anatomy, physiology and organ systems. There are two months in first year on cardiac physiology, and another two months on clinical cardiology in second year. Comparatively, there is nothing on cancer in first year, and a total of 5-10 hours in second year (an hour for each of the most common types of cancer). There is a grand total of one hour of radiation oncology across all four years, yet 50% of the 200,000 people diagnosed with cancer each year in Canada will get radiation at some point as part of their treatment. Radiation treatment is a giant black box to pretty much all non-oncologists. In clerkship, there is zero mandatory clinical oncology time. Western University used to have two weeks of mandatory clinical oncology, but they made it elective a few years ago. I am not aware of any university in Canada that has any mandatory clinical oncology rotations in clerkship.
Family medicine residency has no clinical oncology time and almost no formal teaching on it. Internal medicine has a single four week medical oncology rotation across the first three years of residency, and one half day of formal teaching per year on cancer. Yet family doctors and internists see and treat cancer patients (cured, on treatment, or coping with metastatic disease) all the time. I believe this needs to change, and that patients will be better off if all doctors are more comfortable and knowledgeable about oncology. Palliative care doctors should not be the only non-oncologists with a significant clinical oncology education. Generalists (internists, GPs) are well equipped to treat diabetes, hypertension and other prevalent diseases because they are trained for it; what about cancer care?
I will use one example to illustrate my point, but I want to remind my readers that I know next to nothing about the economic and political aspects related to the following example. Many breast cancer patients are now on hormonal therapy (such as tamoxifen) for 10 years after diagnosis. The chances of a new complication from these pills, or of a recurrence of their cancer, is increasingly remote after 5 years of follow up. Yet these patients are seen in an oncology clinic every year in order to go over their mammography report, get a prescription refill, be monitored for side effects, and undergo a clinical breast exam. These patients often have to travel a significant distance (several hours in some cases), pay $25 in parking, and have the added anxiety of knowing they have to come back to a cancer centre every year. It is not my goal to criticize medical oncologists in any way with this example. I would simply assert that years five through 10, family doctors could take over this responsibility with the option of re-referring to the cancer centre should issues arise. Patients could stay closer to home, save money on parking and potentially have their anxiety reduced if they saw their GP instead. It could be part of their annual physical exam, saving the patient an additional appointment. Yet the infrastructure is not in place for this yet, and I suspect many family doctors need more education in order to be comfortable prescribing and monitoring hormonal therapy for breast cancer. The same type of argument could be made for long term PSA follow up for men cured of their prostate cancer, and likely many other situations that I cannot think of off the top of my head.
In cases like this, patients would be equally or better served if some of the clinical work could be offloaded from an already overloaded oncology sector to a primary care setting. From a GP’s office to general inpatient hospital wards, cancer care could improve if non-oncologists had significantly more education in oncology. To do this, oncology education needs to truly start at the undergraduate medical education level and be supported throughout residency for all doctors in training.