SOCIÉTÉ INTERNATIONALE
D’ONCOLOGIE PÉDIATRIQUE/
INTERNATIONAL SOCIETY
OF PAEDIATRIC ONCOLOGOGY

COMMITTEE ON
STANDARDS OF CARE AND TRAINING
IN PAEDIATRIC ONCOLOGY

REQUIREMENTS FOR THE TRAINING
OF A PAEDIATRIC HAEMATOLOGIST/ONCOLOGIST

RECOMMENDATIONS FOR THE ORGANISATION
OF A PAEDIATRIC CANCER UNIT (PCU)

INTRODUCTION

Actually 65 – 70 percent of all children and adolescents with cancer can be  cured if adequate treatment is provided.
In view of the incidence of cancer in the young and in order to improve the rate and quality of survival, the Board of SIOP has adopted two recommendations worked out by the SIOP committee on Standards of Care and Training:

• Requirements for Training of a Paediatric Haematologist / Oncologist;and
• Recommendations for the Organisation of a Paediatric Cancer Unit (PCU)

Additional documents regarding Standards of Care and Training in Paediatric Oncology will added in future.

Text approved by Board December 1991

REQUIREMENTS FOR THE TRAINING OF A PAEDIATRIC HAEMATOLOGIST/ONCOLOGIST

Preamble

The term “Paediatric Oncologist” encompasses paediatricians specially trained to diagnose and treat malignant neoplastic disease of childhood, including the leukaemia’s. This document henceforth will use only the terms “Paediatric Oncology” and “Paediatric Oncologist” since it is concerned with standards of training in Oncology alone or as part of a combined programme. It is envisaged that certification will be provided in both Paediatric Oncology and Paediatric Haematology/Oncology during a transition period while these separate and different specialities achieve distinct identities of their own.

Introduction
To define who is qualified in Paediatric Oncology will be important in the future. After 1992 it will be easier for a doctor to work in a nation other than his or her country of origin, education or certification.
It will therefore be advantageous to know that certain minimal requirements for specialty training have been met.
Furthermore, it is one of the tasks of SIOP to indicate what standards should be used for care and training in Paediatrics Oncology. This document will deal only with the training of doctors.

Definition of training in Paediatric Oncology
To provide the Paediatrician with the background to diagnose and manage malignant haematologic and oncologic diseases. This includes an understanding of the physiology of blood and bone marrow function as well as the patho-physiology of haematologic disorders and malignant disease.
Also included is the basic knowledge on tumour biology and pathology, general principles of chemotherapy, pharmacology, radiotherapy and surgery An understanding should be developed of the psychological support of the patients and the special ethical considerations in paediatric oncology. Paediatric oncology certification should be offered only to paediatricians who have completed accredited training in general paediatrics including neonatology and intensive care.
Adequate training can be obtained only in hospitals or institutes that have intramural state-of-the-art facilities for diagnosis, treatment and research.  Programmes must provide at least two years of progressive educational experience and responsibility in the elements of paediatric oncology.

Patient population and facilities
Adequate numbers of patients with malignant diseases ranging in age from newborn through adolescence must be available. Space in an ambulatory setting must be provided for optimal evaluation and care of patients. This should include facilities for outpatient chemotherapy and transfusions, and an inpatient area with full array of paediatric and related services staffed by paediatric trainees, faculty, and trained oncology nurses. Full support must include radiology, laboratory, pathology, intensive care, respiratory therapy, physical therapy, nutrition, social services and psychology.

Staff
Appropriate consultant faculty should be available to provide the trainee with a defined educational
Experience in related disciplines, including: surgery and surgical specialties, radiation oncology, radiology, clinical pharmacology, gynaecology, infectious diseases, pathology, psychiatry, immunology, cardiology, neurology, endocrinology, gastro-enterology and genetics.

Research
A critical aspect of the training programme is its research environment. There should be evidence of a commitment to research and investigation in paediatric oncology and ongoing active research in clinical, epidemiologic and basic aspects of projects dealing with oncology-related problems by the teaching staff.
Within the institution, the trainee should be exposed to and take part in research programmes which provide an environment conducive to a questioning attitude, to protocol development and to critical analysis. Ideally, the trainees should help to design, conduct, evaluate and prepare for publication a clinical or laboratory research project in the area of paediatric oncology.
The completion of a research project during the training programme is strongly encouraged. The trainee should be able tot communicate his knowledge to others both orally and in written form, conduct lectures, seminars and clinical conferences and prepare a written report of his/her research activities either for faculty review or publication. Exchange of experience among hospitals and countries should be possible.

Scope of training
The training programme must emphasise the fundamentals of clinical diagnosis with special emphasis on history taking and physical examination. A programme in paediatric oncology should provide enough clinical experience with both inpatients, day car patients and outpatients who have oncologic disorders for the trainees to develop facility in diagnosis and managing common and unusual problems. The programme should include haematologic disorders of the newborn, congenital and acquired disorders of red blood cells, white cells and platelets if related to malignant diseases and solid tumours of this age group.

1. In addition to specific haematologic and malignant disorders, the trainee must have the opportunity to become familiar with all aspects of chemotherapy including treatment protocols and management of complications, diagnosis and treatment of infections in the compromised host, appropriate use of transfusion of the various blood components, plasmapheresis and bone marrow transplantation. The trainee should learn the methods of physiologic support of the cancer patient including parenteral nutrition, control of nausea and management of pain. The staging and classification of tumours, complete knowledge of the application of multi modal therapy (surgery, radio- and chemotherapy), learning to function as a member of the oncology team”, learning the epidemiology and aetiology of childhood cancer, making good observations and keeping accurate patient data are vital aspects of paediatric oncology training. The trainee should participate in the activities of the Tumour Board and in the provision of comprehensive care of the child with cancer. He should have experience in support of the patient, family and staff in dealing with terminal illness. Development of skills in communication and counselling is important for the trainee.
2. The trainees must be exposed to the proper use of laboratory techniques for diagnosis. There should be particular emphasis on recognition of the limitations of the various methods and the pitfalls in interpretation of laboratory results. They  should be familiar with the normal variations in laboratory data that occur at different ages and should know the influence of medications, toxins and systemic disease on haematologic values.
3. The trainees should be provided with the background to enable them to utilise the diagnostic procedures of oncology. These include:
   a.       the performance and interpretation of bone marrow aspiration and biopsy
   b.       venipuncture
   c.       lumbar puncture with evaluation of cerebrospinal fluid
   d.       use of the microscope and
   e.       interpretation of peripheral blood films.
4. The trainee should be familiar with the diagnostic services of pathology/radiology, nuclear medicine, computerised tomography, sonography, angiography, clinical chemistry, microbiology, immunology and genetics in evaluation of patients with malignant disorders.

RECOMMENDATIONS FOR THE ORGANISATION OF A PAEDIATRIC CANCER UNIT (PCU)

1. All children with cancer should be offered child-oriented diagnoses treatment, after-care and follow-up. Special attention is also required for adolescents and young adults up to the age of 20.
2. A PCU functions on a multi-disciplinary team-work principle. It can be a special unit integrated in a paediatric department or be located in a large general oncology centre. In the latter case there should be close links with paediatric services and separate facilities for hospitalised children including psychosocial, social and educational  services.
3. A PCU is a part of, or linked to a national and/or an international multi-disciplinary organisation for paediatric oncology, in order to facilitate  communication and coordination of new treatment methods and research. Sufficient data management staff and equipment should be available to participate in clinical trials and to supply data to cancer registries.
4. A PCU provides centralised primary treatment to enough patients (50 or more new patients/year) to warrant specific structures for paediatric oncology in surgery, radio-oncology, pathology, intensive care, supportive care and rehabilitation. All of these facilities should be on site or close-by. It may be necessary to centralise further the primary treatment of brain tumours or other malignancies requiring highly specialised treatment.
5. A PCU is operated by appropriately trained specialists (paediatric oncologist/haematologist, paediatric surgeon with special interest in oncology, paediatric oncology nurses, paediatric phychologists, social workers, teachers, etc.) to
   a.       ensure a round-the-clock- service
   b.       recruit new PCU personnel and
   c.       provide adequate training in paediatric oncology
6. A PCU comprises the following facilities:
   a.       a ward for in-patients sufficiently staffed and equipment (including proper isolation facilities) to execute complex medical orders; establish central lines; monitor long-term infusions; care and support critically ill, myelo-/immunosuppressed or dying children and their parents; handle and prepare the administration of cytostatic drugs and keep adequate records. Accommodation  on the ward or close-by should be provided for parents. Religious/ministerial support should also be available;
   b.       a day-clinic for short-term investigations, short-term infusions or short-term surveillance of patients;
   c.       an out-patient clinic closely linked to imaging and laboratory facilities, providing rapid service for ambulatory treatment and control;
   d.       an administration for organising and coordinating the long-term follow-up and evaluation of former cancer patients.

COMMITTEE ON STANDARDS OF CARE AND TRAINING IN PAEDIATRIC ONCOLOGY