Reed E. Drews, M.D.
2005-04-01
Dr. Drews is Associate Professor of Medicine at Harvard Medical
School and Program Director of the Hematology-Oncology Fellowship at
Beth Israel Deaconess Medical Center.
Several years ago, a colleague, trained solely in hematology and now
working primarily in the laboratory exploring vascular biology, argued
that training in hematology should link not to oncology, but instead -
if joined with any other discipline at all - to endocrinology with its
study of hormones akin to hematopoietic growth factors. Recalling
academic hematology programs that seemingly withered in the face of
burgeoning oncology programs, I fully understood my colleague's
concerns regarding the historic linkage between hematology and oncology
training. Indeed, despite dual training, many graduates of combined
hematology-oncology fellowships focus exclusively on oncology, leaving
most aspects of hematology practice behind. With time, such attending
physicians become increasingly uncomfortable addressing hematologic
concerns, and attending physicians who are willing and able to cover
both arenas (e.g., on a combined hematology-oncology in-patient consult
service) are vanishing. So why not train only in oncology without
hematology?
Hematology training alone is defensible: for instance, hematologists
need not know how to diagnose and treat colon cancer. However, I
believe that oncology without hematology is incomplete. The two worlds
intersect at so many levels that to practice oncology without a solid
foundation in hematology is less than whole. Not only do the two
disciplines meld in understanding the biology of renegade neoplastic
cells in leukemias, lymphomas, and solid tumors, but also they converge
in diagnosing and managing a host of "benign" hematologic conditions
that can accompany or complicate these malignancies. Examples of such
combined clinical scenarios include: microangiopathic hemolytic anemia
accompanying gastric carcinoma or mitomycin-C therapy; underproduction
anemia resulting from myelosuppressive chemotherapies; disseminated
intravascular coagulation accompanying solid tumors, acute
promyelocytic leukemia, or infectious complications of
chemotherapy-induced neutropenia; acquired factor VIII inhibitors
associated with lymphomas or solid tumors; and heparin-induced
thrombocytopenia accompanying heparin therapy of Trousseau's syndrome.
Therefore, oncologists should develop skills in diagnosing and
managing hematologic conditions that often coexist with or complicate
solid tumor care. Thus, coupling oncology with hematology training
makes sense: perhaps we should call it "oncology-hematology" rather
than "hematology-oncology." Adding some training in transfusion
medicine would further bolster clinical knowledge.
The challenge for combined hematology-oncology training programs
today is to produce graduates who, with an admitted bias toward
treating malignancies either hematologic or oncologic, are equally
adept at handling the full range of "benign" red cell, white cell,
platelet, and coagulation abnormalities in their patients. With a
burgeoning base of knowledge in both disciplines, the question now is:
can we accomplish the curricular needs of combined hematology-oncology
clinical and research fellowship training in three years, or should
this be expanded to four years? The answer to this question may depend
on the specific design of the training program - perhaps something to
discuss in a future issue of "Careers in Hematology."
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