City of hope cancer center hematology–oncology fellowship and hematopoietic stem cell transplantation fellowship
Authors: Amrita Krishnan, Karen Reckamp, Lucille Leong
Journal: American Journal of Hematology (2010)

The City of Hope (COH) ACGME-accredited Hematology–Oncology fellowship began in 1978 with two fellows and has grown up to seven fellows per year. It remained as the last fellowship independent of an Internal Medicine Training Program until its affiliation with Harbor-UCLA Internal Medicine Program as the Research Track of the fellowship in 1995. City of Hope Cancer Center is an NCI-designated comprehensive cancer center, a founding member of National Comprehensive Cancer Network, and one of the top medical centers as named by the US News and World Report. This provides an ideal environment for learning patient care and research within both a county hospital and a tertiary teaching hospital setting. In addition, it provides ample opportunities for both basic science and clinical research in the latter years of the fellowship. The fellowship is a fully-funded 3-year program which provides experience through a multidisciplinary approach to prepare trainees for a successful career in academic medicine or private practice. In addition, COH offers an independent Hematopoietic Stem Cell Transplantation (HSCT) Fellowship, which began in the late 1980s. The HSCT fellowship is a 1- to 2-year program at the COH; the largest hematologic transplant center in California. This provides extensive clinical training and research opportunities for transplant fellows. It has been in existence for 16 years and has trained approximately 39 fellows. The goals of fellowship are the provision of trainees with the ability to deliver personalized, interdisciplinary care of the highest quality for every cancer patient seen at COH; the creation of a climate fostering collaboration among basic scientists, clinical researchers, and physicians; and the provision of cancer education and outreach programs. In 2005, COH opened the 340,000 sq ft state-of-the-art Helford Clinical Research Hospital which incorporates the latest in medical, surgical, radiological, and communications technologies, as well as modern diagnostic, radiology, and imaging tools in a digital environment. The hematologic transplantation facility includes facilities for dose intensive therapy for hematologic malignancies and for solid tumor patients, in addition to a medical/surgical intensive care unit. Outpatient care occurs in the Brawerman Center, which has the capacity for over 200,000 visits per year. The hospital itself has 125 beds. COH has a world renowned hematopoietic stem cell transplant (HSCT) program that performs approximately 400 transplants per year. This includes autologous, allogeneic, unrelated donor, and cord blood transplants. A unique aspect of the HSCT fellowship has been the autonomy of the transplant fellows. They are assigned their own patients which they follow from beginning to end of the therapy under the supervision of an attending physician. At Harbor-UCLA Medical Center, the exposure to both Hematology and Oncology is highly clinical. The patient population seen at Harbor-UCLA consists of mostly indigent and uninsured persons—those of whom typically present with advanced pathology. In addition, there is a wide representation of benign hematologic pathology, including sickle cell anemia, other hereditary anemias, and coagulopathies related to pregnancy and surgical complications. Regarding patient care rotations at Harbor-UCLA, the fellows maintain tremendous autonomy, however they are closely supervised. Learning through autonomy is balanced with a comprehensive didactic series covering topics to satisfy both Hematology and Oncology curricula. The ACGME Hematology–Oncology fellowship consists of rotations in the hematology departments at COH and Harbor UCLA. At COH, the exposure is primarily malignant hematology and oncology with an emphasis on stem cell transplantation and Phase I therapeutics for hematologic malignancies. Fellows attend a weekly journal club which is dedicated to evaluating current practices and evidence for the treatment of oncologic and hematologic diseases. Additional weekly and monthly didactic sessions, core lecture series, and board review are included to provide a well-rounded educational experience. Fellows also participate in rotations in our blood bank and apheresis center and hematopathology. They also attend the multidisciplinary lymphoma conference and the hematopathology conference discussed below. The transplant fellowship provides comprehensive training in all aspects of transplant. The program is a clinical-based program that provides experience in the evaluation of patients for transplantation. This includes disease based indications, appropriate functional testing required prior to transplant. In addition, fellows learn about the methods of HLA typing as well as HLA selection of donors and the use of chimerism studies post transplant. Identification of the stem cell source including the use of donor registries will be taught. Fellows participate in the clinical evaluation of donors and assessment of donors for suitability for stem cell transplant. They gain experience in the use of various preparative regimens prior to transplantation and also learn how to manage the complications of transplant such as mucositis, interstitial pneumonitis, hemorrhagic cystitis venocclusive disease, and acute and chronic graft versus host disease. Furthermore, the fellows also follow patients after their transplant and therefore learn how to manage chronic graft versus host disease. They gain familiarity with the medications used for the treatment of this condition as well as the side effects of the medications. Management of post transplant relapse with donor leucocyte infusion or second transplants are also discussed. Diagnosis and management of late complications of blood and marrow transplantation including cataracts, avascular necrosis of the hips, and secondary malignancies are reviewed. Fellows present cases at a new patient conference each week. In addition, complex lymphoma cases are presented at a multidisciplinary conference also attended by pathologists, radiologists, and radiation oncologists every other week. There is a weekly core education series of lectures on hematology and oncology topics that also encompass transplant related issues. A hematopathology conference is held every other week to review challenging diagnostic cases. COH is committed to providing a mechanism for young investigators to gain the required knowledge and expertise to perform innovative, hypothesis-driven, patient-oriented research. As one of its central goals, COH has pursued the enhancement of interactive clinical and translational research at the cutting edge of molecular genetics, immunology and immune-based therapy, bone marrow transplantation and stem cell biology, outcomes research, and experimental therapeutics. COH has built a reputation for outstanding research in cancer therapy, transplantation, and outcomes research, and is committed to the development of promising investigational new drugs and their application in the clinical setting. As such, we recognize the importance of providing a milieu to enhance these opportunities for our fellows. The COH Clinical Investigation Training Program (CITP) provides a structured but flexible, multidisciplinary Clinical Research Certificate program for training of clinical investigators capable of performing high-quality research in Phase I drug discovery, cell-based therapy, epidemiology, and outcomes research. All Hematology/Oncology fellows complete the 1-year curriculum toward a certificate during their training. Hematology–Oncology fellows develop a research project under the guidance of a mentor during the second and third years of training. The HSCT fellows are given a transplant related clinical research project which can be completed during that year of training. The faculty at COH has been involved in fellowship training for more than forty years. Mentors are comprised of an interdisciplinary, diverse group of scientists, biostatisticians, epidemiologists, clinicians, and clinical researchers, as well as experts in the fields of ethics, good clinical practice, and responsible conduct of research. Every mentor has a strong interest in teaching and is experienced in providing scientific education. COH also has a K-12 career development grant for fellows who are interested in becoming academic oncologists. Graduating fellows are eligible to apply for this grant. Three fellows have been through this program and continue their academic careers at COH. Overall, the fellowship program has had 46 fellows between 1998 and 2010. In this time span, the fellows have had an average of two publications, with a wide range of up to 85 for those who continued their career in academic medicine. For the fellows who graduated in the last decade (2000–2010), seven out of 19 remained in an academic institution. Four out of nineteen are in academic affiliated practices, and another seven are in private practice. Amrita Krishnan [email protected]*, Karen Reckamp†, Lucille Leong†, * Department of Hematology and Hematopoietic Cell Transplantation,City of Hope, Duarte, California, † Department of Medical Oncology, City of Hope, Duarte, California.