Interdisciplinary Medical Fellowship in Thyroid Cancer
Memorial Sloan-Kettering Cancer Center (MSKCC)

Executive Summary

In this proposal, we outline a novel clinical fellowship training program focusing on thyroid cancer. The overall goal is to develop a cohort of academic thyroid cancer specialists, trained in research methodology to expand our knowledge of thyroid cancer. There are no fellowship programs in the United States which focus solely on thyroid cancer. The training environment, Memorial Sloan-Kettering Cancer Center, is a large international referral center with over 3000 thyroid cancer patients under active surveillance or treatment. The program faculty is comprised of national experts in endocrinology, nuclear medicine, thyroid surgery, radiology, pathology, and radiation therapy. All faculty hold full-time appointments at the Weill Medical College of Cornell University and all participate in ongoing residency training programs. Fellows who are selected will complete a diverse curriculum that exposes them to all aspects of the care of thyroid cancer patients. In addition, they will receive formal instruction on basic and clinical research methods, including grant writing, to enable them to achieve independence in an academic environment. Opportunities exist at MSKCC for fellows who initiate successful research programs to continue working at the medical center for up to two additional years under the direction of a research mentor. The main goal is to foster the development of the next generation of clinical investigators who will focus on controlling and curing thyroid cancer.

Primary Goal

To develop a group of academic endocrinologists equipped with advanced training in the clinical management of thyroid cancer and in clinical research methodology in order to continue a national effort to prevent, control, and cure thyroid cancer.

Background

Thyroid Cancer is increasing in the United States. The American Cancer Society estimates that there will be more than 22,000 new cases in 2003. The most recent SEER/NCI analysis of cancer trends in the USA over the past 50 years found that thyroid cancer had the highest annual percentage increase of any cancer in women of all races.

Although we are learning more about potential etiologic agents (eg. radiation) and the genetic abnormalities associated with certain types of thyroid cancer, the cause(s) of this upward trend is still poorly defined. The American Cancer Society estimates that approximately 1500 Americans will die of thyroid cancer in 2003. More Americans die of thyroid cancer each year than die of Hodgkin’s disease, cervix cancer, or testicular cancer. Millions of dollars of federal funding support vigorous research efforts to control diseases such as Hodgkin’s, cervix, and testicular cancers, but almost no federal funding exists for clinical research into thyroid cancer.

The clinical realities of managing thyroid cancer patients are rapidly changing. New agents such as recombinant human TSH and new technologies such as Power Doppler ultrasonography and positron emission tomography are reshaping our approach to monitoring for recurrent disease and to determining prognosis. New pharmacological and radiotherapeutic approaches to controlling and treating metastatic disease are also rapidly evolving.

In this climate, we feel that clinicians and clinical scientists who choose to supervise the care of thyroid cancer patients need to have direct exposure to a wide variety of educational experiences which span surgical, nuclear medicine, endocrine, radiologic, and pathologic disciplines.

The Memorial Hospital for Cancer and Allied Diseases is a unique center with a Thyroid Cancer Working Group consisting of twenty-four full-time attending physicians with a major interest in thyroid cancer. These individuals have expertise in diverse medical disciplines, and they all hold full-time faculty appointments at the Weill Medical College of Cornell University. All members of the Working Group, furthermore, have a strong commitment to the education and training of young physicians.

We now propose a formal training program in which highly qualified physicians-in-training would be schooled in the complex and interdisciplinary issues of diagnosis and management of patients with thyroid carcinoma. In addition to obtaining clinical skills these physicians would be immersed in a variety of clinical and/or basic research programs to prepare them as independent investigators. Through this mechanism, we hope to develop a nucleus of talented clinical investigators who will lead the next wave of discoveries leading to the progressive control and cure of thyroid cancer.

Candidates

This program will be open to individuals who are board-certified in Internal Medicine and who have completed two years of endocrinology fellowship or two years of nuclear medicine training in an ABIM accredited program. At the start of the MSKCC fellowship, all individuals must be eligible for board certification in either Endocrinology and Metabolism or in Nuclear Medicine.

Venue and Curriculum

This is a two-year program. Individuals accepted into the program will be involved in an intensive immersion into all aspects of the diagnosis and treatment of thyroid cancer. By the end of the program they will develop the experience and skills to direct a thyroid cancer program at their host institutions. The course of study will be carried out at the Memorial Sloan-Kettering Cancer Center in New York, NY. This center has a large referral base and a large population of thyroid cancer patients under active management. Importantly, approximately 50% of the active outpatients have metastatic disease and are at high risk for mortality from the disease. Candidates will have direct exposure to the following educational modules:

-Ultrasonography of the thyroid

-Techniques in fine-needle aspiration of thyroid nodules

-Observation of surgical removal of thyroid nodules, total thyroidectomy, and neck dissection techniques

-Instruction on formal dosimetric analysis to determine safety limits for 131I

-Nuclear Medicine instruction on the performance and interpretation of radioiodine scans, radioactive iodine therapy, and positron emission tomography

-Fellows will participate in weekly Nuclear Medicine Tumor Board, weekly Thyroid Surgery Conference, and weekly Endocrine Grand Rounds and journal clubs. They will supervise and coordinate a city-wide monthly thyroid cancer conference held at MSKCC.

-Fellows will be expected to be involved with either bench or clinical research projects relating to thyroid cancer. Candidates will be selected at least six-months prior to beginning the program and will develop research plans prior to beginning the fellowship year with one of the attending faculty members.

-Formal training in an NIH-sponsored clinical investigator training program is available. This program offers formal instruction in the design, implementation, conduct, and statistical analysis of clinical research projects. Successful completion of this didactic program leads to official certification as a Clinical Investigator with ability to serve as a principal investigator on cooperative group and NIH-sponsored clinical research trials.

-A pediatric thyroid cancer rotation will be included including exposure to surgical and medical management of children and adolescents with thyroid cancer

-A rotation in the radiation oncology service will provide direct experience on the methods of intensity modulated radiotherapy and state-of-the-art high intensity confocal radiation therapy.

-A rotation in the chemotherapy of advanced thyroid cancer with a medical oncology team will be available. This will also include exposure to Phase I and Phase II protocols, testing new anti-cancer agents.

-A rotation in the Department of Pathology to read both surgical specimens and cytology specimens. Formal training programs exist in both Surgical Pathology and Cytology, which will host the Thyroid Cancer fellow as part of their educational program. A large teaching file of slides will also be available as part of the Pathology curriculum for the fellow.

-Fellows will attend two full-day outpatient clinics throughout the year in adult Endocrinology in which they will have a primary management role in patients with thyroid cancer. They will follow the same patients longitudinally during their entire stay.

-Fellows will admit patients to MSKCC for radioactive iodine therapy.

Additional years at the center are encouraged and will be available depending on clinical discipline and funding sources. Fellows will also learn the fundamentals of writing research manuscripts and funding proposals to support their future independence.

Environment

Fellows will be allowed to participate in all of the activities of the Cornell Affiliated Fellowship in Endocrinology, which is an ABIM-accredited program that has been in continuous operation for fifty years. The faculty of this program are attending physicians at Memorial Sloan-Kettering Cancer Center, the New York Presbyterian Hospital, the Weill Medical College of Cornell University, The Hospital for Special Surgery, and The Rockefeller University. All institutions are located on a single 10-block campus on the upper east side of Manhattan. Many weekly conferences and seminars focusing on all aspects of endocrinology are offered as part of this program. In addition the thyroid cancer fellows have access to all of the basic and clinical research seminars, formal research conferences, and weekly clinical conferences in general medicine and general oncology that are available at this large medical center complex.

Life

Candidates will be offered assistance in obtaining housing through the MSKCC housing office. However, there is no guarantee of a spot in MSKCC housing. Fellows will be offered all benefits accorded to all MSKCC residents and fellows, including medical malpractice coverage and health benefits.

Stipend

The salary will be that established by the NIH guidelines for trainees, depending on the PGY year of the applicant.

Faculty

Nuclear Medicine:
	Timothy Akhurst, Assistant Professor of Radiology Chaitanya Divgi, Professor of Nuclear Medicine Steve M. Larson, Professor of Nuclear Medicine, Associate Program Director H. William Strauss, Professor of Radiology Sam Yeh, Professor of Radiology Henry Yeung, Associate Professor of Radiology
Head and Neck Surgery:
	Ashok Shaha, Professor of Surgery Jatin Shah, Professor of Surgery Dennis Kraus, Associate Professor of Surgery Bhuvanesh Singh, Assistant Professor of Surgery Jay Boyle, Assistant Professor of Surgery Richard Wong, Assistant Professor of Surgery
Medicine:
	Marcia Kalin, Assistant Professor of Medicine Richard Kolesnick, Professor of Medicine and Pharmacology David Pfister, Associate Professor of Medicine Richard J. Robbins, Professor of Medicine, Program Director Nicholas Sauter, Assistant Professor of Medicine Bernard Su, Clinical Assistant Physician R. Michael Tuttle, Associate Professor of Medicine
Pathology:
	Ronald Ghossein, Assistant Professor of Pathology Maureen Zakowsky, Associate Professor of Pathology Edi Brogi, Assistant Professor of Pathology Oscar Lin, Assistant Professor of Pathology
Pediatrics:
	Charles Sklar, Professor of Pediatrics
Radiation Oncology:
	Lanceford Chong, Associate Professor of Radiation Oncology Nancy Lee, Assistant Professor of Radiation Oncology
Radiology/Ultrasonography
	Lucy Hann, Associate Professor of Radiology