FNB Head and Neck Oncology: Check Out NBE Released Curriculum

Head and neck cancers as a group are
amongst the most prevalent cancers in India.
The stress is on multimodality treatment of these tumors as well as on providing
good quality of life along with the cure to these patients.
The outcome of treatment in advanced cancers
is still lagging
behind the international standards. Unfortunately in India, there is no uniformity of treatment protocols
and there is lack of training. The head and neck cancers
are treated by specialists
from many backgrounds like general surgeons, ENT surgeons, Dental surgeons and plastic surgeons, each having
expertise in their own field, but
lacking an overall expertise and complete understanding of the tumor biology and behaviour. Most oncology centers/departments in multispecialty
Hospital have strong radiation oncologists who first see Head and Neck cancer patients and decide about
their management. But only few radiation oncologists take exclusive interest in head and neck cancers
alone.

The number of head and neck cancers that
need specialized management in India is huge. The existing cancer
centers cannot cater
to the needs of the entire population in this respect.
Hence many of the head and neck cancers will need to be diagnosed and treated in a
non-cancer center setting or a multispecialty
Hospital. Such treatment should be carried out only by adequately
trained personnel. There is a need
for training program for wholesome training to
suitable candidates, who will be able to and will devote a significant
part of their clinical practice to
tackle head and neck cancers problems. A two year certification training program is envisaged for this with the
training being imparted to ENT
surgeons or general
surgeons or oncosurgeons.

II. OBJECTIVES OF THE PROGRAMME

NBE is running
a surgical oncology
Program since 2005.
NBE realized the need to create subspecialty within super speciality of surgical oncology
as the problems and management of Head & Neck cancer patients are
unique and different from other cancers.
The three main thrusts of activity for initiating this course
are

establishing uniform and
internationally accepted standards of care in head and neck cancers in the country.

Promote research programs in basic
sciences as well as clinical areas andinitiate educational activities like structured oncology
training program eg. fellowship in head and neck oncology.

Training includes all aspects
relevant to research,
prevention, diagnosis, treatment and rehabilitation of head and
neck cancers, with specific emphasis on
hands-on surgical training in head and neck oncology and contemporary reconstruction.

III. TEACHING AND TRAINING ACTIVITIES

Training in Basic Sciences: The applicant
hospital is required
to make provisions for training & teaching of NBE trainees in
applied basic sciences as relevant to the applicant specialty. Accredited hospitals should also rotate
their FNB trainees (in addition to the routine
duties) in their hospital’s Medical oncology, Radiation Oncology all allied Departments so as to enable them to
gain knowledge in other related specialities.

Library facilities: The applicant department should have subscribed to at least
04 journals in the specialty applied for. At least 02 of these 04
journals should be international.
Electronic journals are acceptable and it is not mandatory to have print journals.
Subscription of journals
should be accessible to FNB trainees.

IV. SYLLABUS

1. Surgical training

During his/her
training, the fellow is expected
to have seen, evaluated and participated in the treatment of at least 200 patients
with head and neck cancer.The fellow
is expected to have participated in at least 200 major
and minor head
and neck surgical procedures over the 2-year fellowship
period.A minimum of two full operative
days per workweek
(equivalent to 16 hours of operating room time)
are recommended.The
fulfilment of the recommended number of site-wise surgical procedures will be considered an essential requirement for fellowship completion- this will be maintained
as a surgical case log in the standard format.

It
is recommended that the scope of the procedures should be expanded to include
surgically amenable benign thyroid/parathyroid disease,
benign salivary gland and skull base tumors etc.Other subspecialty training requiring
head/neck expertise pertinent
to Otolaryngology- Head and
Neck Surgery (CO2 laser surgery or endoscopic
skull base or Plastic Maxillofacial Surgery craniofacial surgery)
can be allowed to be incorporated in training.The fellow will be required to maintain a surgical case log with a comprehensive list of all cases
participated in. Submission of a completed operative case log will be an essential requirement for issuance of the fellowship completion certificate.The
log book will be countersigned by the Program Director each month, and case log review will form an essential
component of the periodic fellowship review (to be performed every 12 months
till the completion of the fellowship).

2. Clinics

The
number of hours spent in the outpatient clinic and patient numbers seen will be documented and standardized. These
may be variable across multiple training
institutions.A
minimum of two full clinic days (at least one of them directly supervised by the Program Director or the Assistant Program Director) is recommended.Clinic
case presentations should be at least one per full clinic day per fellow. There should also be the provision of incorporating
case presentations into the weekly Multidisciplinary Tumor Board Conference.There should
be a recommendation and provision for periodic interaction with the social worker/s and the psychological counsellor/s.Formal training
in patient and grief counselling should be incorporated wherever possible.

3. Academic program and Tumor Board

As
part of the academic program, the trainee will help organize and attend a weekly Multidisciplinary Tumor Board Conference, to be attended
by all disciplines present in the institution and pertinent to the
practice of head and neck oncology,
including but not limited to Head and Neck Surgery,
Reconstructive Surgery, Radiation Oncology, Medical Oncology, Pathology, Radiology, Nuclear Medicine, Dietetics, Speech/ Swallowing Therapy,
Psychological Counselling, Nursing Supervisors, social workers etc. As
many cases as possible should be presented
by the trainees. The tumour
board format and consensus recommendations will prepare the trainees to make well- informed decisions and prepare them for
future team leading positions.

Wherever feasible,
a Head and Neck Board should be encouraged with participation by Head and Neck Surgery,
Plastic/ Reconstructive Surgery,
Psychological Counselling, Dietetics, Physical therapy etc. The
frequency of this meeting will be at the discretion of the participating institution.There
should be a provision for didactic training in a Grand Rounds format. The series of lectures should be delivered
at least once weekly. The recommended
format may include a minimum of (alternating) one trainee lecture and one lecture by program
faculty, and should encourage extensive interaction. All topics pertinent to the management of head and neck oncology
should be incorporated in the lecture
schedule. The list of topics will be proposed by NBE.Morbidity/mortality
meetings, journal club and guest faculty presentations in a standard format are recommended to occur
on a monthly basis for each activity.The
creation of an online training forum under the aegis of the NBE will be encouraged, where the trainees can share
their perspectives via discussion threads.
The registered users will have login privileges for accessing uploaded relevant
course materials and recent
literature.

4. Training in allied specialities

(Even
though the presence
of all of the below mentioned allied
specialists at the training
centre is ideal, trainees should be scheduled for rotations at outside affiliated centres if the above
is not practicable)

a) Dental oncology

FNB trainees may interact with the
dental surgeon regarding preradiation prophylaxis, post radiation conservative dental management and prevention/management of osteoradionecrosis.

Maxillofacial prosthesis training is important, as dental and prosthetic rehabilitation is integral for patients to return to their
premorbid state.

Trainees will be encouraged to participate in rehabilitation following
management of laryngeal/hypopharyngeal cancer,
speech articulation/dysphagia management post glossectomy, and dysphagia rehabilitation post organ preservation treatment.

The fellow is expected to become proficient in TEP troubleshooting, compensatory manoeuvres/rehabilitation, and other aspects of
voice and dysphagia management.

c) Diagnostic anatomical and functional imaging/nuclear medicine:

A week-long interactive rotation between
the trainee and a radiologist experienced in head and neck imaging
is suggested. This allows for discussion
of a wide variety of cases by the trainee to allow understanding of radiological staging
and subsequent surgical
planning wherever indicated. The trainee should be able to
understand the decision making as regards choice of investigation modality, and also understand the indications of therapeutic nuclear
medicine.

d) Pathology:

A week-long interactive rotation with an experienced pathologist is recommended.
Training will include essential aspects as cytopathology, processing of diagnostic biopsy,
surgical specimen orientation, margin assessment, and a basic overview of routine as well as intraoperative pathology.

e) Radiation oncology:

The recommendation is for 2 weeks of rotation each year. At the completion of this rotation, the trainee should be able to understand the
interplay between the two specialties
in guiding decision-making, understand the indications
of radiation therapy in head and neck cancers, and understand the sequelae and toxicities of radiation
therapy and their management/ mitigation.

f) Medical Oncology:

The recommendation will be for 2 weeks
of training. At the completion of this
rotation, the trainee should be able to understand the rationale of decision
making as regards
cytotoxic and biological agents including immunotherapy, and regimen choice
based on treatment
setting and performance status. He/she should also be able to understand and recognize toxicities of common chemotherapeutic agents and their basic management.

g) Pain management and palliative care:

This is recommended as ongoing
interaction with the pain/palliative care specialist
to understand cancer-associated pain and the pharmacological/ interventional modalities utilized to manage the same. This interaction will be aimed
at gaining further
perspective on end-of-life issues.

h) Preventive Oncology:

This constitutes an essential recommendation, and will incorporate strategies of tobacco
cessation, community and physician initiatives, current role of HPV and the appropriate counselling, management of leucoplakia
and other premalignant lesions, trismus rehabilitation, among others.
Fellow is expected
to have conducted at least one screening camp & one public education activity.

5. Research experience

Candidate
should fulfil minimum following requirements in 2 years to be eligible
for examination.One paper publication as lead author in pubmed indexed journal/One conference presentation per year.Candidate should
attend at least two HN conferences (national/international or equivalent) in tenure.The institution will provide infrastructural support, provision for maintenance of electronic or file data, IRB support,
biostatistics support (in-house
or outsourced as applicable)
and permission to trainee to present or publish on behalf of the institution.The
decision on provision of protected research time will rest on a mutual decision
made together by the trainee,
program faculty and the institution.

6. Rotations at outside centres:

External
rotation (outside institute) is recommended if the institute doesn’t have necessary allied departments
suggested for internal rotation. (especially
for Rotations are preferred for dysphagia, dental rehab and reconstruction, pain palliative and psychology)It needs
to be done under an External
Mentor.

The external
mentor will have the following
responsibilities: ensuring a beneficial supplemental training period by providing perspectives of management
practised by another institution, signing off on the operative log book at the end of the rotation, and
ensuring that the trainee gets adequate operating
room experience during the rotation.Trainees
need to log their observation and participation during these external postings.
The trainee also has to submit
a written report on their experience.Upon
the fulfilment of the above pre-requisites, a certificate signifying the satisfactory completion of the external
rotation will be issued. This will be an essential document at the time of completion of fellowship.

7. Meetings/Conferences:

The trainee
is encouraged to participate and present papers
(at least 2 in tenure
of 2 years) at regional, national and international meetings, which will
inspire confidence, bolster awareness
and enhance study patterns.The
institution may, at its discretion, choose to reimburse the registration cost of meeting
sattended.Candidate must
attend at least one meeting every year.Candidate must present
one papers every year in head neck or allied meetings

8. Suggested syllabus

A
selected collection of textbooks including basic science texts, operative and lab manuals and compendia will be
suggested for reading during the training period.By
no means should these lists be considered all-encompassing. The trainee will be encouraged to read other standard
texts and journals as per his/her discretion under the supervision of the program faculty.

9. Surgical Curriculum

The FNB curriculum mandates a minimum of
twice weekly OR with details mentioned
in the log book. Following numbers suggest minimum required surgical
exposure of the candidate.

For head neck oncology – Surgical curriculum year one

Procedure

Seen

Assisted

Perfomed under

Supervision

Lymph node
biopsy + Minor Procedure

25

DL Scopy biopsy

5

5

10

Neck dissection

10

10

5

Glossectomy

5

5

2

Mandibulotomy*

2

2

1

Parotidectomy

2

2

1

Thyroidectomy

5

5

2

Mandibulectomy -segmental

5

5

2

Mandibulectony – marginal

5

5

2

Larnygectomy – total

5

3

0

Maxillectomy

5

3

0

Pectoralis major

3

3

2

Other local flaps

3

3

2

For head neck oncology
– Surgical curriculum year two

Procedure

Performed under Supervision

DL Scopy biopsy

20

Neck dissection

10

Glossectomy

5

Parotidectomy

2

Thyroidectomy

2

Mandibulectomy

10

Larnygectomy – total

2

Maxillectomy

2

Pectoralis major

5

Other local flaps

5

(May vary according
to institutional practice,
Candidate may undergo
a microvascular course prior
to commencement of free flap training Free flaps – Outside rotation at a high volume centre is desirable
if Institute is not performing free flaps)

10. Academic curriculum

Weekly presentations – 30 / year.Following
topics are recommended to be covered in the curriculum over 2 years. Academic curriculum must include one case presentation and one seminar
presentation per week along with journal club and grand rounds

Cancer biologyChromosome related technology (Karyotyping, Comparative genomic hybridization, Fluoresecence in Situ Hybridization)DNA and RNA related technology
(Isolation and quantitation of DNA/RNA, Mutation
analysis, PCR, RT PCR, Real Time PCR, sequencing,
arrays)Protein related technology (Immunohistochemistry and Westernblotting)Tumor ImmunologyCell cycleProgrammed cell death/apoptosisAngiogenesisCancer stem cellsApoptosis and its significance in cancerBiomarkers in head neck cancer

ii. Carcinogenesis

Etiology of cancer

Environmental factors in carcinogenesis

Genetic factors in carcinogenesis

Human Papilloma Virus and cancer

Other tumor viruses

Tobacco carcinogenesis

iii. Principles of cancer screening

iv. Radiology Clinics

    

v. Principles of Radiation Oncology

Physical and biologic basis of radiation oncologyFractionation techniquesBrachytherapyNewer techniques in radiation Oncology

Hypoxia in head neck cancers and hypoxic cell sensitizersRadiotherapy planningIMRT and evidence to support
its use in HN cancer

vi. Principles of medical oncology

Mechanism of action of cytotoxic agentsManagement of febrile neutropenia

Targeted therapyAssessment of response (clinical and RECIST)

Biology of drug resistanceImmunotherapy

vii. Clinical Research Methodology

Making a databaseStudy designs – case control, cohort and RCTsWriting a research protocol

Writing a paper for publicationSurvival analysis

Randomized controlled trialsSystematic reviews
and meta-analysis

Evaluating /critique of a published paper

Evaluating screening tests and biases

viii. Quality of Life:

Measuring QOL – instruments (EORTC, site specific
QOL)

QOL as an outcome measure.

End of life care issues

Principles of palliative
management

Medical ethics in Oncology

ix. Others

Biotherapeutics

Interferons

Cancer vaccines

Case discussions:

Carcinoma of Thyroid
with / without neck nodeUnknown Primary
Carcinoma with cervical
node

Early stage cancer of the oral tongue

 Advanced stage cancer of the oral tongue

Cancer Gingivobuccal complex

Maxillary mass 

Salivary gland neoplasmsOsteoradionecrosis

Laryngeal / hypopharyngeal cancers

premalignant
lesions of the oral cavity

Lectures and seminars:

LIP AND ORAL CAVITY

Imaging for the
mandibleInfratemporal fossa – anatomy, imaging and relevance to resectabilityMuscles of mastication and technique of composite resections videos)Management of early oral cancer (stage I &
II)Imaging of the neck and management of the neck in early oral cancerTypes of neck dissection

Reconstruction options
after surgery for early oral cancer (buccal
mucosa and tongue)Resection margins
in surgery for oral cancer-
evidenceRole of neoadjuvant
chemotherapy in oral cancersAdjuvant therapy
for oral cancersBrachytherapy for lip
cancersPrinciples of reconstruction and local flaps after
lip resections

Role of sentinel node biopsyDental evaluation (pre and post op) and prosthetics after oral cancer
surgery

OROPHARYNX

Staging and Imaging for oropharyngeal cancersHPV and oropharyngeal cancersMethods of detection of HPV

Discuss surgery vs. radiotherapy as primary treatment for oropharyngeal
cancersRole of robotic surgery
in oropharyngeal cancersApproaches to surgery for oropharyngealtumors (techniques with videos)

THYROID

Surgical anatomy of the thyroid, parathyroids and nerves in relation to thyroidPhysiology of TSH and its importance in thyroid cancerThyroglobulin in thyroid cancer

Epidemiology and changing
trends in patterns
of thyroid cancerAetio-pathology, prognostic and staging systems
of DTCMolecular biology of thyroid carcinogenesis (DTC, PDTC and MTC)Management of a solitary
thyroid nodule

Hemithyroidectomy vs. total thyroidectomy for early thyroid
cancersTechnique of total thyroidectomy and central neck dissection (videos/pictures)Management of neck nodes in thyroid cancer
(central and lateral)Management of postoperative hypocalcemiaLocally advanced thyroid cancer- management of the recurrent
laryngeal nervePreparation for RAI
therapyRAI therapyFollow up of patients
after thyroid cancer treatment.TENIS and alternative therapies for non radio-iodine avid cancers

Staging and management of MTCFamilial MTC Management of metastatic MTC

Management of anaplastic thyroid cancer

PARATHYROID

Clinical features
and work up of patient of hyperparathyroidismSurgery for parathyroid adenoma

Parathyroid carcinoma

HYPOPHARYNX

Relevant surgical
anatomy and staging
of hypopharyngeal cancersWork up for a patient
with hypopharyngeal cancerManagement of stage I/II hypopharyngeal cancerManagement of stage III/IV (non metastatic) hypopharyngeal cancer

Reconstruction of defects after surgery for hypopharyngeal cancer-
when and how?Stage wise prognosis and outcomes after treatment for hypopharyngeal cancerTechnique of total laryngectomy (videos/pictures) Speech rehabilitation after total laryngectomy

Speech and swallowing dysfunction after organ preservation strategies

LARYNX

Surgical anatomy of the larynxHistological variants
of laryngeal cancerWork up of a patient
with suspected laryngeal
cancer

Options for treatment of early laryngeal cancersPhysics and principles of laser surgerySpeech therapy
after laser resectionsOrgan preservation strategies for advanced
laryngeal cancerRole of conservative salvage
surgery for recurrence

Technique of supracricoidlaryngectomy (videos/pictures)

SALIVARY GLANDS

Surgical anatomy of the parotid gland
and facial nervePathology of salivary gland neoplasms with discussion on treatment and prognostic significanceStaging and work up of a parotid tumorTechniques of superficial, total, radical parotidectomy (videos/pictures)Assessment of facial nerve dysfunction post operativelyFacial nerve reanimation proceduresAdjuvant therapy
in salivary gland tumors

EAR AND TEMPORAL BONE

Surgical anatomy of the temporal boneNatural history
and mechanisms of spread of temporal bone tumorsImaging of temporal bone tumorsVarious surgical procedures and indications for temporal bone tumorsIndications for
adjuvant therapy

Imaging of a maxillary massPathology of sinonasaltumors

Maxillary defects
and reconstructionsTypes of maxillary resectionsIndications for craniofacial resections

Indications for endoscopic
sinonasal resectionsRole of neo-adjuvant therapy
in sinonasal malignancy

GENERAL HEAD NECK

Management of unresectable HN cancerNutritional support for HN cancer patients
(peri-operative and during radiation therapy)Role of re-irradiation
in HN cancerParapharyngeal anatomy
and tumors of the parapharyngeal spaceSarcomas of the
head and neck

Mucosal melanomasSkin cancerPalliative chemotherapy

Targeted therapy
in HN cancer

RECONSTRUCTION

Principles of Reconstruction
in Head Neck CancerPedicled flaps
-PMMC, Deltopectoral, submental,

Local flaps:
Nasolabial, palatalreconstruction of the lipHypopharyngeal reconstruction

11. Journal club: Journal club presentation may be conducted by the candidate every week. Institute is encouraged, over and above suggested articles, to discuss appropriate articles in Journal Club.

V. LOG BOOK

A candidate shall maintain a log book of
operations (assisted / performed) during
the training period, certified by the concerned post graduate teacher / Head of the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal
at the time of the final examination.

The log book should show evidence that
the before mentioned subjects were covered (with dates and the name of teacher(s) The candidate will maintain the record of all academic activities undertaken by him/her in log
book.

Personal profile of the candidateEducational qualification/Professional dataRecord of case historiesProcedures learntRecord of case Demonstration/PresentationsEvery candidate, at the time of practical
examination, will be required to produce
performance record (log book) containing details of the work done by him/her
during the entire period of training as per requirements of the log book. It should be duly certified by the supervisor
as work done by the candidate
and countersigned by the administrative Head of the Institution.In the absence
of production of log book, the result
will not be declared.

VI. RECOMMONDED TEXT BOOKS AND JOURNALS:

S.
No.

BOOKS

AUTHOR NAME

1.

Stell and Maran’s Textbook
of Head and Neck Surgery and

Oncology

John C. Watkinson and
Ralph W. Gilbert

2.

Head and Neck
Cancer: A

Multidisciplinary
Approach

Louis B. Harrison

3.

Functional and Selective
Neck

Dissection

Javier Gavilan

4.

Jatin Shah’s
Head and Neck

Surgery and Oncology

Jatin Shah, Snehal
Patel,

Bhuvanesh Singh,
Richard Wong

5.

Myer’s – Cancer
of the Head & neck

Jeffrey N.Myers,EhabY.N.Hanna, Eugene N.Myers

6.

Conservative laryngeal

surgery

Sultan Pradhan

7.

Surgery of the thyroid and parathyroid gland, 3rd edition,

Gregory

W Randolph

8.

Cummings otolaryngology

head neck surgery, 7th edition

Paul W Flint

9.

Scott brown’s
otolaryngology head and neck
surgery, 8th edition,

John Watkinson

10.

Surgery for cancer
of the

larynx and related structures,

Carl Silver

11.

Comprehensive management

of skull base tumors,

Ehab Hanna

12.

Basic concepts in head and

surgery and oncology

Krishnakumar Thankappan

13.

Dysphagia management in

Head and neck
cancers,

Krishnakumar Thankappan

14.

Contemporary Oral Oncology

Moni Kuriakose

15.

Principles and practice of
head and neck surgery and

oncology, 2nd edition

Paul Montgomery

16.

Radiotherapy for head and

neck cancers, 5th edition

Adam S Garden

17.

Atlas of head
and neck surgery

James Cohen

18.

The recurrent and superior

laryngeal nerves,

Gregory Randolph

19.

Surgery of the
Trachea and

Bronchi

Hermes Grillo

20.

Netter atlas of human anatomy

Frank Netter

21.

Cunningham’s Manual of

practical
anatomy, volume 3, 15th edition

Cunningham

22.

Atlas of regional and free
flaps for head and neck

reconstruction,
2nd edition,

Mark Urken

23.

Grabbs encyclopaedia of flaps

– head and neck, 3rd edition

Berish strauch

24.

Head and Neck Cancer: An Evidence-Based Team

Approach (1st Edition)

Genden / Varvares

25.

Open Access
Atlas of Otolaryngology- Head and Neck Operative

Johan Fagan

26.

Head and Neck Pathology

Leon Barnes, SimionChiosea, Raja

Seethala, David
Elder (Editor)

27.

Head and Neck Radiology (2

Volumes)

Anthony A. Mancuso