Tito Fojo, MD
Entry Id: TP-66

Eligibility Criteria
Candidates must have a MD degree from an accredited medical school. We require that applicants have satisfactorily completed three postgraduate years of training in internal medicine at the time of their appointment as a fellow in medical oncology

Overview
The National Cancer Institute (NCI) recruits fellows for an intensive three-year assignment in medical oncology. The first year consists of primary responsibility for the clinical care of both inpatients and outpatients with a broad spectrum of neoplastic diseases. In the second and third years, the fellow elects a research program and a mentor from the very wide range of options in clinical and/or laboratory research available at the NCI. During the second year, fellows continue with outpatient responsibilities for about one-half day per week; clinical activities during the third year are optional. The major sites for clinical training are the Medical Oncology Clinical Research Unit located in the NIH Clinical Center, and the Medical Oncology Clinical Research Unit located at the National Naval Medical Center in Bethesda, adjacent to the NIH campus.

Structure of the Clinical Training Program
Fellows in Medical Oncology spend their time about equally between inpatient and outpatient care during the first year. All fellows spend six months in the Medical Oncology Clinical Research Unit (MOCRU) and six months at the Medical Oncology Clinical Research Unit (MOCRU) at the National Naval Medical Center. In the second and third years, eighty to eighty-five percent (80-85%) of the fellows time is protected time devoted to research; for fifteen to twenty percent (15-20%) of the second year the fellow is involved in the care of outpatients in either the MOCRU at the Clinical Center or MOCRU at the National Naval Medical Center.

 
The MOCRU is an adult medical oncology unit whose clinical programs emphasize the diagnosis and treatment of cancer in the context of internal medicine. Accordingly, patients are selected for care in the MOCRU if they have a disease or disease-stage currently under study by senior members of the MOCRU. Current areas of research emphasis include lymphomas, Hodgkin’s disease, breast cancer, prostate cancer, ovarian cancer, acute leukemia, new drug testing, bone marrow transplantation, and AIDS and its associated malignancies. Training in clinical diagnostic procedures such as bone marrow examination, liver biopsy, and peritoneoscopy is emphasized. There is close collaboration with related clinical units in the Clinical Center such as radiation oncology and surgery.

Inpatient Experience (Year 1)
In the MOCRU, first-year fellows care for both inpatients and outpatients simultaneously during their six-month rotation. Each fellow bears primary clinical responsibility for a cohort of patients, whom he/she follows longitudinally for the duration of the rotation. All major diagnostic and therapeutic decisions are made by the fellow in consultation with members of the senior staff. Trainees acquire experience in treating a wide variety of neoplastic disease and in dealing with the entire spectrum of medical complications of cancer and its therapy.

Outpatient Experience (Years 1, 2, and 3)
The outpatient clinic in the MOCRU provides ambulatory care to protocol patients with neoplastic diseases and AIDS. Fellows are responsible for the entire patient population followed here and for the initial screening of all new patients accepted for evaluation by MOCRU physicians. Clinics are organized in a disease-specific fashion, and fellows attend clinic five days a week under most circumstances. During the second and third year, those fellows attending MOCRU clinics follow a much smaller population of patients and rotate every three months through the different disease-oriented clinics; about one-half day per week is devoted to this activity. As in the first year, trainees have primary responsibility for the care of their patients, except when they are admitted to the inpatient service. In that case, inpatients care is assigned to a first-year fellow. Second-year and third-year fellows have no inpatient responsibilities.

MOCRU at Navy is an organizational unit in the Center for Cancer Research of the NCI, but is physically located in the National Naval Medical Center in Bethesda, adjacent to the NIH campus. It is part of the National Naval Medical Center cancer treatment program. The Medical Center is a 450-bed tertiary referral hospital for active duty military, retired military, and military dependents. Patients are referred from around the world with all types of malignant disease including solid tumors (e.g. lung, breast, gastrointestinal) and hematologic malignancies (Hodgkin’s disease, non-Hodgkin’s lymphomas, and acute and chronic leukemias). There is a large population of young adults with malignant diseases such as germ cell tumors. The program has a twenty-bed inpatient service and also provides consultation in oncology and hematology to the National Naval Medical Center (approximately forty to sixty active inpatients at any one time). In addition, civilian patients who are eligible for NCI studies can be admitted to the program for care and study. This represents an integrated effort in cancer patient care, clinical and laboratory investigation, and training. More than 2000 patients are followed by the program in a study and primary care setting, and each fellow has approximately 150 patients for primary care responsibilities.

Inpatient Experience (Year 1)
At the National Naval Medical Center, each fellow is responsible for approximately six to eight inpatients at any given time. The trainee serves as a consultant for approximately one-half of these patients. For the other half, the trainee participates in rendering care in a near direct mode, in some cases managing the patient through hospitalization and subsequent outpatient follow-up. Again, fellows treat a wide range of illnesses, drawing patients and referrals from both the local community and a wide geographic area.

Outpatient Experience (Years 1, 2, and 3)
The MOCRU Clinic at the Naval Hospital provides for the administration of outpatient chemotherapy, transfusions, and the performance of therapeutic phlebotomies and minor procedures including lumbar punctures, paracenteses and thoracenteses. Oncology fellows participate in four half-day clinics per week in their first year. They see an average of six patients per clinic session. Fellows in the clinic provide outpatient consultation and render ongoing primary patient care. They are responsible for the overall management of the patient with the supervision of an attending physician.

Rounds and Conferences
Lectures, clinical conferences, research seminars, teaching rounds, and joint conferences relevant to clinical oncology and cancer research are offered throughout the program. Many of these conferences are organized specifically for clinical fellows, including a formal yearlong lecture series in clinical oncology, which meets twice weekly and offers lectures by staff members throughout the system on issues in neoplastic disease. In addition to multidisciplinary clinical conferences, walk rounds, and a variety of disease-specific multidisciplinary meetings, there are pathology teaching sessions and journal clubs.

Finally, there are numerous research seminars and lectures given throughout the NIH on a daily basis; these are regularly open to the entire NIH community. NCI Grand Rounds are usually on basic science topics or subjects of clinical relevance. Formal course work in the sciences is available through the NIH Foundation for the Advanced Education in the Sciences (FAES).

Structure of the Research Training Program
In the second and third year, fellows focus on their individual research projects. They may select a topic for investigation from the enormous number of possibilities available in the laboratories and branches of the NCI.

Clinical research in MOCRU focuses on the development of more effective combinations of drugs for tumor types having partial sensitivity to chemotherapy, the integration of new agents into combination chemotherapy, the use of high-dose chemotherapy with or without cytokine support, high-dose chemotherapy with bone marrow or peripheral stem cell reconstitution, reversal of multidrug resistance, early clinical trials of new agents with novel mechanisms of action, the development of new antiretroviral therapy for patients with HIV infection, and gene transfer into hematopoietic stem cells. Areas of inte5rest in the laboratory include oncogenic control of gene expression, development of gene therapy vectors, the biochemistry and molecular biology of the folate receptor and reduced folate carrier, repair of drug-induced DNA damage, multidrug resistance and its reversal, T-cell repertoire selection, and graft-versus-tumor effects in bone marrow transplantation.

The clinical research studies at MOCRU Navy involve a wide variety of disease and represent a collaborative effort with other branches in the Center for Cancer Research. Laboratory investigations in the Unit revolve around human tumor cell biology and molecular genetics. There are currently major efforts in the following areas of research: selection of therapy by in vitro drug sensitivity testing of tumors from individual patients, studies of dominant and recessive oncogenes, transcription factors and peptide hormone genes in human tumors, and the construction of early clinical trials of new agents and combinations of agents using both clinical and pharmacologic end points.

Combined Training Program Hematology/Oncology
The NCI/MOCRU, in cooperation with the NHLBI, offers a combined training program in Hematology and Oncology for those individuals who desire to be board eligible in both subspecialties. Oncology fellows who desire Hematology training will spend their first year on the oncology service (see Medical Oncology) and six months of the second year on the clinical Hematology service. The remainder of the training during the second and third year is protected time devoted to research.

During the second year of the fellowship program, fellows receive six months of board training in clinical hematology, with three months spent at the NIH Clinical Center on rotations covering allogeneic and autologous stem cell transplantation, general acute hematology, consultative hematology, hematopathology, and transfusion medicine. In order to provide broader training in non-research driven hematology, fellows spend three months on rotations outside the NIH, including experiences on the acute leukemia service at Johns Hopkins, the general hematology service at the Washington VA Medical Center, and the hematology/oncology service at the Washington Hospital Center, an excellent private facility with a large cancer center.

The American Board of Internal Medicine (ABIM) requires two years of training for oncology and three years of training for combined hematology/oncology. Since our program provides intensive subspecialty training in clinical management and research (clinical or laboratory), the NCI/MOCRU provides an extra year of training for our fellows if they desire. Therefore, oncology fellows are provided three years of training and hematology/oncology fellows are guaranteed four years of training.

Year 1

• Clinical Center-6 months
  • Inpatient
  • Outpatient
• National Naval Medical Center – 6 months
  • Inpatient
  • Outpatient

Year 2

• Hematology-6 months
  • NHLBI Hematology Ward – 2 months
  • Transfusion Medicine – 2 weeks
  • Johns Hopkins Leukemia Service – 1 month
  • Consultation Hematology & Coagulation – 6 weeks
  • VA Medical Center – 1 month
• Oncology Research – 5 months
• Oncology Consultation – 1 month
• Continuity Clinic
  • ½ day per week

Year 3

• Oncology Research

Year 4

• Oncology Research

Application Information
To apply for the Clinical Fellow Program, all candidates must have a MD degree from an accredited medical school. We require applicants have satisfactorily completed three postgraduate years of training in internal medicine at the time of their appointment as a fellow in medical oncology.  Please apply through the ERAS system.

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