Open access Review Educational needs in gastrointestinal cancer: a consensus position paper from the ESMO Gastrointestinal Cancer Faculty Florian Lordick,‍ ‍ 1 Radka Obermannova,2 Doris Vola,3 Jean-Yves Douillard,3 Keith Mcgregor,4 Eric Van Cutsem,5 Josep Tabernero,6 Fortunato Ciardiello,7 Andrés Cervantes‍ ‍ 8 To cite: Lordick F, Abstract a consensus and modified Delphi process.2 Obermannova R, Vola D, Gastrointestinal (GI) cancers are common in all parts of the We aimed to define the most important et al. Educational needs in world. Effective prevention and early detection of GI cancers educational needs of GI cancer physicians. gastrointestinal cancer: a are not universally implemented. Therefore, it must be We created a web server-based questionnaire consensus position paper from the ESMO Gastrointestinal anticipated that the incidence and the mortality of GI cancers containing the following simple question: Cancer Faculty. ESMO Open will remain high within the next decades. The European What are in your opinion the three most 2019;4:e000533. doi:10.1136/ Society for Medical Oncology (ESMO) Gastrointestinal Cancer important educational needs for the next 10 esmoopen-2019-000533 Faculty aims to increase the skills of medical oncologists years to train clinical and/or research fellows and other disciplines involved in treating GI malignancies. We aimed to increase the survival chances for patients with GI in GI oncology? Received 1 May 2019 cancers, augment their quality of life and enable successful The survey was distributed online to the GI Accepted 8 June 2019 faculty members on 8 May 2018, with the aim return to normal social and professional life during the period of survivorship. ESMO also aims to decrease the economic of getting an overview on current educational Published online burden of GI cancer in our societies and national healthcare priorities in GI tract cancers. The submitting 5 July 2019 systems. Therefore, the ESMO Gastrointestinal Cancer deadline was 8 June 2018. The answers were Faculty initiated a consensus process based on the Delphi collected at the ESMO head office. Results method to identify the most important educational needs of were made available for the coordinator of physicians who are concerned with GI malignancies. This the ESMO GI faculty (FL), who prepared paper summarises the process and its results and outlines a meeting that took place on 22 June 2018 the mission of ESMO in education. at the 20th ESMO World Gastrointestinal Introduction Cancer Congress in Barcelona. Results of the In 2016, 17.2 million cancer cases and 8.9 survey were presented at a 2-hour meeting in million cancer deaths were reported world- Barcelona, and the discussion about the state- wide. Cancer increased by 28% between ments was recorded and put into a protocol 2006 and 2016. Almost 30% of newly diag- by one faculty member (RO) and verified by nosed cases and almost 40% of cancer deaths the coordinator (FL). Results of the survey are attributed to gastrointestinal (GI) tract and of the meeting were circulated among cancers.1 These numbers underline the ESMO faculty members to get feedback in the urgent need for a well-educated new gener- sense of a confirmatory Delphi round and are ation of medical oncologists and physicians presented here in a consensus position paper. from other disciplines treating GI cancer to © Author (s) (or their tackle the demands of prevention, diagnosis, employer(s)) 2019. Re-use treatment and follow-up of patients with Results permitted under CC BY-NC. No GI cancers. In order to fulfil the mission of Ninety members of the ESMO GI faculty were commercial re-use. Published the European Society for Medical Oncology invited to take part in the process. Sixty-two by BMJ on behalf of the European Society for Medical (ESMO) to be a leader in providing educa- faculty members (69%) from 22 countries Oncology. tion for current and future oncologists, we answered the online survey (figure 1). The For numbered affiliations see aimed to define the most important educa- professional specialties of participants are end of article. tional needs of GI cancer physicians. shown in figure 2. Forty-five faculty members took part in the face-to-face meeting and Correspondence to Professor Florian Lordick; ​ Methods discussion on 22 June 2018. florian.​lordick@​medizin.​uni-​ Members of the ESMO gastrointestinal According to the answers received from leipzig.​de faculty (n=90) were requested to take part in the survey, we formed 10 categories and Lordick F, et al. ESMO Open 2019;4:e000533. doi:10.1136/esmoopen-2019-000533 1 Open access Multidisciplinarity and multiprofessional care Multidisciplinarity and multiprofessional care are seen as a key element in the management of patients with cancer. This includes the ►► Active and educated participation in multidisciplinary board discussions. ►► Ability to work in the context of a multidisciplinary team (MDT), including the appropriate referral for and the use of surgery and radiotherapy or other local treatments for oligometastatic cancer. ►► Comprehensive knowledge on multidisciplinary treatment of GI cancers, including knowledge about endoscopic treatment techniques for cure and for palliation of symptoms, new surgical, radiation and Figure 1 Country of work of participants in the European interventional radiology techniques. Society for Medical Oncology Gastrointestinal Faculty ►► Comprehensive understanding of the expertise position paper. and tasks of non-physician healthcare professionals, including oncology nurses, psycho-oncologists, social workers, physiotherapists and dietitians, among structured the needs expressed during the survey accord- others. ingly. These ten categories are GI faculty members felt that ESMO should further 1. Multidisciplinarity and multiprofessional care. increase its activities in this area and offer pragmatic 2. Standards and clinical training. workshops on working in MDT with radiologists, radio- 3. Biology and translation. therapists, pathologists, nuclear medicine specialists, 4. Medical oncology care training. gastroenterologists and surgeons. Participants said that 5. Specific disease situations. ESMO should train medical oncologists to lead the multi- 6. Prevention and screening. disciplinary approach, as medical oncology is the specialty 7. Evidence-based medicine and decision making. that must have the global perspective of the disease. 8. Clinical research skills. However, it is recognised that in some countries, there are 9. (Self-)management and career building. trained and highly dedicated GI oncologists who can also 10. Patient orientation. do this. Techniques and communication skills to lead an It is acknowledged that among the 10 categories, several MDT should be developed and applied. It was criticised are not specific for GI oncology and should apply in that sometimes and at some sites, medical oncologists still general to the medical oncology practice and continuous do not have sufficient understanding and knowledge of education. This observation underlines the view of the surgical oncology, radio-oncology and other non-medical ESMO GI faculty that for management of such a broad oncology specialities. field like GI oncology, an integral way of viewing cancer It was discussed that web-based tools could be of value medicine and a holistic approach to medical oncology is and should be further developed to use the multidis- needed. ciplinary approach. Latest results, developments and technologies from research should be part of the multi- disciplinary training process. This should also include diagnostic disciplines like imaging. Standards and clinical training Knowing the standards and having a good clinical training is without any doubt a prerequisite for good clinical care. More specifically, the following aspects should be trained: ►► Assignment of patients for the best treatment modali- ties (=good interpretation of standards), which refers back to the multidisciplinarity training category (point 1). ►► A critical analysis of the scientific evidence and how this should inform clinical decision making. Figure 2 Primary professional activity of participants in ►► Communication with the patient. the European Society for Medical Oncology Gastrointestinal ►► Supportive/palliative care skills. Faculty position paper. ►► Understand the needs of cancer survivors. 2 Lordick F, et al. ESMO Open 2019;4:e000533. doi:10.1136/esmoopen-2019-000533 Open access Clinical case discussions between junior and senior ►► How to deal with the toxicity of chemotherapy, GI oncologists for teaching purposes could be of help. targeted therapy, immunotherapy and combinations Faculty members encourage ESMO to update regularly ►► Strategies to reduce long-term side effects. the clinical practice guidelines, to extend the courses ►► Strategies to implement systemic treatment breaks, such as the masterclasses and preceptorship programmes for example, by introducing local therapies into treat- in Europe and beyond (Asia-Pacific region, Middle East, ment of advanced disease. Africa and Latin America), and to further facilitate clin- ►► Sequence of different treatment options. ical fellowships and exchange programmes. Collabora- ►► Understanding the importance of long-term side tion with patient organisations was also seen as useful and effects of anticancer treatment and its impact on necessary. quality of life. ►► Treatment of elderly patients. ►► Palliative and supportive care, including professional Biology and translation symptom control and nutrition. A majority of faculty members are convinced that profound understanding of cancer biology and how to translate biology into clinical practice is key for improving Specific disease situations prevention and treatment of GI malignancies. For GI Some situations are seen as particularly complex. It was cancer, this means felt that these require special attention and training. ►► Understanding of genomics to be comprehensively Among others, faculty members mentioned covered in both undergraduate and postgraduate ►► Optimal strategy in rectal cancer. training with application into clinical practice. ►► Adjuvant treatment in rectal cancer. ►► Understanding of basic immunology, tumour–host ►► Management of potentially curative oligometastases interaction and immunotherapy. of GI cancers. ►► Understanding the molecular characteristics of GI ►► Multidisciplinary treatment of localised gastro-oe- cancer and correlate them with therapeutic options sophageal and pancreatic cancer. in terms of precision oncology. ►► Role of local treatment of peritoneal carcinomatosis. ►► Understanding the importance of tumour heteroge- ►► Treatment strategy based on tumour and liquid biopsy neity, prognostic and predictive markers, and clonal for metastatic GI cancers (currently mostly applied for evolution during systemic therapy. colorectal cancer). ►► The prognostic and predictive value of biomarkers, of These topics can be perfectly addressed in ESMO precep- molecular subtyping and of contemporary multiomics torships and in ESMO online resources, such as ESMO approaches. e-learning lectures and trainings. ►► The mechanisms of carcinogenesis and treatment resistance/clonal evolution of GI cancers and novel diagnostic techniques to capture these (circulating tumour DNA and tumour sequencing). Prevention and screening ►► How to integrate imaging techniques in the manage- Although prevention and screening are not routine tasks ment of different GI cancers and how new technol- in the daily practice of many medical oncologists, the GI ogies, for example, artificial intelligence, can add to faculty underlined the utmost importance of these topics. patient care. It was felt that a significant improvement of disease It was mentioned that ESMO educational activities like burden in GI oncology can only be achieved if advances preceptorships sometimes focus too much on clinical in prevention and early detection of GI malignancies will perspectives alone, but biological, molecular and immu- be accomplished. Therefore, medical oncologists should nological teaching should be reinforced as well. The ►► Be involved in the development of primary and potential value of continuing medical education training secondary prevention strategies. courses in GI cancer biology was discussed. ►► Know about agents and interventions for preventing cancer development. ►► Know about risk factors and detrimental habits. Medical oncology care training ►► Know about GI cancer screening tools and Treating patients and guiding them through the trajec- programmes with the benefits and potential risks. tory of disease is a core activity of medical oncologists. ►► Know about familial and hereditary cancers. Therefore, it was emphasised that a high level of treat- Apart from the training of individual medical oncolo- ment expertise must be learnt by all GI oncologists in gists, the GI faculty sees an important role for ESMO to training and thereafter. This should include be engaged in information and education of the general ►► Immunotherapy: understanding mechanisms of population, as well as in political lobbying for promoting immunotherapy and basic immunology. a healthier lifestyle, avoidance of risky behaviour, and ►► Confirming the right indications for chemotherapy, support of early detection and screening programmes in immunotherapy and targeted therapy. the national healthcare systems, where appropriate. Lordick F, et al. ESMO Open 2019;4:e000533. doi:10.1136/esmoopen-2019-000533 3 Open access Evidence-based medicine and decision making them build their career. Within the multifaceted demands Cancer medicine, including GI oncology, should be in this field, the following points were highlighted: highly science-driven. Knowledge is expanding at a ►► Time management strategies. rapid pace. The physician’s individual expertise and the ►► Skills to lead the MDT approach. patient’s preference, both part of the traditional model of ►► Presentation skills. evidence-based medicine,3 need to be combined with the ►► How to organise interdisciplinary work and patient best external evidence to come to good clinical recom- care locally. mendations. GI faculty members mentioned the following ►► How to build professional development from early important educational needs in this context: stages of training (career consulting). ►► Critical analysis of the external evidence. ►► How to build a career as a clinician scientist. ►► Efficient literature review skills and how to identify ►► Knowledge and skills in health economics. good and meaningful trials. It was felt that mentorship programmes and meet-the- ►► Help medical oncology fellows maturing the concept expert opportunities at congresses and courses could be that evidence-based clinical decisions do not always helpful. mean following the guidelines. ►► How to keep informed about not only what guidelines are stating but also what has been proven by the latest Patient orientation studies. The patient perspective is an integral part of evidence- ►► Evaluate limitations of clinical research, including based medicine.3 Respecting patients’ needs is a corner- critical evaluation of methodology. stone of good cancer care. Specific educational needs ►► To be able to assess the prognosis of each condition were raised by the faculty: and to describe the delta benefit for each decision. ►► Improve communication skills with patients in the era ►► Understanding the impact and measure of quality of of personalised medicine. care. ►► Learn techniques of shared decision making. ►► Understanding the impact of clinical benefit. ►► Understand the value and use of patient-reported It was acknowledged that ESMO already provides excel- outcomes. lent tools for improving in these skills, including clinical ►► Understand the needs of cancer survivors. trials workshops, magnitude of clinical benefit scale and ►► Understand the need of specific patient groups like others. However, communication about the availability of young adults and elderly patients. these tools can probably be improved. ►► Learn from collaboration with psychosocial health- care professionals and researchers. ►► Learn from collaboration with self-help groups and patient advocacy groups. Clinical research skills It was discussed that, for interacting effectively with In the same line, GI faculty members feel that a good patients, new approaches should be built up, including training and knowledge in clinical research skills are an web-based and app-based technologies. educational need complementary to other skills. Training should focus on ►► Statistical knowledge. Conclusions ►► Clinical trial methodology. ESMO is well equipped for taking the lead in the educa- ►► Good clinical practice. tion of GI cancer specialists. Numerous ESMO-initiated ►► How to write a trial protocol. and ESMO-related activities exist. These include ►► Getting familiar with novel trial designs (eg, basket, ►► ESMO conferences (https://www.​esmo.​org/​ umbrella and adaptative designs). Conferences). ►► Clinical research networking and how to conduct ►► Oncology meeting resources (https://​ oncologypro.​ multinational trials. esmo.​org/​Meeting-​Resources). ►► Biobanking and use of sampled biomaterials. ►► ESMO-European School of Oncology courses in It was felt that, in addition to the above-mentioned ESMO medical oncology (https://www.​esmo.​org/​Confer- tools, closer interaction with networks and organisations ences/​ESMO-​ESO-​Courses-​on-​Medical-​Oncology-​for-​ that work specifically on clinical research, for example, Medical-​Students). the European Organisation for Research and Treatment ►► ESMO academy https://www.​esmo.​org/​Confer- of Cancer, could be helpful. ences/​ESMO-​Academy-​2019). ►► ESMO preceptorship courses https://www.​esmo.​org/​ Conferences/​Preceptorship-​Courses). (Self-)management and career building ►► ESMO advanced courses https://www.​ esmo.​ org/​ For being efficient in patient care and making an impact Conferences/​Advanced-​Courses). on the future development of GI oncology, we need to ►► ESMO workshops and courses https://www.​ esmo.​ train fellows in their level of (self-)management and help org/​Conferences/​Workshops-​Courses). 4 Lordick F, et al. ESMO Open 2019;4:e000533. doi:10.1136/esmoopen-2019-000533 Open access 2 Masaryk Memorial Cancer Institute (MMCI), Masaryk University, Brno, Czech Republic 3 Scientific and Medical Division, European Society for Medical Oncology, Viganello, Switzerland 4 Head Office, European Society for Medical Oncology, Viganello, Switzerland 5 Department of Digestive Oncology, University Hospitals Leuven and KU Leuven, Leuven, Belgium 6 Vall d'Hebron University Hospital and Institute of Oncology, Universitat Autònoma de Barcelona, Barcelona, Spain 7 Department of Medical Oncology, Second University of Naples, Naples, Italy 8 Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain Contributors FL and AC designed the consensus process. All authors contributed data. FL and DV organised the workshop. FL and RO drafted the manuscript. All authors reviewed and approved the final manuscript. Funding The authors have not declared a specific grant for this research from any Figure 3 Young oncologists Meet Your Expert at the funding agency in the public, commercial or not-for-profit sectors. Discussion Hub at European Society for Medical Oncology Competing interests FL reports receiving grants, personal fees and non-financial Asia 2018. support from BMS; and personal fees from Astellas, Astra Zeneca, Biontech, Eli Lilly, Elsevier, Infomedica, Merck, MSD, Roche, Servier and Amgen outside the submitted work. EVC reports participation in advisory boards for Astrazeneca, ►► ESMO scientific journals (Annals of Oncology, ESMO Bayer, Bristol-Myers Squibb, Celgene, Lilly, Merck Sharp & Dohme, Merck KGaA, Open, and Immuno-Oncology Technology; https://www.​ Novartis, Roche and Servier, and receiving research grants from Amgen, Bayer, esmo.​org/​About-​Us/​ESMO-​Oncology-​Journals). Boehringer Ingelheim, Celgene, Ipsen, Lilly, Roche, Merck Sharp & Dohme, Merck ►► ESMO-American Society of Clinical Oncology global KGaA, Novartis, Roche and Servier paid to the institution outside the submitted work. JT reports personal fees and others from Array Biopharma, AstraZeneca, curriculum in medical oncology (endorsed by 47 soci- Bayer, BeiGene, Boehringer Ingelheim, Chugai, Genentech, Genmab A/S, Halozyme, eties; https://www.​esmo.​org/​Career-​Development/​ Imugene Limited, Inflection Biosciences Limited, Ipsen, Kura Oncology, Lilly, Global-​Curriculum-​in-​Medical-​Oncology). MSD, Menarini, Merck Serono, Merrimack, Merus, Molecular Partners, Novartis, ►► ESMO guidelines https://www.​esmo.​org/​ Peptomyc, Pfizer, Pharmacyclics, ProteoDesign SL, Rafael Pharmaceuticals, F. Hoffmann-La Roche Ltd, Sanofi, SeaGen, Seattle Genetics, Servier, Symphogen, Guidelines). Taiho, VCN Biosciences, Biocartis, Foundation Medicine, HalioDX SAS and Roche ►► ESMO e-learning resource centre on Oncology Pro Diagnostics outside the submitted work. FC reports receiving personal fees from (https://​oncologypro.​esmo.​org/​Education-​Library/​ Roche/Genentech, Merck Serono, Pfizer, Amgen, Servier, Lilly, Bayer, Bristol-Myers ESMO-​E-​Learning-​and-​V-​Learning?​hit=​ohp). Squibb and Celgene; and grants from Bayer, Amgen, and Merck Serono outside the submitted work. AC reports having a consultant or advisory role at Merck Serono, ►► ESMO Young Oncologist activities (https:// Roche, Beigene, Bayer, Servier, Lilly, Novartis, Takeda, Astelas and Pierre Fabre; w w w . ​ e s m o . ​ o r g / ​ C a r e e r - ​ D e v e l o p m e n t /​ receiving research funding from Genentech, Merck Serono, Roche, Beigene, Bayer, Young-​Oncologists-​Corner). Servier, Lilly, Novartis, Takeda, Astelas, Fibrogen, Amcure, Sierra Oncology, Astra ►► Young Oncologist Committee (https:// Zeneca, Medimmune, BMS, MSD and Pierre Fabre; receiving speaker honoraria from Merck Serono, Roche, Angem, Bayer, Servier and Foundation Medicine; and w w w. ​ e s m o . ​ o r g / ​ A b o u t - ​ U s / ​ W h o - ​ We - ​ A r e /​ receiving grant support from Merck Serono and Roche. RO, DV, JYD and KMG have Young-​Oncologists-​Committee). no conflict of interest to declare. ►► Fellowship programme (https://www.​ Patient consent for publication Not required. e s m o . ​ o r g / ​ C a r e e r- ​ D e v e l o p m e n t / ​ O n c o l o g y -​ Provenance and peer review Not commissioned; externally peer reviewed. Fellowships), career and professional development tools (https://www.​esmo.​org/​Career-​ Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which Development) and travel grants (https://www.​ permits others to distribute, remix, adapt, build upon this work non-commercially, esmo.​org/​Career-​Development/​Young-​Oncologists-​ and license their derivative works on different terms, provided the original work is Corner/​Travel-​Grants-​for-​ESMO-​Meetings). properly cited, any changes made are indicated, and the use is non-commercial. ►► Multiple networking opportunities, like meet-your-ex- See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. pert sessions at ESMO meetings (figure 3). The GI faculty—as other ESMO faculties—should be encouraged to increase its active role in education. Coop- References eration between the faculties and the Young Oncologist 1. Fitzmaurice C, Akinyemiju TF, Al Lami FH, et al. Global, Regional, Committee is key. In view of the increasing number of and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-Years for 29 Cancer female cancer physicians, gender balance should also be Groups, 1990 to 2016: A Systematic Analysis for the Global Burden of taken seriously when nominating members of the facul- Disease Study. JAMA Oncol 2018;4:1553–68. ties. The GI faculty could act as a pioneer in this process. 2. Dalkey N, Helmer O. An Experimental Application of the DELPHI Method to the Use of Experts. Manage Sci 1963;9:458–67. 3. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based Author affiliations medicine: what it is and what it isn't. BMJ 1996;312:71–2. 1 University Cancer Center Leipzig, Leipzig University Medical Center, Leipzig, Germany Lordick F, et al. ESMO Open 2019;4:e000533. doi:10.1136/esmoopen-2019-000533 5