Contents:

• Supportive Care (SC) Fellowship Track
• Hemostasis and Thrombosis Research Fellowship Track
• Cancer Genetics Fellowship Track
• Breast Oncology Fellowship Track

Supportive Care (SC) Fellowship Track

Outline: This is a 1 year educational experience, under the supervision of Dr. Steven Grunberg, available to a 2nd or 3rd year, largely clinic-based, Fellow with a special clinical or research interest in Supportive Care.

Educational Purpose: To complement the fellow’s training by developing a special understanding of and expertise in areas encompassing the diversity and depth of broadly defined supportive care including symptom management.

Spectrum of disorders, patient characteristics, procedures and services: Topics will include but are not limited to:  

• Evaluation and management of anemia, neutropenia, and thrombocytopenia
• Evaluation and management of nausea and emesis
• Assessment and control of cancer pain syndromes
• Management of diarrhea and mucositis
• Neuropathy and neurologic complications of cancer
• Osteoporosis
• Fatigue in the cancer patient
• Assessment and treatment of hot flashes
• Measurement of quality of life
• Issues pertaining to cancer in the elderly
• Prophylaxis and treatment of venous thromboembolism associated with cancer
• Cognitive dysfunction and depression
• Palliative surgery, radiation, and interventional pain control procedures

Teaching Methods: 

• Attendance at local, regional, and national didactic lectures by experts. The fellow will develop a supportive care attendance ‘track’ along with the mentor at the ASCO meeting
• Individual and group interactive discussions with mentor and faculty with specific strengths in selected supportive care areas
• Practice-based learning (through caring for individual patients with a wide range of symptoms and supportive care needs along the entire palliative care continuum towards the end of life)
• Systems-based practice (liaison closely with outpatient clinic pharmacist, nursing staff, and physicians to develop systematic plans and policies for a variety of common symptom and supportive care situations)
•  The Fellow will conceive, design, plan, and implement a clinical or research project,  analyze the data, and write a paper on the topic
• ·Elective external rotations (up to 2 months)

 Educational Resources:

• ASCO Symptom Control curriculum
• Attend MAASC meeting
• Dr. Steven Grunberg who will serve as the senior mentor
• Textbook of Supportive Care (Klastersky, Weiss)
• Subscription to Journal of Supportive Oncology
• Up to 2 elective months away from the main institution for specialized experiences in supportive care, agreed upon by Dr Grunberg

Teaching Rounds and Conferences :

• The Fellow will research and assemble data and devise lectures for presentation at local and regional educational venues including but not limited to:
  •  Annual Northern New England Fellows Conference
  •  Vermont Cancer Center ASCO-ASH review
  •  Journal Club
  •  Fellows’ Tuesday AM seminar
  •  Vermont Cancer Center Fellow Grand Rounds
  •  Invited lectures at regional community hospitals

• The fellow will attend Rounds or Conferences in other departments such   as Psychiatry, Pharmacology, Palliative Care, and Ethics as appropriate and possible.

Evaluation Methods:  

• ·   Written evaluation by Dr Grunberg
• ·   Additional written evaluations by pharmacist, nurse, co-fellows, and supervisors  
      of electives 

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Hemostasis and Thrombosis Research Fellowship Track

This is a 1-2 year experience available to 2nd/3rd year Fellows in Hematology/Oncology interested in intensive training in the fields of thrombosis, hemostasis, and/or vascular disease epidemiology. Trainees at other levels or in other programs (residents, medical students) can also participate by arrangement with a mentor.

Faculty:

• Mary Cushman, MD, MSc, Associate Professor of Medicine and Pathology
• Chris Holmes, MD, PhD, Assistant Professor of Medicine 
• Edwin Bovill, MD, Professor and Chair, Pathology; Director, Special  Coagulation  Laboratory, FAHC
• Russell Tracy PhD, Professor of Pathology and Biochemistry
• Paula Tracy, PhD, Professor and Interim Chair, Biochemistry
• Kenneth Mann, PhD, Professor, Biochemistry
• Nancy Jenny, PhD, Assistant Professor of Pathology
• Sally Huber, PhD, Professor of Pathology
• Others as appropriate for specific projects

Goals:

The goal of this program will be to train fellows centered on research projects in cardiovascular disease epidemiology or treatment, including arterial and venous disease. Goals can be modified based on the needs of the candidate’s specific research project.

Most participants will receive training in:

1. Evaluation and management of patients with venous thrombosis. Education on   venous thrombosis genetics, principles of genetic counseling and treatment in those at high risk.

2. Epidemiology methods, including the appropriate uses of statistical testing and epidemiologic study design (primarily observational epidemiology, analysis of large data sets).

3. The opportunity to engage in Clinical Research training through the formal curriculum of the K30-funded Clinical Research Training Program (B. Littenberg, PI).

4. Operational aspects of a laboratory doing translational and epidemiological research, including:

1. logistical aspects of biological samples in multicenter studies
2. clinical laboratory principles
3. assay methods including ELISA, automated coagulation tests, nephelometry, high  throughput DNA analysis and novel assay development.
4. quality assurance/quality control
5. Data analysis

5. Perform a research project to learn methods in molecular epidemiological research in vascular disease, including evaluation of phenotypic and genetic risk factors. Learn the role of this type of research for hypothesis formation about disease pathogenesis and public health applications.

6. Human Subjects research policy education.

Resources Available:

1.  The Laboratory for Clinical Biochemistry Research  (www.med.uvm.edu/lcbr) has over 40 ongoing independent and collaborative research projects focused on vascular diseases including heart disease, stroke, and venous thrombosis. Other interests are in obesity, diabetes, aging, dementia, and frailty. We use a wide variety of assays in population and family-based research settings particularly in the areas of coagulation, fibrinolysis, thrombosis, inflammation, and immune system function, including cell manipulation assays. Results are linked to animal model studies, especially research in murine atherosclerosis. The main purposes are hypothesis formation about pathogenesis of vascular disease, but other interests involve public health applications. Over 1 million human biological samples are stored in the lab repository for use in research. Projects here will involve development of collaborations with mentors at other institutions as well as UVM. Office space at the LCBR or other site, and use of a computer with needed software (data analysis, word processing, endnote, etc), will be provided. PI’s include Drs. Bovill, Cushman, Huber, Jenny, and R.Tracy.

2.  The Thrombosis and Hemostasis Program in the Division of Hematology-Oncology provides a clinical population of patients (primarily with venous thrombosis) in which clinical-translational research projects can be developed. Hospital-based projects related to quality improvement or other topics can also be pursued. PI’s include Drs. Cushman and Holmes.

3.  The Translational Research Laboratory of Dr. Holmes focuses on the role of the activated platelet in promoting coagulation and its potential role in malignancy.  Projects focus on questions which bridge between the clinic and the laboratory and provide a unique opportunity to learn both laboratory research techniques and clinical research approaches. Opportunities for learning include

          1) design and implementation of translational research and clinical trials
          2) introduction to the approval process for clinical trials through IRB submissions
          3) data management principles
          4) data analysis 
          5) basic laboratory techniques

Based on trainee interest, projects may focus primarily on the clinical or basic science portions of a particular project or both. Ongoing collaborations are with the cardiology division, gynecology-oncology, oncology, and blood bank researchers.

4. Kenneth Mann. This program is aimed at understanding how thrombin is generated and how thrombin generation is regulated. Our approach comes via the convergence of four themes:

          1) studies describing physical properties of coagulation enzyme complexes, their constituents and how these complexes assemble into efficient enzyme catalysts
          2) studies in which multiple coagulation catalysts/inhibitors are mixed to attempt to duplicate the performance of the combined catalyst system associated with the tissue factor pathway of thrombin expression (synthetic plasma)
         3) studies in minimally modified biological systems (whole blood) to evaluate the correctness of hypotheses derived from purified systems
         4) studies with mathematical models (computer model) which can be used to quantitatively define the process of blood clotting both to aid in experimental designs 1,2,3; to evaluate pharmacologic agents, and to diagnosis and treat of hemostatic and thrombotic diseases.

Other focused work relates to factor V structure and function, especially activated protein C resistance.

5. Paula Tracy. The principle objective is to understand how platelets participate in and regulate the formation of the important bioregulatory molecule, thrombin. Thrombin generation is effected by a Ca2+-dependent, membrane-bound complex of the cofactor protein, factor Va, and the serine protease, factor Xa. Three major goals are:

1) to provide a quantitative understanding of how the functional interactions of factors Va and Xa with the platelet membrane surface are regulated. The membrane receptors, the intracellular signalling pathways and the enzymatic processes controlling these events are being identified using biochemical and molecular biological approaches.
2) to isolate and characterize the platelet subpopulation that has been identified based on its ability to support formation of a functional prothrombinase complex. This is based on findings that all platelets do not express equivalent procoagulant activity. 3) to define how megakaryocytes developmentally regulate the endocytosis and possible synthesis of the required cofactor factor V(a), and to determine the cellular events regulating its endocytosis, its intracellular trafficking to storage granules and the phenotypic changes in the factor V molecule resulting from these interactions. Since platelet-derived factor Va is essential for normal blood clotting, defining how platelets acquire this essential protein, process it and express it at their membrane surface is key in regulating thrombin generation.

The formation of thrombin at the surface of platelets is pivotal to the physiological and pathophysiological functions they provide as they localize to vascular and extravascular tissue sites.

Funding Opportunities:

Some of us are faculty on an NIH Training Grant in Hemostasis at the University of Vermont (PI, Kenneth Mann), which may be used for project support. Other funding may be pursued from the American Heart Association and the Vermont Cancer Center. We are the core institution of a trans-Atlantic research consortium, the Leducq International Network Against Thrombosis (LINAT), that supports collaborative training of research fellows in at multiple institutions in the US and Europe (PI, Dr. Bovill). Research projects at member institutions (Leiden the Netherlands, Leuven Belgium, Paris France, Oklahoma City OK, Seattle WA) can be considered. Please refer to the network’s website for details:
 http://www.med.uvm.edu/pathology/HP-DEPT.ASP?SiteAreaID=728

Responsibilities for Fellows in Hematology-Oncology:

1.  One year+ continuity clinic in Thrombosis and Hemostasis.
2.  Attendance at the following meetings
             a.  Laboratory Meetings of the lab(s) where the fellow is affiliated
             b.  Monthly Interdisciplinary Vascular Medicine Conference
             c.  Thrombosis and Hemostasis Program weekly meeting
             d.  At least weekly meetings with research mentor.

3.  Research Project:  The Fellow will identify a research mentor in their first fellowship year and is expected to carry out a project and publish the results, including at least one presentation at a national meeting. Fellows are encouraged to write a research grant proposal to support their project under the guidance of their mentor.

4.  Normally the fellow will spend their full third year, apart from the required continuity clinic, working on their research project.

5.  It is preferred but not required that fellows spend a fourth year, so their research experience consists of 2 full years of research training.

Responsibilities for Trainees at other Levels

These will be determined on an individual basis depending on the level of the trainee and the project undertaken.

Recent Student, Postdoctoral Fellow, or Resident Peer-reviewed Publications:

 ^van der Hagen PB, Folsom AR, Jenny NS, Heckbert SR, O’Meara ES, Reich LM, Rosendaal FR, Cushman M. Subclinical atherosclerosis and risk of future venous thrombosis in the Cardiovascular Health Study. In Press, J Thromb Haemost.

#Cao J, Peterson D, Psaty BM, Kuller LH, Barzilay J, Bleyer A, Manolio TA, Wexler J, Blaum C, Cushman M. The association of microalbuminuria with clinical cardiovascular disease and subclinical atherosclerosis in the elderly: the Cardiovascular Health Study. In press, Atherosclerosis.

**Zakai NA, Katz R, Hirsch C, Shlipak MG, Chaves P, Newman A, Cushman M. Prospective study of anemia status, hemoglobin and mortality in the elderly: the Cardiovascular Health Study. Arch Intern Med 2005;165:1-7.

*Kennedy M, Cushman M, et al. Risk factors for worsening ankle-brachial index in the elderly: the Cardiovascular Health Study. In press, Arch Intern Med.

*Kennedy M, Andreescu ACM, Greenblatt MS, Jiang H, Thomas CA, Chassereau L, Wong C, Durda P, Cushman M. Factor V Leiden, prothrombin 20210A and the risk of venous thrombosis among cancer patients. British J Haematol 2005;128:386-8.

**Zakai N, Wright J, Cushman M. Risk factors for venous thrombosis in medical inpatients: validation of a thrombosis risk score. J Thromb Haemost 2004;2:2156-61.

Vossen CY, van Korlaar IM, Cushman M,.Rosendaal FR, Bovill EG. Validity of a questionnaire for data collection on venous thrombosis. Thrombosis Research 2004;114:259-63.

Vossen CY, Hasstedt SJ, Rosendaal FR, Callas PW, Bauer KA, Broze GJ, Hoogendoorn H, Long GL, Scott BT, Bovill EG. Heritability of plasma concentrations of clotting factors and measures of a prethrombotic state in a protein C-deficient family. J Thromb Haemost 2004;2:242-7.

van Korlaar IM, Vossen CY, Rosendaal FR, Bovill EG, Cushman M, Naud S, Kaptein AA. The impact of venous thrombosis on quality of life. Thrombosis Research 2004;114:11-18.

#Cao J, Thach C, Manolio TA, Psaty BM, Kuller LH, Polak JF, Chaves PHM, Sutton-Tyrell K, Herrington DM, Price TR, Cushman M. C-reactive protein, carotid intima-media thickness, and the incidence of stroke: the Cardiovascular Health Study. Circulation 2003;108:166-70.

@Crainich P, Jenny NS, Tang Z, Arnold AM, Kuller LH, Manolio T, Sharrett AR, Tracy RP Lack of association of the plasminogen activator inhibitor-1 4G/5G promoter polymorphism with cardiovascular disease in the elderly. J Thromb Haemost. 2003;1:1799-804.

*Andreescu ACM, Cushman M, Rosendaal FR. D-dimer as a risk factor for deep vein thrombosis: the Leiden Thrombophilia Study. Thromb Haemost 2002;87:47-51.

Jenny NS, Tracy RP, Ogg MS, Luong le A, Kuller LH, Arnold AM, Sharrett AR, Humphries SEIn the elderly, interleukin-6 plasma levels and the -174G>C polymorphism are associated with the development of cardiovascular disease. Arterioscler Thromb Vasc Biol 2002;22: 2066-71.

##Sakkinen P, Abbott RD, Curb JD, Rodriguez BL, Yano K, Tracy RP. C-reactive protein and myocardial infarction. J Clin Epidemiol. 2002;55:445-51

*Andreescu AC, Cushman M, Hammond JM, Wood ME. Trousseau’s syndrome treated with long-term subcutaneous lepirudin: Case report and review of the literature. J Thromb Thrombolysis 2001 11:33?7.

##Lewis MR, Callas PW, Jenny NS, Tracy RP. Longitudinal stability of coagulation, fibrinolysis, and inflammation factors in stored plasma samples. Thromb Haemost. 86:1495-500, 2001

##Sakkinen P, Wahl P, Cushman M, Lewis M, Tracy RP. Clustering of Procoagulation, Inflammation, and Fibrinolysis Variables with Metabolic Factors of the Insulin Resistance Syndrome (IRS). Am J Epidemiol 152:897-907, 2000

*Andreescu ACM, Possidente C, Hsieh M, Cushman M. Evaluation of a pharmacy-based surveillance program for heparin-induced thrombocytopenia. Pharmacotherapy 2000;20:974-80.

^ LINAT exchange graduate student

* Hematology/Oncology Fellow

** Medicine resident

# Cardiology Fellow

## Pathology resident

@UVM Masters in Pathology student

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Cancer Genetics Fellowship Track

Outline: This is a 1-2 year experience available to a 2nd/3rd year Fellow in Hematology/Oncology interested in intensive training in the field of cancer genetics including clinical, research, and educational components.

Faculty:

• Marie E. Wood, MD, Director, Familial Cancer Program, Professor of Medicine (Track Supervisor)
• Marc S. Greenblatt, MD, Associate Professor of Medicine
• Laurence McCahill, MD, Assistant Professor of Surgery
• Wendy McKinnon, MS, Cancer Genetic Counselor
• Sandy May, Research Assistant, Molecular Diagnostic Laboratory
• Marcus Bosenberg MD, PhD, Assistant Professor of Pathology
• Cheung Wong, MD, Associate Professor, Dept. of OB/GYN, Director of GYN/ONC
• Richard Zubarik, MD, Assistant Professor of Medicine, Chief of Endoscopy
• Robin Hayden, MSN, APRN

Goals:

The overall goal of this program will be to educate physicians regarding the practice of cancer genetics and become familiar with basic science and clinical research issues in cancer genetics. Participants will:

• Learn how to identify and evaluate patients with a strong family history of cancer.
• Learn how to perform individualized cancer risk assessment based on family histories.
• Gain an in-depth understanding of high-risk cancer screening for individuals with hereditary/familial risk for cancer.
• Become knowledgeable about cancer prevention strategies for high-risk individuals
• Understand how and when to use genetic testing for hereditary cancer
• Gain an understanding of available options (research and clinical) for cancer genetic testing.
• Become familiar with risks, benefits, and limitations of cancer genetic testing
• Learn how to manage patients with hereditary cancer with special emphasis on breast and colon cancer
• Develop cancer genetics counseling skills
• Appreciate the scientific and ethical principles of conducting research in the field

Responsibilities

1. One weekly half-day cancer genetics continuity clinic in addition to regular continuity clinics

2. Attendance at following meetings:

• Twice monthly Familial Cancer Program meetings (1st/3rd Wed of the month)
• Molecular Diagnostic weekly laboratory meeting
• Weekly Breast (Thursday-noon) and monthly Gastrointestinal (1st Monday AM) Tumor Board.

3. Clinical/Laboratory Research Project

4. The Fellow will identify a research mentor and is expected to carry out a project with the intention of publishing the results. Fellows are encouraged to either write a research grant proposal under the guidance of a mentor or a clinical trial and submit to the institutional review board.

Didactic Lectures/Topics

Topics will include

1. Laboratory Methods in Genetic Testing
2. Principals of Genetics
3. Genetic Counseling/Testing
4. Risk Assessment
5. Ethical, Legal, and Social Implications of Cancer Genetic Testing
6. Cancer Genetic Syndromes
      a.  Hereditary Breast/Ovarian Cancer
      b.  Hereditary Colon Cancer
      c.  Hereditary Melanoma
      d.  Pediatric Cancer Genetic Syndromes
      e.  Multiple Endocrine Neoplasia
7. Complete review of ASCO Cancer Genetics curriculum

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Breast Oncology Fellowship Track

Outline: This is a 1-2 year experience available to a 2nd/3rd year Fellow in Hematology/Oncology interested in intensive training in the field of Breast Oncology including clinical, research, and educational components.

Faculty:

Medicine – Hematology/Oncology

• Susan Burdette-Radoux, MD, Associate Professor (Track supervisor)
• Hyman B. Muss, MD, Professor (Track co-supervisor)
• Marie E. Wood, MD, Director, Familial Cancer Program, Professor
• Patricia O’Brien, MD, Director of Lymphedema Clinic

 Surgical Oncology

• Seth Harlow, M.D., Associate Professor of Surgery, Director of Breast Clinic
• David Krag, MD, Professor of Surgery
• Laurence McCahill, MD, Associate Professor of Surgery
• Ted James, MD, Assistant Professor of Surgery

Pathology

• Donald Weaver MD, Professor of Pathology 
• Gladwyn Leiman, Professor and Director of Cytopathology
• Abiy Ambaye, Assistant Professor of Pathology 

Radiology

• Robert Oppenheimer, MD, Professor of Radiology  
• Susan Harvey, MD, Assistant Professor of Radiology

Radiation Oncology

• Ruth Heimann, MD, Professor of Radiology 
• Deborah Rubin, MD, Associate Professor of Radiology

Vermont Cancer Center

• Russ Hovey, PhD, Assistant Professor  (mammary gland biology)

Office of Health Promotion Research

• Berta Geller PhD, Research Assoicate Professor

Goals:
The overall goal of this program will be to educate physicians regarding the multidisciplinary practice of breast oncology and become familiar with basic science and clinical research pertaining to breast cancer. Participants will:

• Learn how to evaluate and make multi-modality decisions for treatment of early breast cancer, develop expertise in management of advanced breast cancer as well as breast cancer in the elderly
• Become familiar with  the principal issues in pathologic and other prognostic assessments, as well as special imaging studies employed specifically for the evaluation of breast cancer
• Understand cancer risk assessment, develop cancer genetic counseling skills and gain experience in use of genetic testing in the prevention and management of hereditary breast cancer syndromes (see related Cancer Genetics Track goals)
• Appreciate local and national clinical research processes and directions, as well as the scientific and ethical principles of conducting research in the area

Responsibilities

• One weekly half-day session at Breast Multidisciplinary Clinic in addition to regular continuity clinics for a minimum period of 6 months
• One weekly half-day session at Cancer Genetics clinic in addition to regular continuity clinics for a minimum period of 6 months
• At least one year of a Fellow continuity clinic will be with Dr Muss, Dr Burdette-Radoux, or Dr Wood caring for breast cancer patients.
• At least 4 sessions at Lymphedema Clinic
• Accrue and follow patients on CALGB, NSABP, and Vermont Cancer Center breast cancer protocols
• Observe examples of breast biopsies, surgical procedures (lumpectomy, partial and total mastectomy, and reconstructive surgery)
• Observe treatment planning for breast irradiation.
• Attendance at following meetings
  • Twice monthly Familial Cancer Program meetings (1st/3rd Wed of the month)
  • Weekly Breast Tumor Board (Thursday 12-1pm)
  • Monthly Breast Protocol Review Committee (4th Thursday 8-9am)
• Clinical/Laboratory Research Project (REQUIRED)

The Fellow will identify a research mentor and is expected to carry out a project with the intention of publishing the results. Fellows are encouraged to either write a research grant proposal under the guidance of a laboratory research mentor or design and begin accrual to a clinical trial

• Meeting attendance with poster or abstract submission to
  • ASCO breast cancer sessions and present high impact abstracts at ASCO ASH Review conference (usually fully funded)
  • Miami Breast Cancer Conference (Fully funded)
  • San Antonio Breast Cancer Conference (Partial travel and Dues)
  • Cancer and Leukemia Group B Breast and Cancer in the Elderly Committee meetings (Fully funded)
  • Observe breast cancer support group meetings, attend Schwartz Rounds (when pertinent and possible), present to survivors at Stowe Weekend of Hope as well as to breast cancer health care providers and staff at annual Vermont Cancer Center breast cancer symposium.

 Educational Methods

             Didactic Lecture Topics

•  Evaluation and management of early and advanced breast cancer
•  Principles and practice of cancer genetics and counseling
•  Palliative and End of Life Care

 Self study

•  Review of ASCO MKSAP curriculum in Breast Cancer
•  Textbook of Breast Diseases.

 Conferences and meeting attendance

• University of Vermont Medicine, Pathology and Surgical Grand Rounds as well as Vermont Cancer Center Research Seminars pertaining to breast cancer.
• Miami Breast Cancer Conference (Fully funded)
• San Antonio Breast Cancer Conference (Partial travel and Dues)
• Cancer and Leukemia Group B Breast committee

Evaluation Methods:

•  Written evaluation by Dr. Susan Burdette-Radoux and/or Dr. Hyman Muss
•  Additional written evaluations as pertinent by research mentor, and supervisors of pertinent electives

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