Medical Oncology Education in Europe: Equipping Medical Oncologists to Provide the Best Care for Patients with Cancer

Medical oncologists need a thorough knowledge of underlying cancer pathophysiology and development and of available diagnostic and therapeutic modalities. They also require an in-depth understanding of the needs of individual patients and their caregivers [1]. In order to provide optimal patient care, medical oncologists also need training to lead the multidisciplinary approach required to provide the holistic care required to optimize outcomes in cancer [2].

Developments such as new medical therapies, including targeted agents and immunotherapy in a wide range of cancers and increased emphasis on a holistic, patient-centred approach, underline the need for continuous updating of knowledge and practice among medical oncologists at all levels, from those undertaking their initial specialist training and practicing oncologists to those in advanced practice and cutting-edge research.

Access to education in medical oncology varies considerably in different countries and regions. There are still many differences in education and training in medical oncology in different countries both during undergraduate medical training and during specialist oncology training [3]. In some countries, specialist training may include a significant amount of radiotherapy and/or haematology. However, haematology and oncology are two separate and distinct specialities in most but not all European countries. This can limit the opportunities and recognition of competencies for young medical oncologists when they want to travel between countries during or after finishing their residency. A universal challenge is that there is usually a lack of connection with research and training in research during residency training in medical oncology.

The importance of training in communication for medical oncology is often underappreciated. Communication skills training programs for oncology clinicians (physicians and nurses) have been developed since the 1990s and should be widely implemented in training programmes for medical oncologists [4].

Key elements to achieve effective and consistent medical oncology education should start with a clear, up-to-date curriculum setting out what should be covered, define standards, and harmonize education in different countries to ensure all patients have an equal chance of receiving treatment from well-trained physicians. High-quality educational courses across all levels, from undergraduate medical students to medical oncology trainees and experienced specialists, and regularly updated online and print materials and publications are also important in delivering education. Training opportunities such as fellowships provide effective ways of sharing and building expertise and skills, and educational meetings offer opportunities to communicate the latest developments and knowledge, exchange ideas, and plan for further progress. In addition, guidelines play a central role in communicating and implementing evidence-based best practices.

Several organizations support the development and provision of educational resources and activities for medical oncology across Europe. These include the European Society for Medical Oncology (ESMO), the leading professional organization for medical oncology in Europe. ESMO provides a wide range of educational initiatives as part of achieving its core mission. The aim is to: “offer the best care to people with cancer, through fostering integrated cancer care, supporting oncologists in their professional development and advocating for sustainable cancer care worldwide” [5]. As part of this, ESMO works through a wide range of educational programmes, meetings, fellowships, and resources to educate doctors on the best practices and latest advances in oncology [6].

Further, medical education goes beyond European borders, for example, with the ESMO Africa summit, ESMO South America summit, ESMO Asia, or ESO (European School of Oncology) Masterclasses in Eastern Europe and Middle and South America. The European Cancer Organisation is a not-for-profit federation of member organizations that work together at a European level to improve outcomes and quality of care for cancer patients [7]. As part of achieving this vision, it convenes member societies, patient groups, and other stakeholders for discussion and exchange, building consensus, and coordinating activities through Focused Topic Networks.

The ESO is an independently funded non-profit organization dedicated to quality education and training as part of achieving its vision: “to ensure that all cancer patients have access to unbiased and evidence-based competent care from adequately training health professionals” [8]. Through the College of the European School of Oncology (ESCO), the organization offers medical, radiation, and surgical oncologists a structured educational pathway to build their oncology careers. ESO also provides online educational courses and sessions, in addition to postgraduate programmes and training fellowships [9]. ESTRO (European Society of Radiation Oncology, www.estro.org) also as an example provides various educational courses and sessions.

Several professional organizations provide educational programmes in specialized areas of oncology that are relevant to the particular types of cancer they cover. For example, The European Association of Neuro-Oncology (EANO, www.eano.eu) runs webinars in addition to a comprehensive postgraduate programme and a mentorship scheme for young clinicians and researchers in neuro-oncology [10]. In the field of haematology, the European Hematology Association (EHA, www.ehaweb.org) provides peer-reviewed online education and training covering a range of haematological malignancies [11]. ESMO and EHA work closely together to develop relevant guidelines together, for example, Multiple myeloma: EHA-ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up [12].

Education in supportive and palliative care of patients is of major importance to implement a patient-centred care approach, as set out in The Lancet commission paper on the integration of oncology and palliative care and the ESMO position paper on supportive and palliative care [13, 14]. International societies such as MASCC (Multinational Association of Supportive Care in Cancer, www.massc.org) and the EAPC (European Association of Palliative Care, www.eapcnet.eu) provide comprehensive education in this area as well.

The Recommendations for a Global Curriculum in Medical Oncology were developed by ESMO and the American Society of Clinical Oncology (ASCO) to set out standards to guide the clinical training for physicians to qualify as medical oncologists [1]. The two organizations developed the first outline for a global core curriculum for training in medical oncology nearly 20 years ago, recognizing the need for a set of international recommendations to help ensure that patients have an equal chance of receiving state-of-the-art treatment from well-trained physicians regardless of where they live.

Recognizing recent progress in the field, the latest curriculum (published in 2016) incorporates chapters, for example, on molecular pathology, personalized cancer medicine, immunotherapy, translational research, genetic counselling, supportive/palliative care, and survivorship. Targeted therapies are integrated into chapters for separate tumour entities, recognizing their rapid development for different types of cancer. The curriculum incorporates modern didactic principles into its template-based format that breaks down outcomes into learning objectives, awareness, knowledge, and skills. A logbook provides a support tool for medical oncologists in training and their supervisors, to track educational activities and progress.

The Global Curriculum in Medical Oncology has achieved, and continues to achieve, major improvements in the scope, quality, and consistency of medical oncology education and training across the world. The European Commission based its formal recognition in 2011 of medical oncology as a medical speciality on the curriculum’s recommendations, underlining its importance. Its reach is illustrated in its wide accessibility and endorsement. The latest global curriculum has been endorsed by 51 national oncology societies and is available in 11 languages. A global survey of 62 countries around the world carried out in 2019 found that more than two-thirds (68%) of the 41 countries with established training in medical oncology had adopted the ESMO/ASCO Global Curriculum [15]. The Global Curriculum is a living document that is regularly reviewed and updated; the curriculum working group, which includes more than 100 leading oncologists, is currently finalizing the latest edition.

More widely, the ESMO Educational Committee works to promote education in oncology and ensure international educational programmes, activities, and certification programmes to maintain a high standard of professional qualification and practice [16]. The committee includes the chairs of the ESMO educational sub-committees and the chairs of other committees and working groups covering a very wide range of different areas in oncology, such as cancers in adolescents and young adults and translational research and precision medicine. They identify and plan educational resources that meet oncologists’ needs, both now and in the future, by responding to emerging developments and developing new formats and approaches, including online and digital programmes. Some recent developments include establishing a working group on real-world data and digital health, whose remit includes educating oncology professionals on these issues in oncology research and clinical practice.

The ESMO Academy is a 3-day course held each year that provides a detailed and up-to-date review of key topics in medical oncology [17]. Presented by leading international experts, it includes standard of care and perspectives on the main tumour types, including haematological malignancies, methodology and interpretation of clinical trials, pharmacotherapy and drug interactions, and aspects of supportive and palliative care. It is designed principally to help young oncologists prepare for the ESMO examination, but is also useful for experienced oncologists wanting to update their knowledge; webcasts from the Academy are made available to ESMO members and event attendees.

ESMO Preceptorships provide the opportunity for young medical and clinical oncologists, as well as general oncologists, to update their knowledge on a specific malignancy or oncology topic, including cross-sectional areas such as survivorship [18]. They comprise plenary topics given by a multidisciplinary faculty of international experts. Typically, 1.5 days in duration in small groups the courses are located at various locations across Europe, Africa, Latin America, and the Asia-Pacific region or virtually.

Examples of Preceptorships include Ovarian Cancer, Head and Neck Cancer, Breast Cancer, Adolescent and Young Adult Malignancies, Prostate Cancer, Gastric Cancer, Lung Cancer, and other Thoracic Malignancies, Immuno-Oncology, and Supportive and Palliative Care. A total of 17 ESMO Preceptorships were held in 2021 and 20 in 2022.

ESMO Advanced Courses provide interactive educational courses for experienced oncologists and other specialists that address specific challenges in patient management in different tumour settings (Table 1) [19]; 12 courses were held in 2021 and 13 in 2022. Also, typically 1.5 days in duration and held throughout the year in Europe and the Asia-Pacific area or virtually, these courses include state-of-the-art lectures from world-leading experts, workshops, and interactive discussion seminars. Numbers are limited (typically approximately 60 delegates) to ensure good interactivity. Places are awarded on a competitive basis at no charge for course registration.

The ESMO Practicing Oncologists Working Group works to identify the practice needs of oncologists who are hospital and office-based and provide educational resources that support sharing and implementation of best practice care [20]. This includes, for example, issues such as how to interpret results from molecular diagnostics in daily practice and what is known about hereditary cancer syndromes. The group may also contribute to preceptorship programmes, with a recent programme on treatment de-escalation strategies and molecular biology for practicing oncologists. Monthly webinars on a wide variety of topics are arranged together with the ESMO Guidelines Committee and the Young Oncologists Committee and faculty, with the recent launch of the ESMO Guidelines: Real World Cases webinar series that explores how to apply latest evidence-based guidelines in different types of cancer.

The annual 5-day ESMO-ESO residential course for fourth- and fifth-year medical students provides insights into all aspects of medical oncology to give participants a clear picture of this challenging and interesting field before selecting their specialization [21]. The highly interactive course for medical students provides a condensed, high-standard educational programme covering key elements of medical oncology, intending to motivate participants to consider the specialty as a career. Topics include a practical approach to cancer diagnosis, staging and prognosis and principles of medical therapy, as well as reviewing the commonest tumour types. In a mix of interactive teaching and workshops, participants hear from leading experts and discuss clinical cases with a multidisciplinary approach, ending with a “test your knowledge” exam.

ESO offers a range of postgraduate certificate programmes, designed to provide an opportunity to study a particular type of cancer in depth with internationally respected experts (Table 2) [22]. These courses are delivered on a part-time basis over 13–17 months as a blend of in-person seminars and online modules. Graduates are awarded diplomas by ESO and the collaborating university (the University of Ulm, Zurich and della Svizzera italiana, depending on the course); successful completion demonstrates that participants have up-to-date knowledge and skills in offering state-of-the-art diagnostic and treatment, research, and patient care.

The ESMO Examination is a written test with 100 multiple choice questions [23]. The written examination covers all fields of medical oncology, including basic tumour biology, histology, and diagnosis, staging, management, and evaluation of all cancer types. The management of cancer symptoms and of side effects due to antineoplastic therapy is also an integral part of the examination. Passing the ESMO Examination certifies an excellent knowledge in medical oncology according to the ESMO criteria and is the written part of Board Certification in Medical Oncology in Switzerland and Slovenia. In all other countries, the ESMO Examination has no legal standing, as only national authorities can grant physicians the right to practice. It can be sat each year at the time of the ESMO Congress at centres across a wide range of countries and is available in English, French, Spanish, and Slovenian.

The number of oncologists taking the ESMO Examination is increasing each year, with a total of 515 participants in 2021 and more than 700 registered for 2022. Successful candidates are certified for 5 years and can then gain recertification by retaking the ESMO examination or participating in the ESMO Medical Oncologist’s Recertification Approval (MORA), which provides proof of continuing medical education. Recognizing the growing need for more specific certification of professional development in specialized areas of oncology, ESMO members who have passed the ESMO examination at least once can now access the ESMO Certificate of Professional Development in Upper Digestive Tumours [24].

The ESMO Fellowship programme gives young oncologists dedicated time for clinical and laboratory research [25]. Fellowships are available for short-term educational visits lasting a few days through to clinical programmes from 6 weeks to 1 year and research for up to 2 years. More than 600 young oncologists have developed their careers through ESMO Fellowships at leading European cancer research centres over the last 30 years.

A survey carried out in 2021 of oncologists with longer-term ESMO research fellowships (1–2 years) showed that 65% had “non-research” positions at the time of applying; only 40% had research or leadership roles. Following their fellowships, 60% had research or leadership roles. Nearly three-quarters of fellows continued to collaborate with their host institute on research projects, clinical trials, and publications after their fellowship ended.

ESO runs a Clinical Training Centres Fellowship programme as one of its core activities, intending to support young health professionals in developing their careers in cancer care [26]. The programme enables participants to spend 3–6 months at a centre of excellence in Europe, where they are able to sharpen skills in their specialty and expand their experience. ESO currently offers two fellowship programmes: the Doctors Fellowship programme for medical and clinical oncologists and other doctors working in cancer care and the Paediatric Fellowship programme for paediatric oncologists and haematologists.

The annual ESMO Congress, held in the autumn each year, is the opportunity to learn first-hand about the latest developments in the field, including results from phase III trials with practice-changing potential, interact with key opinion leaders, ask questions, and debate burning topics in medical oncology, and explore opportunities for career progression [27]. Participants can attend in person or via an interactive virtual format.

ESMO Congress educational sessions are designed to give up-to-date and evidence-based information across key fields of medical oncology, while the scientific programme provides a forum for researchers in basic and clinical science to present and discuss their findings.

Young Oncologist (YO) Track Sessions at the annual ESMO Congress are specially designed by young oncologists for young oncologists, providing educational sessions that cover topics relevant to daily practice and research activities, and career development. The YO Masterclass features international leaders in medical oncology addressing topical questions in a practical way; at ESMO 2022, the focus was on clinical trial design and development in the 21st century. The YO Forum session explores the research journey, from writing a grant application to building a research team. A Clinical Case Discussion Forum facilitates round table discussion of clinical cases in solid tumours. YO Mentorship sessions enable small groups of young oncologists to meet opinion leaders in specific fields of medical oncology to share their experience and vision, both professionally and personally; the informal setting enables open conversation with mentors and peers.

Other sessions provide opportunities for young oncologists to explore how to start their career abroad and to debate controversial topics in oncology, such as the role of tumour mutational burden as a tumour agnostic biomarker. Medical students and newly qualified physicians have a special session covering the ESMO-ESO Medical Students Course, how to prepare and present your first poster at a congress, and a poster walk to view, discuss, and present selected posters presented at the congress.

Other annual meetings are more dedicated to specific tumour types, including ESMO Breast Cancer; the European Multidisciplinary Congress on Urological Cancers (run by ESMO, the European Society of Radiation Oncology and the European Association of Urology); ESMO Immuno-Oncology Congress; the ESMO World Congress on Gastrointestinal Cancer; ESMO Gynaecological Cancers Congress; ESMO Sarcoma and Rare Cancers Congress; and the European Lung Cancer Congress. There are also regional conferences/educational activities, including the ESMO Asia Congress and the ESMO Summit Africa and Latin America [28].

The European Cancer Summit is organized by the European Cancer Organisation each year to enable wide-ranging discussion on key issues in reducing the burden of cancer and improving patients’ lives [29]. The 2022 Summit focuses on delivery and collaboration.

ESMO Clinical Practice Guidelines and ESMO Consensus Conferences are prepared by leading experts and based on evidence-based medicine to provide medical oncologists and other healthcare professionals with practical recommendations to help deliver the best care to cancer patients [30]. They include information on incidence, diagnosis, staging and risk assessment, treatment and response evaluation, and follow-up. Guidelines are available for a very wide range of specific cancer types, including common cancers such as metastatic breast cancer and non-small-cell lung cancer and rarer cancers, including bone sarcomas and gastrointestinal stromal tumours, as well as cross-sectional issues, such as management of neurotoxicity in patients with cancer, cancer cachexia in adult patients, and care at the end of life. For an improved decision-making regarding the value of anti-cancer therapies, the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is incorporated in the ESMO Clinical Practice Guidelines and is being used as part of Health Technology Assessment (HTA) processes. As such, the ESMO-MCBS is intended to both assist oncologists in explaining the likely benefits of a particular treatment to their patient as well as to aid public health decision makers prioritize therapies for reimbursement.

Further, some European guidelines in medical oncology are developed jointly by relevant professional organizations, such as the Joint EHA-ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-up: Multiple Myeloma (2021) [31].

The European Cancer Organisation develops and publishes Essential Requirements of Quality Cancer Care, which set out organizational specifications to give oncology teams, patients, policymakers, and managers an overview of the elements needed in any healthcare system to provide high-quality care throughout the patient journey [32]. Developed by European specialists representing all disciplines participating in cancer care, these papers provide roadmaps to achieve high-quality multidisciplinary care for a wide range of specific tumour types including pancreatic cancer, lung cancer, prostate cancer, and colorectal cancer.

The portal OncologyPRO provides access to a wide range of online educational resources [33]. These include:

• Oncology meeting resources, such as ESMO annual congresses, ESMO Breast Cancer 2022, and ESMO Gynaecological Cancers Virtual Congress 2022, where ESMO members can access abstracts, e-Posters, slides, and webcasts and congress news from key meetings.

• Courses covering a wide range of topics, including ESMO Preceptorships and ESMO Advanced Courses, designed to educate medical oncologists about the current starts of care. Examples include: ESMO Preceptorship on Breast Cancer; ESMO Advanced Course on Innovation and Emerging Knowledge in Colorectal Cancer; and ESMO Virtual Advanced Course on Clinical Questions in Prostate Cancer.

• ESMO virtual plenaries, monthly presentations of the latest, original scientific data from randomized phase III trials in oncology or remarkable results from phase II studies.

• ESMO E-learning and V-learning modules provide webcasts from leading European medical oncologists giving an update on latest developments and recommendations in a particular field, together with a CME test that confers ESMO MORA points.

• ESMO Guidelines including eUpdates, together with slide sets from guidelines and updates to pocket guidelines.

e-ESO is the online learning platform of the European School of Oncology, offering open access, sponsor-free educational materials for oncologists across the world [34]. It provides four ways to learn online that users can select according to what works best for their own career development:

• e-Sessions – one-off, 45-min educational lectures by leading oncology experts live online, with opportunities for questions and discussion led by an expert discussant. Participants can view recorded video e-Sessions or attend live e-Sessions. There are a wide range of topics, for example: Dermatological toxicity: prevention and management; Cervical screening: primary and secondary prevention; Boost brachytherapy in prostate cancer; and Frontiers in bone marrow transplantation for acute leukaemia.

• Courses – series of online lectures, pre-recorded videos, and panel discussions with oncology specialists covering specific areas, such as: Improving cancer outcomes and leadership course: an ESO, European Cancer Organisation (ECO), Sharing Progress in Cancer Care (SPCC) European initiative; ESO-International Society of Paediatric Oncology (SIOP) Europe masterclass in paediatric oncology; ESO-European Society of Pathology (ESP) digital pathology seminar; and Rare female genital cancers

• Pathways – easy, ready-to-use series of e-Sessions that cover important areas of oncology. Each pathway comprises a series of concise e-Sessions. Topics include: Breast cancer surgery; Gynaecology: cervical cancer; and Paediatric solid tumours.

• Podcasts – series of podcast episodes that oncologists can listen to whenever they want, featuring leading medical professionals answering questions and sharing useful insights in their field.

Participants completing e-Sessions, courses, and pathways are awarded a certificate of participation, CME credits, and College of the European School of Oncology (ESCO) credits.

There is great value in providing educational opportunities in medical oncology that are broader than local and national training, enabling expertise, experience, and knowledge to be shared between medical oncologists from different countries. It is also beneficial to extend the scope of education in medical oncology to include other relevant fields including supportive care and palliative care, recognizing the importance of providing patients with holistic care across the entire patient journey. There is a wealth of high-quality educational and training initiatives available to medical oncologists at all levels across Europe. It is essential to ensure that these opportunities are easily accessible to all as part of providing the best possible cancer care.

We thank Susan Mayor, PhD, for her support in developing and editing this review article.

K.J. reports personal fees as an invited speaker from Amgen, art tempi, Helsinn, Hexal, med update GmbH, MSD, Mundipharma, onkowissen, Riemser, Roche, Shire (Takeda), and Vifor; personal fees for advisory board membership from Amgen, AstraZeneca, BD Solutions, Hexal, Karyopharm, and Voluntis; and royalties from Elsevier and Wolters Kluwer. E.d.A. reports Honoraria and/or advisory board from Roche/GNE, Novartis, SeaGen, Zodiac, Libbs, Pierre Fabre, Lilly, and Astra-Zeneca; travel grants from Roche/GNE and Astra-Zeneca; and research grant to my institution from Roche/GNE, Astra-Zeneca, GSK/Novartis, and Servier. T.A. reports personal honoraria from BMS, CeCaVa, Novartis, and Pierre-Fabre; institutional financial support from iFIT, Neracare, Novartis, Sanofi, and SkylineDX; and institutional research grant from Novartis, outside the submitted work. M.S. reports honoraria for educational or scientific activities from Merck, Bayer, BMS, Roche, and Janssen Phamaceutica. G.C. reports Honoraria for speaker’s engagement: Roche, Seattle Genetics, Novartis, Lilly, Pfizer, Foundation Medicine, NanoString, Samsung, Celltrion, BMS, and MSD; Honoraria for providing consultancy: Roche, Seattle Genetics, and NanoString; Honoraria for participating in Advisory Board: Roche, Lilly, Pfizer, Foundation Medicine, Samsung, Celltrion, and Mylan; Honoraria for writing engagement: Novartis and BMS; Honoraria for participation in Ellipsis Scientific Affairs Group; and Institutional research funding for conducting phase I and II clinical trials: Pfizer, Roche, Novartis, Sanofi, Celgene, Servier, Orion, AstraZeneca, Seattle Genetics, AbbVie, Tesaro, BMS, Merck Serono, Merck Sharp Dome, Janssen-Cilag, Philogen, Bayer, Medivation, and Medimmune.

F.L. reports honoraria for educational activities or scientific advice from Amgen, ArtTempi, Astellas, Astra Zeneca, Bayer, Biontech, BMS, Daiichi Sankyo, Eli Lilly, Elsevier, Falk Foundation, Incyte, Medscape, MedUpdate GmbH, Merck, MSD, Novartis, Roche, Servier, Springer-Nature, and StreamedUp. Institutional research support is granted for his scientific projects from BMS and Gilead.

Funding is not applicable for this review article.

Conception and design: K.J. and F.L. Provision of study materials or patients: n.a. Collection and assembly of data: K.J., E.d.A., T.A., M.S., G.C., and F.L. Data analysis and interpretation: K.J., E.d.A., T.A., M.S., G.C., and F.L. Manuscript writing: K.J., E.d.A., T.A., M.S., G.C., and F.L. Final approval of manuscript: K.J., E.d.A., T.A., M.S., G.C., and F.L.