A Cancer Education Framework for Australian Medical Schools: an Announcement of a New Educational Program

This framework draws upon national and international cancer curricula to identify the essential cancer-related learning outcomes for Australian medical students. The framework incorporates feedback from medical, radiation and surgical oncologists, haematologists, and palliative care physicians on what medical graduates need to know about cancer. The consensus view was that medical students require a basic understanding of the principles of cancer management and the opportunity to see cancer patients in a cancer service unit. The framework assumes that certain knowledge, skills, and attitudes are already embedded in current Australian medical school curricula, presenting instead only the core cancer content in order to provide a clear and concise framework designed to maximise integration within existing curricula. Supplementary Information The online version contains supplementary material available at 10.1007/s13187-022-02173-9.


Introduction
This framework has been designed to assist medical schools to incorporate important components of cancer education into an existing medical curriculum. The framework aims to provide a minimal set of clinical experiences and learning outcomes, which if resourced, will provide Australian medical students with a basic understanding of the knowledge and principles underpinning current cancer management.

Background
The impact of cancer on the Australian population and health care system cannot be overstated. Currently, half of all Australians will be diagnosed with a cancer by the age of 85 (1,2). Whilst cancer is the leading cause of death in Australia, more than two-thirds of patients are alive five years after their diagnosis (3). Consequentially, there are more Australians living with cancer, placing an incredible demand on the health system (4).
Several studies have shown that Australian medical students are ill-prepared to care for cancer patients upon graduation (5)(6)(7)(8). Additionally, medical students and junior doctors themselves have highlighted shortcomings in their own cancer education (8)(9)(10)(11)(12). The lack of a national medical curriculum results in individual medical schools with considerable diversity in teaching and clinical exposure (5,13). As such, no minimum requirements for cancer education exist in Australia. At a national level, an ideal oncology curriculum (14,15) and a palliative care curriculum have been developed (16). To date, it is unclear as to the level of uptake of either curricula within Australian medical schools (8,10). There remains a lack of consensus on what content to include in a cancer curriculum (17,18) and how best to deliver such a curriculum (19). In panel sessions conducted with Australian cancer clinicians reviewing the Ideal Oncology Curriculum for Medical Schools (15), it was agreed that medical students require a fundamental understanding of the principles of cancer management, coupled with exposure to cancer patients in cancer service units, in order to observe patient care in the clinical setting. Similarly, there was agreement that medical students do not require specialist knowledge, such as drug or radiotherapy dosages. These findings are consistent with those presented in both national and international literature (20)(21)(22)(23)(24)(25).

A Simplistic Approach
The acquisition of the basic principles of cancer management has provided the basis for the development of the Cancer Education Framework for Australian Medical Schools.
Once the salient points of management were identified, the necessary knowledge required to underpin these points were identified and incorporated into the framework. Knowledge that would be expected in all Australian medical schools (such as the cell cycle, concepts of incidence and mortality and evidence-based practice) have not been included in the framework. The rationale here is to keep the framework as simple as possible to optimise its utility and adoption by Australian medical schools. The learning objectives presented in the framework are by no means exhaustive but rather provide a minimal blueprint from which to build a basic cancer curriculum within an existing medical school curriculum. The framework draws heavily from the Cancer Council Australia's Ideal Oncology Curriculum for Medical Schools (15), and the aforementioned review by cancer clinicians (26). Other curricula used in the development of this framework include the Palliative Care Curriculum for Undergraduates (16)

and the International Summer School 'Oncology for Medical
Students' curriculum (25).

International Applicability
Cancer is a global concern and a review of the framework by cancer clinicians and general practitioners from Europe and North America highlighted the applicability of the framework to international medical school curricula. The local context section of the framework could easily be modified to incorporate the incidence and mortality, and cancer disparities, specific to the country in which the medical school is situated. This could be further modified to address any additional regional issues as required.

The Framework
The framework is comprised of three sections: one focusing on clinical exposure to cancer patients and clinical cancer service units, whilst the other two focus on the principles of cancer management and cancer-specific knowledge: Clinical Exposure

General Principles of Cancer Management
Upon graduation, students should be able to:  Discuss the difference between treatment approaches with curative and palliative intent  Outline the principles of multidisciplinary management  Discuss how tumour and patient factors influence the way in which patients are managed  Describe the role of neo-adjuvant and adjuvant therapy  Outline the roles of locoregional and systemic therapy  Outline organ-sparing approaches  List common oncological emergencies and outline how these are managed  Discuss the principles of symptom control  Discuss the role of clinical practice guidelines  Discuss the role of clinical trials

Principles of Surgery
Upon graduation, students should be able to:  Outline the aim of cancer surgery  Describe the importance of adequate surgical margins  Discuss general preoperative factors  Identify common complications of cancer surgery and how these can be managed  Discuss the risks of tumour spill  Describe the role of surgery in tumour staging

Principles of Radiation Oncology
Upon graduation, students should be able to:  Outline the aim of radiotherapy  Discuss indications for radiotherapy  Describe the cellular response to radiotherapy  Identify the various methods used to deliver radiotherapy  Discuss why radiotherapy is delivered using fractionated doses  Identify common side effects of radiotherapy and how they are managed

Principles of Medical Oncology
Upon graduation, students should be able to:  Outline the role of medical oncology  Discuss indications for systemic therapies  Describe the method of action of systemic agents (i.e. chemotherapy, targeted and hormonal therapies and immunotherapies)  Identify common side effects of systemic therapy and how they are managed

Principles of Palliative Care
Upon graduation, students should be able to:  Outline the role of palliative care  Discuss common end of life issues  Discuss the provision of palliative care in various settings  Discuss the role of other modalities in the palliative setting  Identify commonly used procedures to relieve symptoms  Outline the role of the GP in providing palliative care

Local context
Upon graduation, students should be able to:  Identify the most commonly occurring cancers in men and women in Australia  Identify the leading causes of cancer death in men and women in Australia  Outline the differences in cancer outcomes between Indigenous 1 and nonindigenous Australians  Outline the differences in cancer outcomes between urban and rural Australians

Cancer prevention
Upon graduation, students should be able to:  Describe methods of primary and secondary prevention  Differentiate between population-based screening and surveillance  Discuss the scientific evidence to support population-based methods of screening for cancer  Identify risk factors for common cancers

Cancer biology
Upon graduation, students should be able to:  Outline the concept of carcinogenesis  Describe dysplasia, carcinoma in situ, invasive cancer  Describe tumour types  Identify important familial cancer syndromes  Discuss hormonal influences and tumour markers for common cancers  Describe patterns of spread of common cancers  Describe recurrence patterns of common cancers 1 In Australia Aboriginal and Torres Strait Islander people are acknowledged as the original inhabitants. No disrespect is intended to the Aboriginal and Torres Strait Islander peoples through the use of the internationally used term Indigenous.

Diagnostic process
Upon graduation, students should be able to:  Outline the necessity of a histopathological diagnosis  Discuss staging and grading of tumours  Describe the prognostic implications of differentiation  Identify potential cancer presentations  Describe the physical signs of cancer  Discuss commonly used diagnostic investigations

Patient-centred care
Upon graduation, students should be able to:  Discuss the importance of involving patients in the decision making process  Identify factors that influence patient choices  Outline the impact of bad news on the patient's ability to process information  Discuss the psychological impact of screening and diagnostic tests  Consider the patient's own social context and how a cancer diagnosis will affect the patient, their family and carers  Discuss the role of cancer support groups  Outline the role of health professionals in survivorship care  Identify reliable and accurate sources of information for patients

Resources
There are a number of resources that can be used to underpin the learning objectives presented in the framework, which relate to cancer-specific knowledge and the principles of cancer management. In many instances, medical schools will already have suitable resources, or will wish to create their own. Some schools may wish to incorporate external resources or simply provide the framework to students as an extracurricular learning opportunity. Given that the five essential cancer clinical experiences represent experiential learning, these will require resourcing by the school. To assist schools and students in addressing the learning outcomes comprising the knowledge components of the framework, some suggested resources are included below.
It should be noted that none of these resources are exactly matched to the learning outcomes in the framework. In many cases, they cover content at a greater depth than required, or extend beyond the scope of the framework. However, these resources provide a good starting point and are freely available on the Internet, making them accessible to all schools and students.

Ideal Oncology Curriculum for Medical Schools (IOC) was published by Cancer Council
Australia (CCA) and used as the basis for the development of the Cancer Education