Any prospective musculoskeletal oncology fellowship applicant must first consider his or her intended career path after a fellowship. At the present time, there are nearly 200 practicing orthopaedic oncologists. If you consider there are fewer than 3,000 new primary bone tumors and approximately 8,000 new soft tissue sarcomas in the United States each year, you will recognize a job practicing full time orthopaedic oncology in the city of your choice may be difficult. This issue needs your full attention: you may be attracted to the field of musculoskeletal oncology because of the intellectual challenges, the rewards taking care of sicker patients or the gratification from tackling difficult surgical cases, but you should also know this may be one of the most arduous and perhaps competitive career paths in orthopaedic surgery.
Because there is a need to train only a few new orthopaedic tumor specialists per year, there are only a handful of accredited programs available. These programs can be scrutinized individually, either by visiting the program, meeting with faculty informally at a national meeting, or through discussions with recent graduates.
I will start from the premise that all accredited fellowships are, at the minimum, of high quality and capable of turning out a well trained surgeon. Still, there are a few distinctions between the programs, more in terms of unique attributes than strengths and weaknesses (though you may of course find a particular attribute more or less appealing).
An ideal fellowship will involve the fellow in the multidisciplinary care of both benign and malignant bone and soft tissue tumors, and the management of metastatic bone disease. A program based at a cancer center is probably more likely to share the soft tissue tumors with general surgeons. On the other hand, such an affiliation is likely to also generate more referrals for the management of meta- static lesions and probably has a more robust cancer biology research program. The choice among fellowship programs, in my opinion, does not hinge on the nature of the base institution.
Most fellowships are one year in length and are adequate for learning the principles of tumor surgery, equipping you with the skills you need to care for patients. Research opportunities vary from program to program and frequently involve both clinical and basic science opportunities. The fields of molecular biology and genetic engineering will bring many exciting advances to the diagnosis and treatment of tumors over the next few decades and should be available at a strong research program. In general, basic science research of any substance will require at least a two-year fellowship. If your desire is to practice clinical medicine and perform clinical research, a two-year fellowship with a year at the bench should probably not be considered.
Clinical training should prepare the trainee for initial patient evaluation, staging principles, and nonoperative and operative treatment alternatives for the entire range of musculoskeletal tumors. Fellowships offering the opportunity to work with a diverse faculty are especially valuable. It is important to look at the provenance of the attendings rather than the pure number: a program with fewer attendings may offer more diversity than one with more, particularly if a larger program is inbred (most orthopaedic oncologists can trace their heritage to one of only a handful of mentors with Drs. Enneking in Florida and Dr. Mankin in Boston chief among them). The more styles of patient care you are exposed to during your training, the more prepared you will be to handle clinical practice on your own.
Many of the patients you will encounter have emotional and psychological needs that must be addressed in a sensitive manner. Learning how to do this well is paramount. It is therefore worthwhile to study your potential mentors, and look beyond their brilliance in the lab or facility in the operating room and ask, “Do I want to be like this doctor?”
Your teachers may have a bias for allografts versus endoprosthetic replacement. This is fine, as long as the program as a whole will teach you both types of replacement, along with techniques using allograft-prosthetic composites, and performing vascularized fibular grafts. Your training will be better at a place where the attendings themselves trained at a variety of programs and perform a variety of techniques.
A comprehensive training program for a budding orthopaedic oncologist demands broad exposure to orthopaedic pathologists, radiation and medical oncologists and radiologists of the highest order. Although you will not be primarily responsible for reading the slides, formulating a radiation therapy treatment plan, mixing a chemotherapeutic cocktail or interpreting the imaging studies, you will do all of these tasks as part of your day to day job. The better you do them, the better orthopedic oncologist you will be. Look for good teachers in these departments as well.
How much time you have during your fellowship to focus on your learning relates to the general “service” structure of the program you choose. In general, on-call responsibilities tend to be more service oriented than educationally oriented, and should also be avoided if possible. One exception to that rule, perhaps, is the opportunity some programs offer to take part in postmortem tissue procurement procedures. This offers further anatomy exposure and a working knowledge of bone banking.
Orthopaedic oncology can be among the most rewarding subspecialties in medicine and there is, accordingly, no great shortage of such practitioners. You may therefore find the process of navigating the career ladder a bit more challenging in this field. The best preparation for your career is a strong fellowship experience. There are not many programs to choose from, so examine each carefully and select the one best matched to your talents and plans.