Until the late 1980s, gastroenterology (GE) was considered a subspecialty of Internal Medicine. Today, GE also incorporates Hepatology. However, Digestive Oncology training is poorly defined in the Hepatogastroenterology (HGE)-curriculum. Therefore, a Digestive Oncology curriculum should be developed and this document might be a starting point for such a curriculum. HGE-specialists are increasingly resisting the paradigm in which they play only a diagnostic and technical role in the management of digestive tumors. We suggest minimum end-points in the standard HGE-curriculum for oncology, and recommend a focus year in the Netherlands for Digestive Oncology in the HGE-curriculum. To produce well-trained digestive oncologists, an advanced Digestive Oncology training program with specific qualifications in Digestive Oncology (2 years) has been developed. The schedule in Belgium includes a period of at least 6 mo to be spent in a medical oncology department. The goal of these programs remains the production of well-trained digestive oncologists. HGE specialists are part of the multidisciplinary oncological teams, and some have been administering chemotherapy in their countries for years. In this article, we provide a road map for the organization of a proper training in Digestive Oncology. We hope that the World Gastroenterology Organisation and other (inter)national societies will support the necessary certifications for this specific training in the HGE-curriculum.

Until the late 1980s, gastroenterology (GE) was considered a subspecialty of Internal Medicine. However, since then, GE has become more complex, in both endoscopy and drug therapy, and the speciality now also incorporates Hepatology. We now train Hepatogastroenterologists (HGE-specialists). It is a challenge to develop a training program that will produce HGE-specialists who are competent in all aspects of HGE by the end of their program[1,2].

In 2002, the Dutch Board for Hepatogastroenterology extended GE training to 4 years, with a Common Internal Medicine Trunk of 2 years[3]. [3]. In the final year of training, a fellow subspecializes, if possible/desirable, in advanced endoscopy, neuromotility, hepatology, or (digestive) oncology. Training in hepatology has been well defined[4,5]. Digestive Oncology training is currently poorly defined[1]. The European Board for Gastroenterology and Hepatology has defined subspecialties in advanced endoscopy, hepatology, clinical nutrition, and, indeed, Digestive Oncology. However, a proper curriculum is lacking (http://www.eubog.org)[6]. The World Gastroenterology Organisation (WGO) formulated a document outlining standards for HGE training[5]. However, again Digestive Oncology was poorly defined. Therefore, a Digestive Oncology curriculum needs to be developed and subjected to regular revision. This document serves as a starting point for such a curriculum.

Today, there are remarkable opportunities for those seeking a career in Digestive Oncology[1,7]. The revolution in molecular biology, advances in interventional endoscopy and anti-cancer therapies, as well as the management of subsequent treatment-related side effects, have permanently changed the way we care for our patients with digestive tumors. HGE-specialists are increasingly resisting the paradigm in which they play only a diagnostic or technical role in the care of digestive tumors. They now perceive the empty space they need to fill with their knowledge. HGE-specialists are pre-eminently competent to organize supportive care around the Digestive Oncology patient. They recognize the caveats in the poor nutritional condition of the patient and are able to immediately take supporting measures that are necessary for completion of the patient’s treatment. This also holds true for situations in which patients experience toxicity induced by different anti-cancer treatments. A new generation seeks to assume this more central role in the multidisciplinary care of our patients. With proper training, we see no reason why future generations of gastroenterologists should be barred from the delivery of anti-cancer therapies, because some might term it “chemotherapy”.

Minimally invasive laparoscopic approaches have been developed for almost all digestive tumors, and image-guided intervention is providing an innovative therapeutic option for early cancers[8]. Modern evidence-based “outcomes research” provides an objective tool for assessing clinical results. Patient-completed questionnaires and standardized assessment of individual preferences have helped us to understand survivorship issues among Digestive Oncology patients, including the long-term effects of treatment on quality of life[9,10].

The HGE-specialist has the immense advantage that he/she has can both recognizing malnutrition or obstructing symptoms threatening the patient’s condition in an early state, can subsequently visualize this endoscopically, and can then take the necessary measures to resolve such devastating situations. Obviously, full insight into the possible treatment plan for this vulnerable patient group is warranted.

Surgical excellence remains critically important in the field of Digestive Oncology. Despite the development of modern anti-cancer drug therapy, (intra-operative) radiotherapy, and the combined use of these treatment modalities, the need for optimal surgery has not been eliminated. Rather, the pre-operative use of such therapies has challenged surgeons to develop the necessary skills to operate on highly pre-treated tumors, whilst simultaneously reducing the burden of surgical morbidity. Similarly induction chemo(radio)therapy for oesophageal and gastric cancers has also expanded the role of surgery, by allowing the resection of some cancers previously considered inoperable[11,12]. Future leaders in Digestive Oncology must be skilled gastroenterologists and surgeons capable of advanced endoscopy, laparoscopic techniques, and image-guided therapy. They must also be scholars, well versed in the nuances of modern diagnostic and staging procedures, fully appreciative of the benefits and limitations of anti-cancer therapy (chemotherapy, immunological, and targeted therapy) and radiation therapy (including chemoradiation).

Comprehensive training also requires exposure to research, either in the basic sciences, translational research, and/or clinical trials. This will prepare future HGE-specialists to explore hypotheses about digestive tumors in an effort to improve patient care.

The European Society of Digestive Oncology (ESDO) was founded in 2008 (http://www.esdo.com). Currently, more and more academic centres are offering fellowships in Digestive Oncology. According to the ESDO membership details, essential requirements of the digestive oncologist include: expertise in multidisciplinary care, the ability to perform and understand the limitations of complex tumor treatments, a clear understanding of the biology and science of digestive tumors, and the ability to collaborate in (translational) research. We suggest that active membership of ESDO should be encouraged for HGE-specialists who devote > 50% of their total professional activity to the field of digestive tumors, who have presented at least one oncology paper in a national meeting, are board certified by the European Board of Gastroenterology and Hepatology (http://www.eubog.org) or the respective equivalent in their country of origin, and have additional oncology experience following formal HGE training. The goal of advanced training in Digestive Oncology is to enhance knowledge and skills beyond the expertise obtained during a normal HGE residency program. The duration of advanced fellowship training might be 24 mo, with a minimum of 12 mo of clinical exposure during the formal 6 years of HGE training (focus year) and 12 mo of formal Digestive Oncology. If applicants have completed research in Digestive Oncology, for example a PhD under the auspices of governing bodies such as ESDO (or equivalent in their country), they might apply to have the 6 mo research requirement waived during their 24 mo of advanced fellowship training in Digestive Oncology: this should be discussed.

All training programs are required to provide a structured educational experience at an advanced level to ensure that trainees acquire the knowledge and skills necessary to gain expertise beyond that acquired in the standard HGE residency[1]. Access to patient care and multidisciplinary team discussions with medical oncologists, radiation oncologists, surgeons, pathologists, and radiologists who have expertise in digestive tumors are an additional requirement for the trainees. Programs must provide structured clinical opportunities for trainees to develop advanced skills in interventional endoscopy. Each fellow on the advanced Digestive Oncology program should be involved in at least 100 major interventional procedures for the treatment of digestive tumors. Additionally, a research component should be discussed with structured supervision for at least 6 mo. If basic science laboratory training is offered, the necessary facilities must be available under the supervision of a trainer who has demonstrated at least a national reputation in research, as evidenced by publications in peer-reviewed journals, and membership of digestive oncological societies. As an example of one of the Dutch HGE-approved fellowships for a focus year in formal HGE training, the following section describes the suggested curriculum for Digestive Oncology.

In the Netherlands, during the last year of HGE training, it is possible to focus on Digestive Oncology[3]. In this year, a minimum of six sessions per week must be spent on oncology-related activities in the context of the focus area. The content of the training within the professional body and the terms for the fellowship have been designed under the auspices of the National Board for Hepato-Gastroenterology.

Risk factors in HGE-cancers; indicators for endoscopy in diagnosis; indicators for endoscopy in staging; indicators for nutritional support; combined modality therapy; role of palliative chemotherapy; chemoprevention; (family) screening; and genetic testing. The Curriculum of the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) described in the Global Core Curriculum for training in Medical Oncology provides the main framework for the training for Digestive Oncology[14].

The goal of the future European HGE-Board fellowship program remains to produce, for the local countries, a framework of well-trained digestive oncologists who will be leaders in academic Digestive Oncology and be qualified to promote improvements in national care to reduce the incidence, morbidity, and mortality of digestive cancer, and improve quality of life[6]. Disease management teams include specific cancer sites (oesophageal, gastric, colorectal cancer (CRC), pancreatic, liver, hepatobiliary, anal, neuroendocrine, and gastrointestinal stroma cell tumors) and comprise surgeons, (digestive) oncologists, radiation oncologists, palliative care physicians, dieticians, pathologists, radiologists, nuclear physicists, clinical geneticists, and laboratory researchers. In case of GI-lymphomas, such management teams should also include hematologists. Working in these disease management teams, fellows have an opportunity to participate in the development of multidisciplinary management plans for patients, as well as the design and pursuit research opportunities, including clinical trials. The role of these teams includes, for example, the enhancement and promotion of CRC-screening, early tumor detection, primary and secondary prevention, and management of pre-malignant or malignant HGE diseases, as well as the translation of research into the clinical setting.

The future program of the European Board’s curriculum should be designed to provide the fellow with a practical knowledge of the most up-to-date diagnostic and therapeutic strategies for digestive tumors[15]. The aim is to develop familiarity with, and stimulate interest in, clinical and laboratory studies designed to advance knowledge in the field. The responsibility for clinical care is shared by the faculty, fellows, residents, medical students, and nurse practitioners. Fellows are directly involved in the management of patients with digestive tumors. The volume and nature of the clinical experience is such that the fellow has an opportunity to participate in the management of patients with all types and stages of digestive tumors.

During the general HGE training, fellows should acquire better theoretical knowledge of the etiology, pathogenesis, natural history, clinical manifestation, work-up, and treatment of digestive tumors[15]. Such knowledge should include nutrition, if necessary pre-operative, during treatment, and for palliative care. Knowledge of logistics, health care economics, and medical ethics seems mandatory[16]. The fellow must have observed, and been responsible for, adequate numbers of patients with digestive tumors, both as inpatients and outpatients. Such patients include those with complications encountered during work-up, surgery, chemotherapy and radiotherapy. They should also include those in need of enteral and parenteral nutritional support, such as nasogastric feeding, PEG-/percutaneous endoscopic jejunostomy (PEJ)-feeding. Close cooperation with a hospital dietician should be part of this.

Clinical experience must be gained in paid positions, obtained by open and transparent competition. Teaching must be an integral part of this Digestive Oncology program. Supervision of clinical work should be defined locally.

The goal of the advanced 24-mo educational program of the European Board of HGE is to provide a broad view of all aspects of digestive tumours, and a familiarity with diagnostic and therapeutic approaches. Rotations in medical oncology for at least 4-8 mo are supplemented by lectures on systemic therapy. In an oncology setting, staff work in the presence of patients with cancer every day. The emotional impact of this work must be recognized, and fellows should be coached on this, not only to appreciate the impact of the cancers on the patients, but also on the impact of oncology care on non-licensed support staff[17].

The description of the end of training competency, learning environment, and the training are as indicated in the Gastroenterology Consensus Document in the Netherlands dated 14 December 2004[1,3].

With relation to oncology, we can quote from the current terms the following passages: (1) General end of training competency: medical aspects: prevention; knowledge of preventative medicine with emphasis on pre-malignant disorders of the digestive tract; and (2) specific syndromes: (a) the specialist is experienced in the area of malignant disorders of the digestive tract; and (b) during the training in HGE there should be sufficient attention and space for the following basic courses: (i) Clinical genetics; and (ii) Clinical epidemiology.

An important part of the workload of HGE-specialists involves oncology. Areas in which the HGE-specialist must have expertise and skills include: (1) prevention, screening and surveillance; (2) diagnosis and staging; (3) endoscopic therapy, both curative and palliative; (4) supportive treatment, for example in relation to nutrition; and (5) diagnosis and treatment of both short-term and long-term complications of oncological therapies, for example radiation damage and drug-induced treatment induced mucositis.

Differences in HGE training between the USA/Europe, India/China and, for example Sub Saharan Africa, are magnified by the obvious resource gaps between Third and First World countries. Redesigning training programs more efficiently would be another goal based on a common trunk system for HGE[18]. India and China, with a common trunk of Internal Medicine for 2-3 years, have incorporated private hospitals into their programs. Well-equipped private hospitals should be used during Digestive Oncology focus years in the East and West. In Eastern Europe, Ministers of Health recently suggested that training for HGE should be reduced to 4 years in total[19]. Arguments about specialist training are getting louder as governments get poorer because the current credit crisis. However, a properly organized scheme for Digestive Oncology is mandatory to give patients the best chance of benefiting from national resources.

In this article, we present the critical elements of multidisciplinary fellowship training for the digestive oncologist, and suggest minimal competencies for the standard HGE-curriculum. Digestive Oncology is substantially under-represented in the undergraduate and postgraduate curricula of present day HGE training programs. Cancer prevention and screening, in particular, have suffered from poor exposure in the past[20,21].

At the present time, the HGE specialist organizes the work-up, endoscopic-intervention of early digestive tumors, nutritional support and palliation of HGE- oncological patients. Interestingly, HGE-tumors are diagnosed by endoscopists often at the tip of their scope. Chemotherapy (neo-adjuvant) should be included based on competence[11,12,22]. HGE-specialists have an essential role in the treatment of complications of digestive cancer and cancer therapy, from the placement of stents to the relief of obstructions and feeding tubes/PEG’s to help anorexia and malnutrition, to the management of radiotherapy-induced bowel disorders. Malnutrition increases complications and reduces tolerance to systemic treatment[23]. The HGE-specialist has a critical role in primary and secondary prevention of digestive tumors. However, just preventing a polyp from becoming a tumor, just making a diagnosis, just staging a tumor by EUS, just making referrals, just treating early complications of the oncologist, radiotherapist or surgeons, just taking care of palliation are unlikely to be “only” roles of HGE-specialists nowadays. It is this idea of expansion of the scope of HGE-units that will necessitate advanced Digestive Oncology training for a minority of HGE-specialists. What about immunotherapy in cancer, such as is performed for IBD? What about chemotherapy, a red line for HGE-specialists? Subspecialization within medical oncology has occurred to provide the required expertise needed to provide optimal patient care. The field of Digestive Oncology is also rapidly evolving. It requires specialized knowledge and skills to appropriately and safely administer various anti-cancer drug agents, with subsequent management of their toxicities. Some HGE-specialists trained as sub-specialists of Internal Medicine already administer chemotherapy in their countries. Maintaining the continuity of patient care is certainly a worthwhile goal.

In our opinion, HGE-specialists with advanced oncology training should be part of the gastrointestinal oncology team and be able to administer anti-cancer therapy in the years to come. In this article we provide a road map to organize this training. The scope and personalization of the HGE-curriculum is our major challenge, and one that will change HGE once again in the coming years. The proper positioning of Digestive Oncology is an important part of this. We hope that the WGO, American Gastroenterology Association, the European Board of Hepatogastroenterology, and other (inter)national societies will organize the necessary certification for this HGE-specialization.