Careers in Hematology:
Hematology-Oncology: Do Two Halves Make a Whole?
Reed E. Drews, M.D.
Dr. Drews is Associate Professor of Medicine at Harvard Medical
School and Program Director of the Hematology-Oncology Fellowship at Beth
Israel Deaconess Medical Center.
Several years ago, a colleague, trained solely in hematology and now
working primarily in the laboratory exploring vascular biology, argued that
training in hematology should link not to
oncology, but instead - if joined
with any other discipline at all - to endocrinology with its study of
hormones akin to hematopoietic growth factors. Recalling academic hematology
programs that seemingly withered in the face of burgeoning oncology
programs, I fully understood my colleague's concerns regarding the historic
linkage between hematology and oncology training. Indeed, despite dual
training, many graduates of combined hematology-oncology fellowships focus
exclusively on oncology, leaving most aspects of hematology practice behind.
With time, such attending physicians become increasingly uncomfortable
addressing hematologic concerns, and attending physicians who are willing
and able to cover both arenas (e.g., on a combined hematology-oncology
in-patient consult service) are vanishing. So why not train only in oncology
Hematology training alone is defensible: for instance, hematologists need
not know how to diagnose and treat colon cancer. However, I believe that
oncology without hematology is incomplete. The two worlds intersect at so
many levels that to practice oncology without a solid foundation in
hematology is less than whole. Not only do the two disciplines meld in
understanding the biology of renegade neoplastic cells in leukemias,
lymphomas, and solid tumors, but also they converge in diagnosing and
managing a host of "benign" hematologic conditions that can accompany or
complicate these malignancies. Examples of such combined clinical scenarios
include: microangiopathic hemolytic anemia accompanying gastric carcinoma or
mitomycin-C therapy; underproduction anemia resulting from myelosuppressive
chemotherapies; disseminated intravascular coagulation accompanying solid
tumors, acute promyelocytic leukemia, or infectious complications of
chemotherapy-induced neutropenia; acquired factor VIII inhibitors associated
with lymphomas or solid tumors; and heparin-induced thrombocytopenia
accompanying heparin therapy of Trousseau's syndrome.
Therefore, oncologists should develop skills in diagnosing and managing
hematologic conditions that often coexist with or complicate solid tumor
care. Thus, coupling oncology with hematology training makes sense: perhaps
we should call it "oncology-hematology" rather than "hematology-oncology."
Adding some training in transfusion medicine would further bolster clinical
The challenge for combined hematology-oncology training programs today is
to produce graduates who, with an admitted bias toward treating malignancies
either hematologic or oncologic, are equally adept at handling the full
range of "benign" red cell, white cell, platelet, and coagulation
abnormalities in their patients. With a burgeoning base of knowledge in both
disciplines, the question now is: can we accomplish the curricular needs of
combined hematology-oncology clinical and research fellowship training in
three years, or should this be expanded to four years? The answer to this
question may depend on the specific design of the training program - perhaps
something to discuss in a future issue of "Careers in Hematology."