PROGRAM DESCRIPTION

Overview: Sinai Health System, Sunnybrook Health Sciences Centre and the University Health Network (Toronto General Hospital, Toronto Western Hospital, Princess Margaret Cancer Centre and Toronto Rehabilitation Institute) are teaching hospitals within the University of Toronto health sciences complex. Over the past 15 years, the Department of Otolaryngology—Head & Neck Surgery at the University of Toronto has developed a highly integrated multidisciplinary Head and Neck Fellowship Program incorporating these three campuses. The Toronto Western Hospital, where neurosurgical expertise is concentrated serves as the main site for surgery involving the skull base.

This program is recognized internationally for patient care, research, and education, principally involving the disciplines of radiation, medical and surgical oncology; the program interfaces with medical imaging, pathology, dentistry, speech, nutrition, nursing, social work, psychiatry, and research scientists.

The program provides well-balanced exposure to all areas including skull base surgery, microvascular surgery, endocrine surgery, and innovative head and neck research. The Division of Head and Neck Oncology and Reconstructive Surgery oversees the Fellowship Progroam. Dr Jeremy Freeman is the Fellowship Director.  The Director of Research is Dr. John de Almeida with areas of research focus in health services research (Lead: Tony Eskander), outcomes research (Lead:  David Goldstein), quality and safety (Lead:  Eric Monteiro), clinical trials (Lead: Doug Chepeha) and skull base (Lead:  Allan Vescan).  The Fellowship Education program is overseen by Dr. Jeremy Freeman with Dr. Jonathan Irish as the Division Head and Drs. Kevin Higgins and Doug Chepeha providing oversight on the fellowship education curriculum (journal clubs, monthly education evenings and special topic lectures).

Head and neck cancer services in the Province of Ontario provide services to 15.5 million people.  There are 8 head and neck centres in the province. Three of the 8 centres in the Province are within the University of Toronto program.  From a clinical care perspective the 3 head and neck centres under the University of Toronto umbrella are large volume centres by any measure.

The Princess Margaret Cancer Centre at the University Health Network is the largest regional program in Canada with 7 full time head and neck surgical oncologists (Drs. Patrick Gullane, Ralph Gilbert, Dale Brown, Jonathan Irish, Douglas Chepeha, David Goldstein and John de Almeida).  The Princess Margaret Head and Neck Program provides a complete spectrum of head and neck services including endocrine, microvascular surgery and minimally invasive approaches including robotic surgery.  The program has a strong multidisciplinary translational research program, with four core labs focused on different aspects of head and neck oncology.

Mount Sinai Hospital (MSH) is part of Sinai Health System and has a strong collaborative program with Princess Margaret with multidisciplinary clinics, collaborative research and collaborative clinical care.  MSH continues to offer tertiary/quaternary head and neck services with an internationally acclaimed program in endocrine oncology initiated by Dr Jeremy Freeman. Drs. Witterick, Vescan, de Almeida and Monteiro provide ablative and reconstructive head and neck surgery and in collaboration with the UHN neurosurgery group, provide a world-class program in MIS skull base surgery at MSH and Toronto Western Hospital. MSH has an active and productive molecular oncology program in endocrine and oral cancer.

The Sunnybrook/Odette Site offers tertiary/quaternary Head and Neck Oncology Services including endocrine, advanced ablative head and neck surgery and microvascular surgery.  The group at Sunnybrook has a major presence in the Odette multidisciplinary Skin Malignancy Site Group. Dr. Kevin Higgins is the site chair for Head and Neck at Sunnybrook. The group continues to collaborate with the UHN group and has an active research program in molecular imaging and outcomes research.  Dr. Tony Eskander has a strong health services research program and is a faculty member with Institute for Clinical Evaluative Sciences. Dr. Danny Enepekides is the Head of Surgical Oncology at the Odette Cancer Centre at Sunnybrook, one of the leading departments in the country.

The University of Toronto Fellowship program volumes provide a significant experience in the entire breadth of head and neck surgical oncology and reconstruction.  The Division volumes include:  >350 free microvascular free flaps (Sunnybrook, UHN), >300 regional flaps flaps (all sites), >250 oral cancer surgical procedures (all sites), >400 skull base procedures (all sites), >800 thyroidectomies (all sites).

The fellow is exposed to a large volume of head and neck related cases; the experience is tailored to the desires and ultimate career goals of the fellow. The fellow is expected to integrate with residents in the teaching program and act as mentor to them.

Fellows are given incremental responsibility according to performance. Supervision is available at all times.  Fellows are not required to manage patients outside the scope of head and neck oncology or related diagnoses.

The didactic academic program is strong and formalized with a large number of teaching rounds, tumor boards, continuing medical education events, courses, and visiting professorships.  In addition, Drs. Kevin Higgins and Doug Chepeha provide oversight to the curriculum with monthly fellowship rounds, 5 journal clubs, 4 special topic lectures and social events.

Objectives

1. To train a well rounded head and neck oncological surgeon versed in patient care, teaching skills, and research appreciation in the arena of head and neck oncology.
2. To train the fellow in the technical aspects of ablation, reconstruction and endocrine surgical skills according to the current concepts in all of these disciplines
3. To teach the fellow the multidisciplinary aspects of management of the head and neck oncological patient including radiation oncology, medical oncology, immunotherapy and current experimental clinical trials.
4. To imbue the fellow with the highest core values and ethical behavior in his/her interaction with patients, colleagues, medical personnel, students and administrative co-workers.

Strengths:

1. High volume of large case mix of head and neck oncological patients
2. Acknowledged experts and teachers with world class reputation
3. High level of clinical and surgical responsibility with supervision
4. Intense formalized education program
5. Endowments that allow attendance at various local, national and international meetings
6. Availability of basic science and clinical research opportunities
7. The large program comprising 6 clinical fellows and one research fellow allows for a level of wonderful camaraderie and establishment of lifelong friendships

Eligibility: AHNS Advanced Training Council fellowships are available to all candidates who have completed ACGME accredited Otolaryngology, General Surgery or Plastic Surgery residency programs and whom are currently board eligible in those specialties. Any successful graduate of a Canadian Otolaryngology, General Surgery, Plastic Surgery.

Fellows’ Duties/Responsibilities: The program broadly encompasses a wide variety of neoplastic head and neck diagnoses. The major subsites include all head and neck mucosal malignancies. Other subsites include salivary glands, thyroid, complex head and neck skin malignancies, and head and neck sarcoma that are managed by the head and neck surgical group in collaboration with the respective radiation oncology and medical oncology site group members. During the one or two-year fellowship program, the clinical rotations include the University Health Network (UHN), Mount Sinai Hospital, or Sunnybrook. There are four fellowship positions available per year.

The duties of the Head and Neck Oncology Fellow are as follows within the respective institutions:

1. Participate in outpatient clinics pertaining to the head and neck.
2. Participate in surgical procedures pertaining to the head and neck.
3. The “core teaching curriculum” requires that a topic be researched monthly within the Head and Neck Program.
4. Completion of at least three clinical-oriented research projects that results in peer-reviewed publications. Opportunity is available for basic science projects. Support is available for presentation of the fellow’s work at scholarly meetings.
5. Attend weekly interdisciplinary Tumor Board Rounds at The University Health Network, Mount Sinai Hospital or Sunnybrook.
6. Present at least one Grand Rounds per year related to the Head and Neck Program and participate at all Tumor Board related rounds at The University Health Network, Mount Sinai Hospital or Sunnybrook.
7. Prepare a topic for the fellows’ monthly Education Seminar that takes place on the first Monday of each month.

Research Opportunities: Research in basic science and clinical studies is available. The fellow is expected to participate in at least 3 projects per year of fellowship and to publish results hopefully after presentation at an accredited meeting. Support funding for the projects and travel is available.

Supervision, Teaching & Call:

• All clinical and research activities are strictly supervised.
• The fellow is variously responsible for teaching medical students and post graduates in the outpatients, operating room, emergency room and on clinical rounds.
• On call varies among the campuses. This is no more than one night in three; there is always a resident on first call and staff to back up the fellow.

PAST FELLOWS

Of the fellows who have successfully completed this fellowship program, over 80% of them have pursued academic careers and a significant number are department chairs.