Meeting Unmet Needs By Integrating Hematology/Oncology and Palliative Medicine

As novel therapeutics improve survival rates among patients with advanced cancer, there is also an increased need for oncologists who are trained in palliative care to effectively manage those patients.

However, specialists with that dual specialization are uncommon in the United States, with only 630 such physicians, according to data from the American Society of Clinical Oncology (ASCO).

A factor for the scarcity is the nascence of hospice and palliative medicine—it was formally recognized as a subspeciality only in 2008. Other factors, however, could be related to the emotional, financial, and time burdens involved in dual certification, says Adriana K. Malone, MD, Associate Professor of Medicine (Hematology and Medical Oncology), and of Medical Education at the Icahn School of Medicine at Mount Sinai.

“After all the training they have been through, fellows are ready to start their careers in earnest,” says Dr. Malone, also Director of the Hematology/Medical Oncology Fellowship at the Icahn School and The Tisch Cancer Institute (TCI).

To address the need for dual-certified specialists in oncology and hospice and palliative medicine, the Icahn School and TCI have developed a Combined Hematology/Oncology and Hospice and Palliative Medicine Training pilot project.

The five-year pilot project emerged from efforts by ASCO during the 2022 fellowship match cycle to find ways to create an efficient pathway for dual certification. Four institutions, including the Icahn School, were initially invited to develop an Accreditation Council for Graduate Medical Education (ACGME)-approved fellowship. TCI/the Icahn School accepted its first fellow to its integrated program in 2023, and accepts one fellow per cycle.

The Program at Mount Sinai

Each participating institution has a unique approach to program design.

At the Icahn School, Dr. Malone collaborated with Mollie A. Biewald, MD, Associate Professor of Geriatrics and Palliative Medicine, and Anup S. Bharani, MD, Associate Professor, Geriatrics and Palliative Medicine, on a three-year fellowship that optimizes the training experience.

During the first year, fellows complete the majority of their hospice and palliative medicine certification requirements. This is supplemented by electives in hematology and oncology and continuity clinic responsibilities through an outpatient supportive oncology practice. In the second and third years, the fellow completes certification in hematology and oncology.

“Even before this integrated program, our oncology fellows have long rotated in palliative medicine,” Dr. Malone says. Faculty in both oncology and palliative medicine departments have long championed for an integrated program, which had been vital for fostering this initiative, she added.

“We chose to have the fellow primarily join the palliative medicine program the first year and then orient in the second year with hematology/oncology so they feel fully integrated into each fellowship group,” says Dr. Biewald.

The program ensures exceptional clinical training by exposing fellows to a high volume of cases, both common and complex, in a diverse patient population under the tutelage and mentorship of recognized experts in oncological and palliative medicine.

The fellowship also supports individuals who are interested in careers in research and academia. There are regular presentations from researchers whose work bridges both fields, and each fellow is required to conduct a capstone research project.

“From the moment they start the program, they are speaking with potential research mentors and figuring out how to develop a research project,” Dr. Malone says.

Concretizing a Pilot Into a Formal Program

At the end of the five-year pilot at TCI/the Icahn School , Dr. Malone and her colleagues will assess outcomes and consult with ACGME and ASCO on next steps for establishing a formal dual training fellowship.

The inaugural fellow, Fionnuala Crowley, MBBS, is currently in her second year of training. She co-authored the commentary “American Society of Clinical Oncology guideline update on palliative care for patients with cancer: Addressing the reality gap,” published in Cancer in November 2024. It made recommendations for cancer centers and health care systems to successfully integrate palliative care as part of oncologic care.

“I have skills to care holistically for every patient I meet—skills that I would not have if I did a regular hematology/oncology fellowship,” says Dr. Crowley. “Every patient I see with cancer benefits from these skills and my ability to sit and attend to their suffering.”

As Dr. Crowley progresses in her training, and as TCI/Icahn School welcomes the latest and third fellows of the pilot in July, Dr. Malone and her colleagues are constantly assessing ways to improve the program.

“This is a niche area where there is a lot of need for research and knowledge that spans both fields,” Dr. Malone says. “By providing integrated training, we can equip fellows to enter this specialized field and propel it forward.”