HCA Fellowship to Peter MacCallum Cancer Institue, Melbourne, Justin Yeung, Colorectal Fellow Feb 2009-2010, BMed Sci, BMBS, FRCS (Gen Surg), DM
Introduction
I would like to thank the trustees for the award of the HCA traveling fellowship which allowed me to visit the Peter MacCallum Cancer Institute in Melbourne, Australia. This helped improve my experience within the field of minimal invasive colorectal surgery and the management of complex colorectal cancers.
Preparation
The organization for this fellowship started following a meeting with the Peter MacCallum colorectal surgeons, Professor Jack MacKay, Associate Professor Alexander (Sandy) Heriot and Mr Craig Lynch at the Tripartite Coloproctology meeting in Boston, USA in 2008. As I was the first overseas colorectal fellow to that unit, I was extremely grateful to the help that Ms Lynn Oreili, Administrative Manager at the Peter MacCallum provided me. This was with the Australian Medical Council and the Australian Immigration department registration as well as with helping us find accommodation prior to arriving in Melbourne.
I am also very grateful to my wife Jo who took a career break as she joined me in Australia providing me with support for the whole year.
Daily Life
It can be difficult to find the right accommodation prior to arriving in Australia, especially when Melbourne is such a large city and the suburbs can be unfamiliar. We were fortunate enough to find a traditional two bedroom property in Hawthorn, a very popular suburb in Melbourne. It meant that we could move straight in when we first arrived. The house was only ten minutes from the local train station and the local shops. After a 15 minute train ride, I would be at Parliament Station which was only a five minute walk from the Peter MacCallum Hospital. Everything was so easily available in Melbourne. Restaurants served good quality and multiethnic foods; coffee drinking was almost as important as wine appreciation and outdoor activities were plentiful throughout the year.
The Australian Health system and Peter MacCallum Cancer Centre
The health system is very similar to the UK, with large cities like Melbourne being served by several tertiary hospitals, whilst rural communities were served by either smaller hospitals or GP run medical centres. The Peter MacCallum Cancer centre, affectionally known as the "Peter Mac", was the quaternary cancer referral centre for regional and also interstate hospitals. It was a surprise to me when I learnt that patients could travel up to 4 hours by car to come to the Peter Mac for a follow-up clinic appointment. The hospital therefore provided a great temporary housing facility which offered these patients a "home away from home" when they were having treatments such as chemotherapy.
Only sixty years old, Peter Mac has quickly become Australia's foremost integrated cancer centre, providing quality treatment and support to both patients and their families. The colorectal unit pioneered the multidisciplinary management of locally advanced and recurrent colorectal cancers and has continued to promote the culture of collaboration and collegiate network between clinical practice and laboratory research in both Melbourne and Australia. There are approximately 400 researchers in key research programs including Cancer Cell Biology, Cancer Immunology, Cancer Genomics, Growth Control and Differentiation, Molecular Imaging and Translational Medicine and Cancer Therapeutics. In addition to a very large tissue and tumour bank, the Peter Mac is also a hive of cancer clinical trial activity, and a centre of continuing medical education.
The PeterMac Colorectal Unit
I really enjoyed my year with the colorectal team as they had a wealth of experience, following training in many centres including Australia, New Zealand, USA and the UK.
The team also consisted of two residents (equivalent to a FY2), a registrar (ST3 level), two specialist nurses (Ms Meg Rogers and Mrs Claire Scott), as well as a stomal therapist (Ms Carolyn Atkin). The Peter Mac has a well equipped ITU/HDU as well as a dedicated surgical ward, Ward 3. I found that the nurses were well trained and therefore had a greater autonomy in the treatment of patients. The ward also had its own dedicated specialist social worker, pharmacist, OT, physiotherapist and dietician. This meant that they were well familiar with patients' conditions and could predict discharge requirements supporting patients to return home as soon as possible. There was a weekly Wednesday morning meeting that was attended by all disciplines including medical and nursing staff, bed coordinators, and managers where all the upcoming cases for the next 10 days were discussed. This helped with the planning of resources and personnel as well as highlighting any potential problems. The pre-admission and anaesthetic clinics lead by Dr David Skewes, Dr Hilmy Ismail and Dr Adrian Hall also provided an excellent service. Cardiopulmonary exercise testing (CPX) was commonly used as one of the anaesthetic work up investigations that all complex colorectal patients preparing for surgery had, identifying those who required further medical workup or nutrition prior to surgery. The Peter Mac had five operating theatres, of which theatre 1 which was ideal for training and performing laparoscopic colorectal surgery with the help the Karl Storz OR1 equipment. In addition, there was video linkage to our conference room where we held regular laparoscopic training days for colorectal consultants from different regions.
Surgical Expereince
There was a large range of surgical pathology that was treated at the Peter Mac. In addition to primary colonic, rectal and anal cancers, we were often referred patients who had locally advanced cancers, recurrent cancers, or those with rarer cancers including pseudomyxoma peritoneii.
I was involved with over 120 cases and 150 colonoscopies during my fellowship including total pelvic exenterations, intra operative radiotherapy and TRAM flap formation for advanced rectal cancers, as well as the debulking of pseudomyxoma peritoneii and instillation of intra-abdominal chemotherapy. The training provided in Melbourne was excellent. Although I was the Primary surgeon in most cases, there was always a Consultant Surgeon assisting me during the procedure. I also had good training in therapeutic endoscopy and laparoscopic resection of colorectal cancers. Finally, I had the opportunity to see the first few robotic rectal cancer resections to be done in Australia.
Other Experiences
The Peter Mac also had strengths in family history screening. Every week, I had the opportunity to join the multidisciplinary family history clinics and helped with counseling and management of these conditions. The diagnostic imaging department was also an excellent source of help as they provided MRI, CT, interventional treatment as well as PET. All patients with rectal cancers had a CT, MRI and PET performed as part of their staging investigations.
Teaching
I thoroughly enjoy teaching and therefore I used my opportunity in Australia to teach a large variety of allied medical personnel. I helped give lectures to the ward, ITU and theatre nurses as well as helped with the training of junior doctors. As I was an ATLS instructor, I therefore taught on the Australian equivalent course, the EMST, in Sydney as well.
Research
There was a strong track record for research at the Peter Mac and therefore I got involved in several projects including research into the use of PET on stratifying the prognosis of patients with locally advanced rectal cancer following neoadjuvant therapy, and the identification of incidental colonic hot spots picked up on PET scan.
Conclusion
Would I recommend this experience?:- I certainly would. I had a great opportunity to learn a lot of new techniques that I have now brought back to the UK. I have also met a lot of people who have become very close friends. If you ever get a similar opportunity, I would strongly recommend that you take it!
Teaching Courses
- Colorectal Cancer - A Multidisciplinary Approach, Melbourne
- ATLS (EMST Australasian Royal College of Surgeons), Sydney
- Laparoscopic Colorectal Surgery course, Peter MacCallum, Melbourne
Meetings
2009 Australian Medical and Surgical Gastroenterology Meeting, Sydney
Published Research Papers
- Preoperative Staging of Rectal Cancer
Yeung JM, Ferris NJ, Lynch AC, Heriot AG.
Future Oncol. 2009; 5: 1295-306. review
Pending Articles
- Review of the use of intra operative radiotherapy in colorectal cancer (Accepted Article).
- Genetically inherited colorectal cancers.
- PET prediction of prognosis for patients with locally advanced rectal cancer following neoadjuvant chemoradiotherapy and surgery.
Invited Oral Presentations
- 2010 American Society of Colon and Rectal Surgeons, USA PET prediction of prognosis in locally advanced rectal cancers following neoadjuvant chemoradiotherapy.
- 2010 Association of Coloproctology of Great Britain and Ireland, UK Do incidental PET-CT colonic hot spots correspond to significant pathology?