Discipline Training Strategy
STRATEGY 1:
A state-of-the-art post graduate training and experience in the multi-modality approach towards work-up and treatment of breast cancer and benign breast disease.
The fellow will evaluate the patients in the clinic (dedicated benign breast clinics, cancer clinics, and survivorship clinics), be involved in the work up and diagnosis, participate in the dedicated weekly “Breast Tumor Board” visit once the diagnosis of cancer is established, operate under supervision (including reconstructive procedures), assess pathology and address postoperative issues along with adjuvant treatment with chemotherapy / hormonal therapy / radiation and psycho-social issues. This program emphasizes seeing through the entire care of a given patient to instill the concept of interdisciplinary communication, accountability and continuity of care. To provide the comprehensive experience for fellows, the program leverages the relationship with the South West Cancer Center (SWCC), which is the most comprehensive cancer program in West Texas through intimate collaboration between TTUHSC main campus in Lubbock and the University Medical Center (UMC).
Following is the outline of training provided by each discipline in the integrated program. Fidelity to the true interdisciplinary nature of breast cancer is maintained by structured clinical experience that is measured in half days throughout the year rather than disjointed rotations (40 half days = 1mo). All operative and non-operative experience is logged in SSO log system and is evaluated every quarter with the program director.
Breast Imaging
The overall training in breast radiology is approximately 48 weeks (1/2 per every week) [1.2 month] during the fellowship year. This encompass half a day at the dedicated breast imaging facility every week under supervision of a dedicated breast radiologist. This design of rotation provides a comprehensive exposure to all aspects of breast imaging including but not limited to mammography, sonography, magnetic resonance, and interventions such as image guided biopsy. This design is made specifically to provide continuity of care experience and interdisciplinary approach, whereby the fellows will be able follow their patients to the final outcome of work up including concordance or discordance assessment and pathology. This opportunity to experience “closing the loop” of care is unlikely to come from a fragmented rotation through one discipline at a time. The fellow is involved in evaluating mammograms, assessing the need for further imaging studies and biopsies. He / she attends structured didactic sessions that emphasize the basic and advance imaging and biopsy (indications and techniques) and also focus on emerging technologies. This approach is combined with case studies. The fellow reads approximately 1000 mammograms and perform at least 30 image guided biopsies (ultrasound and stereotactic) during a year under supervision of a breast radiologist. He / She presents all biopsy cases at the concordance meeting and assesses the indication for further surgery.
Diagnostic and interventional breast ultrasound is one of the key components of training. The fellow is offered to attend the courses “Basic Ultrasound for Surgeons” and “Advance Breast Ultrasound” offered by the American College of Surgeons and the American Society of Breast Surgeons. He / She performs diagnostic (at least 100) and interventional (at least 50) ultrasounds in the office setting; also at least 30 ultrasound guided procedures in the operating room. This structure focuses on preparing the fellow to obtain ultrasound certification within first year of practice.
The fellow is involved in decisions regarding MRI and evaluates these images under supervision of the Breast Radiologist. There is an emphasis on correlating MRI findings with mammograms, ultrasounds and eventually pathology.
Surgical Training
The surgical training takes place at the TTUHSC main campus at Lubbock Department of Surgery and comprises of 3 half days of clinic and 2 half days of operating time (240 weeks) [6 months]. The BCE is a standalone center at SWCC led by the Breast Surgical Oncologist at TTUHSC. The center offers a dedicated team of oncology certified clinical nurses, research personnel, nurse navigators, community outreach coordinators and patient educators. The TTUHSC-Lubbock Department of Surgery also offers a residency training programs; typically interns (year-1) residents rotate on breast service. Clearly, the objectives of year 1 resident objectives do not conflict with those of the fellow. As fellows progress through the rotation, they are able to take the interns through basic procedures under faculty supervision. The resident’s objectives help fellows to take the junior trainee through simple procedures. The fellows are involved in teaching the third year medical students that rotate on the service. The clinics are dedicated as: (i) Risk assessment and prevention program (RAPP), (ii) New cancer clinics, (iii) Benign breast clinics, and (iv) Survivorship clinics. All new cancer patients are evaluated by the surgical oncologist, medical oncologist, and radiation oncologist; Genetics and Plastics surgery appointments are made on case by case basis. The fellow is expected to follow all new patients with each specialty and be actively involved in the integration of care. All new patients are presented by the fellow at the breast tumor board; the fellow will document the discussion and plan of care.
In the operating room the fellow benefits from the experience of 2 dedicated breast surgeons. Fellows learn how to perform partial mastectomies with intraoperative ultrasound guidance; wire localization is used as needed. They also learn oncoplastic closure techniques, complete mastectomies (simple, nipple sparing), sentinel lymph node procedures, axillary node dissections as well as reconstructions under supervision (a total of at least 150 procedures). All surgical procedures performed by the fellow will be documented (SSO operative log). Level of supervision is modified according to achieved proficiency that is evaluated every quarter. Fellows are expected to follow at least 30 patients in the Comprehensive rehabilitation programs that address shoulder range of motion and prevention and management of lymphedema.
Medical Oncology Training
The overall training in medical oncology is approximately 48 weeks (1/2 per every week) [1.2 month] during the fellowship year. This encompasses half a day at the dedicated breast oncology clinic every week under supervision of a medical oncologist. This experience offers evaluation of new cancer patients, on treatment follow up, survivors, and palliative care. Proficiency is accomplished by participation in the decision-making process regarding neoadjuvant versus adjuvant therapies, the role of tumor biology as evaluated through immunohistochemistry or molecular profiling for individualized care. At the end of the training, the fellow is expected to comfortably discuss the interpretation of metastatic work-up, choice of hormonal and chemotherapy, side-effect profile of various agents in clinical use and management of complications.
Radiation Oncology Training
The overall training in medical oncology is approximately 48 weeks (1/2 per every week) [1.2 month] during the fellowship year. This encompasses half a day at the radiation oncology clinic every week under supervision of a dedicated radiation oncologist. This experience offers training of selection process for whole breast irradiation, partial breast irradiation, use of 3D conformal technique and decision-making no adjuvant radiation. The fellow is involved in interdisciplinary evaluation and treatment planning of new cancer patients under supervision of the radiation oncologists. Fellows are expected to participate in discussion on indication and techniques- of radiation therapy. The fellows get first-hand experience of CT Simulation / Treatment Planning for whole and partial breast irradiation during a formal dedicated time slot in Radiation Oncology. At the end of training, the fellow is expected to be able to discuss the indications, planning and complications of radiation and their management.
Pathology
The overall training in pathology is approximately 48 weeks (1/2 per every week) [1.2 month] during the fellowship year. This encompasses half a day at the pathology lab every week under supervision of a dedicated breast pathologist. This lab time is strategically designed to allow for grossing of specimens in real-time from the prior week’s surgical schedule. The fellow orients the specimens with paints in the operating room and takes the fresh specimen to pathology for identification of tissue for banking. The dedicated half day in the pathology department offers formal slide review of all cytology and histopathology specimens of new cancer and other biopsies. The fellows receive formal training in gross and histopathological evaluation of breast disease. Dedicated breast pathologists are a part of breast tumor board where the fellow is able to discuss the microscopic appearance of various patterns of malignancy with the rest of the team. The fellows are expected to be able to assess the margins of resection under supervision of a pathologist. By the end of training, the fellows are expected to understand the role of core biopsies, cytology, tissue banking, importance and limitations of intra-operative reporting (touch preps and frozen sections) and the impact of final pathology on treatment and follow up.
Genetics
The medical and surgical oncology rotations cover the genetic exposure for breast fellows. The High Risks clinic runs in very close proximity to the surgical and medical oncology clinics. Fellows are involved in identifying high risk patients from both these clinics and are able to follow the counseling and genetic work up of these patients. Moreover, the SWCC women’s oncology area that houses the breast program also houses the gynecologic oncologic program. Fellows are able to follow these patients with the gynecologic oncologist as well for completion of management plan. The gynecologic oncologist also regularly attends the breast tumor board and the valuable input provides additional learning experience for fellows. The fellows are expected to learn the formulation of genetic risk based on the family tree know the NCCN guidelines for testing and identify the relevance of newer panel tests offered.
Psychosocial Training
Texas Tech University has program psychosocial distress screening and management; the graduate students from the program are available for counseling during multidisciplinary cancer clinic. All new patients undergo distress screening and counselors are involved at a threshold of score set forth by the program. Fellows are actively involved in majority of new patient assessment in the multidisciplinary clinics and gain experience in screening and counseling for distressed patients.
Community Outreach
TTUHSC/SWCC – BCE has a robust outreach program with a specific outreach coordinator hired by the center. The center works very closely with the Komen Foundation - Lubbock Area Affiliate, and the American Cancer Society to provide community outreach. The center offers after-hours screenings for working women and is currently engaged in exploring development of a grass root organization in the Lubbock Area for advocacy and education. Fellow provides educational sessions for the lay public outreach events and health fairs.