Breast Fellow’s Schedule 2015-2016

The fellow will have a preceptorship format. He/she will spend 4-5weeks at a time with each attending.  During that time the fellow will be totally integrated into the practice of the respective attending at Columbia main campus, East 51st Street Office, and Lawrence Hospital.  The fellow will evaluate, present and discuss plan of management of all new patients with the respective attending. The fellow will also be involved in pre and post-operative care as well as follow-up cases.  The fellow will participate in all offsite clinical activities, and during the attending’s academic time the fellow will focus on research.

The fellow is responsible for running the breast service and the residents assigned to that service. The fellow will be aware of the operative cases performed on the service and supervise the resident to make sure that OR coverage is secured. She/He will follow-up as well as discharge hospitalized patients.  The fellow will evaluate all breast surgery consults, document a note in the chart within 24 hours for elective cases and at the most within 12 hours for emergent cases. All consult cases will be discussed with an attending as soon as feasible. 

The fellow will dedicate time to different subspecialties (Breast Imaging, Pathology, Plastic Surgery, Medical and Radiation Oncology).  In addition, during each attending’s academic day, the fellow will dedicate time to research as well as to sessions with genetics (on Mondays).  There will be a supervising attending during each subspecialty rotation; the respective attending will evaluate the performance of the fellow during that rotation.

During the month of July, the fellow will complete the BESAP question modules.  In addition, the fellow will meet with Dr. Ananthakrishnan for didactic sessions on Monday mornings from 9-10 (after breast conference).  

  • July 1 - 26: Medical Oncology (4 weeks)
  • July 27 - Aug 30th: Dr. Feldman (4 weeks, boards 8/13 ? vacation week)
  • August 31st - Sept 27th: Dr. Taback (4 weeks)
  • September 28th - October 25th: Dr. Ananthakrishnan (4 weeks)
  • October 26th - November 22nd: Dr. Chen (4 weeks)
  • November 23rd - December 20th: Pathology (4 weeks)
  • December 21st - January 17th: Breast Imaging (4 weeks)
  • January 18th - February 21st: Dr. Taback (5 weeks)
  • February 22nd - March 20th: Dr. Chen (4 weeks)
  • March 21st - April 13th: Radiation Oncology (3.5 weeks)
  • April 8th - May 9th: Plastic Surgery (3.5 weeks)
  • May 9th - June 5th: Dr. Ananthakrishnan (4 weeks)
  • June 6st - June 30th: Dr. Feldman (4 weeks)

Total time

  • Breast surgery - 33 weeks
  • Medical Oncology - 4 weeks
  • Plastic Surgery - 3.5 weeks
  • Radiation Oncology - 3.5 weeks
  • Pathology - 4 weeks
  • Breast Imaging - 4 weeks

TOTAL: 52 weeks

SURGERY ATTENDING SCHEDULE:

  • Administrator: TBD
  • Dr. Ananthakrishnan
  • Dr. Chen
  • Dr. Taback
  • Dr. Feldman
Monday
  • Dr. Feldman - Office hours HIP 10
  • Dr. Taback - Lawrence/Academic Day
  • Dr. Ananthakrishnan - Office hours HIP 10
  • Dr. Chen - OR
Tuesday
  • Dr. Feldman - OR
  • Dr. Taback - Office hours HIP 10
  • Dr. Ananthakrishnan - OR
  • Dr. Chen - Office hours/procedures
Wednesday
  • Dr. Feldman - Academic Day
  • Dr. Taback - OR
  • Dr. Ananthakrishnan - Office Hours Lawrence
  • Dr. Chen - Office Hours HIP 10
Thursday
  • Dr. Feldman - OR
  • Dr. Taback - Office hours HIP 10
  • Dr. Ananthakrishnan - OR Lawrence
  • Dr. Chen - OR
Friday
  • Dr. Feldman - New patients HIP 10
  • Dr. Taback - OR
  • Dr. Ananthakrishnan - Academic Day/Office hours Lawrence
  • Dr. Chen - Office hours E 51st Street
  • 1.2.1. Evaluate and manage common benign and malignant breast conditions.
  • 1.2.2. Assess the indications and contraindications for, and demonstrate experience in the performance and interpretation of the results of common in-office procedures, including but not limited to breast sonography (see Radiology), cyst aspiration, bone marrow biopsy, fine needle aspiration, percutaneous core biopsy with and without image guidance, punch biopsy of skin.
  • 1.2.3. Assess the indications for techniques to optimize cosmetic outcome, minimize surgical trauma, and achieve best oncologic outcome for cancer operations for all major breast procedures, including but not limited to breast biopsy, wire localization biopsy, duct excision, lumpectomy, simple mastectomy, and modified radical mastectomy with or without skin sparing, chest wall resection, axillary lymph node dissection, and sentinel lymph node mapping. The surgical breast fellow must demonstrate proficiency in the performance of these procedures.
  • 1.2.4. Demonstrate proficiency in interdisciplinary evaluation and pre-surgical treatment planning with multiple disciplines, including but not limited to radiology, plastic and reconstructive surgery, medical oncology, radiation oncology, medical oncology and pathology.
  • 1.2.5. Identify the indications for and techniques of palliative surgical procedures for locoregional relapse as well as metastatic foci.
  • 1.2.6. Evaluate and manage arm lymphedema as a side effect of breast cancer treatment.
  • 1.2.7. Explain evolving surgical technologies such as percutaneous ablation, core vacuum resection, focused ultrasound, ductal lavage and ductoscopy.

Medical Oncology 

Contact Person: Catherine Crew, Dawn Hershman (212.305.1945)
Location: Irving Cancer Center 10th floor.
The fellow will have to attend a minimum of 15 sessions with Medical Oncologist specializing in Breast Cancer.
The fellow will also participate in the weekly research meetings, Friday morning 8-9 on Garden floor of HIP.  

The fellow will have to learn the:

  1. Chemotherapeutic agents, mechanism of action, delivery, regimen and side effects.
  2. Chemotherapeutic options for adjuvant, neo-adjuvant and metastatic disease.
  3. Hormonal therapy options, methods of action, delivery, regimen and side effects.
  4. Chemo-preventive agents, approved and experimental.
  5. Accrual into clinical trials.  

SSO Objectives for this rotation include:

  • 1.5.1. Assess the indications and contraindications for adjuvant systemic chemotherapy and hormonal therapies.
  • 1.5.2. Describe the mechanism of action; risks, benefits and indications of existing and developing targeted therapies.
  • 1.5.3. Describe the prominent molecular pathways in the development and progression of breast cancer.
  • 1.5.4. Describe the most commonly prescribed chemotherapy and hormonal agents and their associated acute and chronic toxicities.
  • 1.5.5. Identify and manage toxicities of prescribed agents.
  • 1.5.6. Identify indications, techniques and interdisciplinary coordination required for neoadjuvant and "sandwich" chemotherapy.
  • 1.5.7. Demonstrate experience in the interdisciplinary management of recurrent and metastatic disease including palliative care.
  • 1.5.8. Balance the use, benefits, side effects and cost of systemic chemotherapy and hormonal agents in the patient with metastatic disease.
  • 1.5.9. Manage the patient and familial needs for psychosocial support, intervention, hospice, and crisis management.

SCHEDULE:

  • Monday: Dr. Hershman/ Dr. Crew (PM- new patients)
    Didactic session with new fellows
    Research meeting
  • Tuesday: Dr. Crew
  • Wednesday: Dr. Kalinsky
  • Thursday: Dr. Hershman
    Dr. Maurer
  • Friday: Dr. Kalinsky

Plastic Surgery

Contact person Dr Jeffery Asherman (212.305.9612)

  1. The fellow will scrub for one month on all breast related procedures including Reduction, Augmentation and reconstruction.
  2. The fellow will have to be familiar with the different reconstructive options their indication, contra-indications, limitations and side effects. The fellow will attend office hours with plastic surgeons while meeting with patients planned for reconstructive procedures.

SSO Objectives for this rotation include:

  • 1.7.1. Tissue expander, implant, and a variety of flap reconstruction techniques for immediate and delayed reconstruction in the setting of post mastectomy reconstructive surgery.
  • 1.7.2. The onco-plastic techniques of breast conservation.
  • 1.7.3. General breast plastic procedures such as augmentation and reduction as they relate to total management of women with benign and malignant breast disease.
  • 1.7.4. Explain and evaluate the interrelationship of adjuvant therapies on planning and timing of plastic and reconstructive surgery.

Radiation Oncology:

Contact person: Dr Eileen Conolly, phone 212.305.5547

The fellow will have to understand the Radiation therapy mechanism of action, options, methods, indications, contra-indications, planning simulation, delivery and side effects. The fellow will also participate in IORT patient selection, planning, and surgical cases.

SSO Objectives for this rotation include:

  • 1.9.1. Describe the process the patient experiences undergoing radiation therapy to the breast, including: simulation, treatment planning, treatment delivery, and acute and chronic effects of therapy.
  • 1.9.2. Assess the indications and contraindications for and complications of:
  • 1.9.2.1. Post breast conservation radiation therapy in both ductal carcinoma in situ and invasive carcinomas.
  • 1.9.2.2. Post mastectomy radiation therapy.
  • 1.9.2.3. The management of chest wall recurrences.
  • 1.9.2.4. Inclusion or exclusion of supraclavicular or internal mammary fields.
  • 1.9.3. Describe the common DCIS scoring systems and issues pertaining to the use of radiation therapy for DCIS.
  • 1.9.4. Describe and evaluate the considerations in combining systemic and radiation therapy.
  • 1.9.5. Describe and apply interdisciplinary management of recurrent disease.
  • 1.9.6. Identify the indications for and techniques of palliative radiation procedures for locoregional relapse as well as metastatic foci.
  • 1.9.7. Assess the impact of radiation therapy on various surgical options for reconstruction.
  • 1.9.8. Discuss the evolving technologies of more localized radiation techniques.

Surgical Pathology

Contact person Dr Hanina Hibshoosh (212.305.6739) and Dr Diane Hamela- Bena (212.305.0228).
The fellow will have to spend a minimum of 3-4 sessions with each attending and as many sessions in the cutting room to cover all breast surgery specimens.

  1. The fellow will spend time in the cutting room to learn how to process, ink and cut a breast surgery specimen (lumpectomy, mastectomy, sentinel node biopsies, axillary dissections, breast reduction, and implants)
  2. The fellow will review pathology and cytology slides with the respective attending and will familiarize her/himself with diagnosis of benign and malignant breast entities.
  3. The fellow will become familiar with different stains used in breast pathology.

SSO Objectives for this rotation include:

  • 1.6.1. Explain and evaluate the benign and malignant pathological aspects of breast disease.
  • 1.6.2. Understand optimal techniques for marking, processing and assessing the pathology specimen.
  • 1.6.3. Identify special pathology issues pertinent to the treatment of breast cancer.
  • 1.6.4. Explain and evaluate immunohistochemical stains, cytology, and tumor markers and other indicators of prognosis and their relevance to treatment.
  • 1.6.5. Discuss evolving pathology technology.
  • 1.6.6. Stage breast cancer clinically and pathologically.

Breast Imaging

Contact person Dr Ralph Wynn (212.305.0519)
The fellow will have to learn:

  1. The mammography indication, contra-indications and limitations. As well as the mammographic presentation of benign and malignant diseases of the breast and their BIRADS classifications.
  2. MRI, indication, contra-indications and limitations. As well as the MRI presentation of benign and malignant diseases of the breast.
  3. Stereotactic needle biopsies.
  4. Needle localization procedure.
  5. Ultrasound and ultrasound guided procedures.

SSO Objectives for this rotation include:

  • 1.1. Breast Imaging. At the completion of the training period, the fellow should be able to:
  • 1.1.1. Understand the techniques of diagnostic mammography, including the BI-RADS nomenclature, recommendations for additional views, and identify mammographic characteristics of benign and malignant disease.
  • 1.1.2. Demonstrate experience in the performance of breast sonography and distinguish normal breast sonographic anatomy, sonographic characteristics of simple cysts, complex cysts, well-circumscribed probably benign mass, and solid mass of suspicious nature.
  • 1.1.3. Demonstrate experience in performance of image-guided biopsy techniques.
  • 1.1.4. Demonstrate experience in selecting image-guided breast intervention procedures, including but not limited to, ductograms, image-guided (i.e., ultrasound, stereotactic, MRI and others) fine needle aspiration, and core biopsies.
  • 1.1.5. Discuss the evolving breast imaging technologies.
  • 1.1.6. Evaluate the present indications for and possible future applications of MRI in the management of malignant and benign breast disease.
  • 1.1.7. Select, recommend, and interpret the techniques of breast lymphoscintigraphy.
  • 1.1.8. Discuss the complexities, advantages and disadvantages of breast screening trials in women at different age groups.

Genetic Counseling

To be arranged by fellow during the academic day on surgical rotations or on non-surgical rotations on Monday afternoons.
Contact person Ms Donna Russo (212.305.0190).
The fellow will have to interview a minimum of 4 patients with the genetic counselor.
The fellow will have to learn:

  1. Genetic counseling process.
  2. The gene mutations that predispose to breast cancer.
  3. Indications for genetic testing.
  4. New genetic testing options and multiple genes associated with cancer syndromes.
  5. The implication and options for a gene positive and negative patient.

SSO Objectives for this rotation include:

  • 1.4.1. Identify patients at high risk for developing breast cancer, including risk factors such as pathologic, familial, genetic, and previous cancer inducing therapies (i.e., childhood radiation).
  • 1.4.2. Discuss the epidemiological evidence of the effect of environmental factors (broadly defined as nutrition, lifestyle, pollutants, chemicals, social economic status, etc.) on high-risk patients.
  • 1.4.3. Advise patients regarding estimations of risk by contemporary models and risk reduction by screening, medication, and surgery.
  • 1.4.4. Review the available clinical trials for breast cancer risk reduction and facilitate the option of participation in such trials.
  • 1.4.5. Advise patients regarding indications, usefulness, costs, complications and privacy issues of genetic testing.
  • 1.4.6. Take a detailed family pedigree and history.
  • 1.4.7. Interpret the various pathology findings as they influence risk.
  • 1.4.8. Describe and evaluate options for breast conserving therapy in patients suspected of an inherited susceptibility.
  • 1.4.9. Identify resources available for genetic testing and counseling.

Additional Activities

  1. BESAP program
  2. Herbert Irving Cancer Center Annual Retreat
  3. Participate in annual Columbia CME course on breast cancer management (case presentations)
  4. Attend 2 support group meetings a year
  5. Complete web based clinical trials course through NCI/Columbia
  6. Input cases in the SSO case-log system.
  7. Complete at least 2 abstracts for national meetings
  • 1.3.1. Identify and contact local patient advocate organizations, and participate in relevant activities.
  • 1.3.2. Identify ways to provide public service to the community.
  • 1.3.3. Promote the best standard of breast care and screening.
  • 1.10.1. Clinical trials development and patient enrollment.
  • 1.10.2. Prospective and retrospective clinical research.
  • 1.10.3 Enrollment in patients in available national protocols.
  • 1.10.4 The conduct and critical review of research studies.
  • 1.10.5 The preparation of manuscripts suitable for publication in lay or professional journals.

Vacation Time

As an officer of Columbia University, you will receive a total of 23 working days a year of vacation. This will include vacation time as well as any time taken to study for and take boards exams, as well as time to attend national breast conferences. Your days off will need to be approved by Dr. Ananthakrishnan at least one month in advance.