Clinical and Didactic Program

Developing a well-trained surgical specialist in the care of patients with benign or malignant disease mandates an interdisciplinary approach. This fellowship is designed to encourage the trainee to participate in decision-making throughout the entire interdisciplinary spectrum of the patient’s care. This necessitates a coordinated plan of many disciplines to provide didactic as well as practical, clinical educational experience. Advanced training in breast disease is accomplished by the efforts of the following disciplines:

Breast Imaging

Training in breast imaging is under the direction of Barbara S. Monsees, MD, professor of radiology in the Division of Diagnostic Radiology, and chief of breast imaging at Washington University School of Medicine and the Joanne Knight Breast Center. The fellow will spend the equivalent of one month participating in the activities of breast imaging. The fellow will gain experience in reading and interpreting screening mammograms. However, the majority of time will be spent reading diagnostic mammograms; assisting with subsequent imaging including breast ultrasound; and observing and assisting with stereotactic and ultrasound-guided core biopsy, under the direction of the radiology attending staff. Indications, benefits and limitations of the various imaging modalities will be emphasized. Throughout the year, the fellow will be expected to read and interpret imaging studies on patients seen in the Breast Center and confirm those results with the radiologist.

The fellow will spend time and gain in-depth knowledge about the role and utility of magnetic resonance imaging (MRI) of the breast, including a familiarity with the sensitivity and specificity of MRI scanning of the breast. The fellow is expected to learn indications for breast MRI, as well as its limitations, and should develop basic skills in the assessment of MRI results, and be able to recommend appropriate follow-up studies or procedures.

During the year, the fellow will attend the monthly Radiology Journal Club and present at least one time during this Journal Club. The fellow also will attend the weekly Radiology Conference to discuss recent cases, concordance of biopsy results and other topics.

The fellow will be expected to gain basic and advanced training in breast ultrasound. This will be achieved by attending courses offered by the American College of Surgeons (ACS) or the American Society of Breast Surgeons (ASBS). The fellow will receive a certificate of completion from any two of the following courses:

  • Ultrasound for Surgeons (ACS)
  • Advanced Ultrasound for Breast Surgeons (ASBS)
  • Breast Ultrasound Certification (ASBS)

These courses provide both didactic and practical education on the basic physics of breast ultrasound and allow the fellow to train in the clinical application of breast ultrasound using live models and phantom breast moulages. The American College of Surgeons and the American Society of Breast Surgeons provide a certificate at the completion of each course.

Surgery

The surgical training of the fellow will encompass both the outpatient evaluation and management of patients with benign or malignant breast disease. More than 7,500 patients are seen annually at the Joanne Knight Breast Health Center of Barnes-Jewish Hospital and Washington University School of Medicine. Although care of the breast cancer patient will be the primary focus of this program, fellows also will be trained in the evaluation and management of patients with benign problems.

High-Risk Program: The high-risk program at Washington University School of Medicine is overseen by Julie A. Margenthaler, MD, of the Department of Surgery, and Cynthia Ma, MD, of the Department of Internal Medicine, Medical Oncology. The fellow will work with both of these individuals in the clinical evaluation, risk assessment and management of these patients, and recommendation of appropriate patients for chemoprevention trials. The fellow will develop expertise in various methods of evaluating women at high risk for developing breast cancer and the indications, limitations and interpretation of these methods. Experience in intraductal procedures (office and operative) will be included under the direction of Dr. Margenthaler.

Surgical Clinical and Operative Experience: The fellow will spend two days a week for six months in the Breast Center working with all of the breast surgeons. He or she will perform complex and detailed histories and physical exams and present these to the attending surgeon along with an assessment, recommendations for treatment, and if appropriate, plan for operation. The fellow will then participate in the immediate preoperative evaluation and preparation and immediate postoperative care of patients with benign and malignant disease. Operative experience will include, but not be limited to:

  • Excision of benign breast lesions
  • Ductoscopy
  • Needle localization with excisional biopsy
  • Wide local excision of malignant lesions
  • Simple mastectomy
  • Modified radical mastectomy
  • Sentinel lymph node biopsy
  • Axillary dissection
  • Performance of oncoplastic flap procedures

The fellow also will spend time gaining operative experience in the various methods of breast reconstruction under the direction of Keith Brandt, MD.

Pathology

Training in pathology is under the direction of D. Craig Allred, MD, professor of pathology, and Jon Ritter, MD, associate professor of pathology. The fellow will choose appropriate surgical cases in which he or she has been involved in the operation and follow the processing and interpretation of the specimen pathology. This experience should be varied and will include benign, atypical and malignant pathology. The fellow will keep a log of this experience, including slides, for documentation and eventual educational purposes.

Medical Oncology

Education in medical oncology is under the direction of Matthew J. Ellis, MD, professor of medicine and head of the Section of Medical Oncology, Washington University School of Medicine. The fellow also will spend time with Michael J. Naughton, MD, assistant professor of medicine, and Cynthia Ma, MD, assistant professor of medicine, in the Section of Medical Oncology, learning the evaluation and management of patients with breast cancer. Training will focus on the treatment of the patient with newly diagnosed breast cancer, although the fellow also will gain experience in the management of patients previously diagnosed with breast cancer. In an effort to provide education emphasizing a truly interdisciplinary approach, the fellow will accompany patients diagnosed with breast cancer to their subsequent medical oncology appointments. This experience will include patients who are expected to receive neoadjuvant as well as adjuvant therapy, and the fellow will learn the current recommended chemotherapeutic protocols, alternative regimens, expected benefits and sequelae. There will be an emphasis on appropriate selection and enrollment in clinical trials.

The fellow will participate in the weekly Protocol Review Conference (Tuesday, 7:30-8:15 a.m.), where ongoing protocols are reviewed and ideas for initiating new clinical trials are discussed.

Radiation Oncology

Education in radiation oncology is under the direction of Dennis E. Hallahan, MD, professor and chairman of Radiation Oncology at Washington University School of Medicine, and includes the expertise of Marie Taylor, MD, assistant professor of radiation oncology, and Imran Zoberi, MD, assistant professor of radiation oncology. The fellow will follow patients diagnosed with breast cancer through the radiation therapy treatment. He or she will arrange to be present for the initial evaluation, subsequent simulation and the patient’s weekly evaluation by the radiation oncology faculty member. Experience with whole breast radiation is under the primary direction of Dr. Taylor, and with partial breast radiation under the primary direction of Dr. Zoberi. Education in partial breast radiation will include observing and assisting with the operative and/or ultrasound placement of brachycatheters. The fellow also will gain experience with partial breast radiation using the Mammosite technique. In addition, the fellow will follow patients referred for accelerated partial breast radiation protocol.

Completion of the Radiation Oncology Safety Course is mandatory. This course is offered by Washington University School of Medicine and can be completed online. Successful completion and passing of the examination results in a certificate.

Nuclear Medicine

Experience in nuclear medicine – essential to advanced training in the management of breast disease – is under the direction of Barry Siegel, MD, professor of radiology and medicine, and chief of the Division of Nuclear Medicine. Henry Royal, MD, professor of radiology and associate director of the Division of Nuclear Medicine, will assist in training the fellow. The fellow will obtain basic knowledge in the technique and physics of nuclear medicine as they pertain to patients with breast cancer. The fellow will follow at least five to 10 patients diagnosed with breast cancer who are designated to have lymphoscintigraphy performed for sentinel lymph node biopsy, through the radiation therapy process. The fellow will demonstrate sophisticated knowledge in the isotopes used, dosage, injection techniques, complications and interpretation of subsequent scanning of the breast and axilla. Isotope injection will be performed under the direction of the nuclear medicine faculty. Indications, interpretation and limitations of PET/CT scanning will be essential knowledge for the fellow, and be reinforced by meeting with the faculty to discuss PET scans performed on designated patients. The fellow will be responsible for the reading material and for demonstrating an understanding of this information to faculty.

Genetics

Clinical genetics services are provided under the direction of Alison Whelan, MD, professor of medicine and assistant professor of pediatrics, and include the expertise of Jennifer Ivanovich, MS, genetic counselor. The fellow will spend eight weeks attending the Genetics Clinic (Tuesday afternoon from 1–5:30 p.m.), where patients with hereditary disease are evaluated and counseled. The fellow will demonstrate proficiency in taking a detailed family history and assist in the overall assessment and discussion with patients referred to Genetics Clinic. The trainee will demonstrate to the faculty sophisticated understanding of the role of genetic counseling, appropriate indications for recommending genetic testing, basic interpretation of genetic testing results and subsequent recommendations. Ethical implications and conduct surrounding genetic counseling and testing will be emphasized. The fellow will be thoroughly familiar with current documents related to genetic evaluation of patients, including the Society of Surgical Oncology Statement on Genetic Testing, authored by V. Suzanne Klimberg, MD, and recommended reading from the genetics curriculum.