Breast Oncology Fellowship Lubbock

TTUHSC/SWCC-BCE offers a one-year multidisciplinary breast fellowship that encompasses training in areas of research, clinical acumen and scholarly aptitude. The ability to understand advances in basic breast cancer biology (basic research), application of observations in the field (translational research), complex nature of clinical trial design and analysis, the rapid advance of technologies and the incumbent psycho-social milieu, emphasizes the complex nature of training a breast specialist. Physicians must be trained in a multi-modality fashion, developing knowledge of benign and malignant breast diseases. This training involves epidemiology, genetics screening / detection, imaging, behavioral, medical, surgical, pathological, radiation oncology, clinical trial design, statistics and analysis. Following is the broad yearlong schema of structured training and weekly schedule of activities to achieve the desired competence.

*Once a month

Environment Specific to Proposed Fellowship

The TTUHSC/SWCC in Lubbock offers a comprehensive Breast Center of Excellence that enjoys enormous support from the university and the hospital senior leadership. This has led to the recruitment expertise from all disciplines with a specific focus on academics and scholarship. The SWCC has a vision to target NCI designation; this has put academic programs at the fore front. The clinical practice has a robust multidisciplinary service that works in a cohesive fashion within the women’s oncology area of the SWCC. The BCE is a structured program which is accredited by the National Accreditation Program for Breast Centers. To provide comprehensive women’s healthcare training including reproductive endocrinology exposure for young women with breast cancer and long-term health concerns of survivors, the program works closely with the gynecologic oncology service. This provides an ideal opportunity for a fellow to work directly with the faculty members in a multidisciplinary fashion and get first-hand training. Fellows get the opportunity to take year 1 residents through cases both in clinics and in the operating room. Third year medical students rotate through the breast service and have a vastly different set of objectives that does not conflict with the fellow’s objective and provides an excellent venue for teaching and mentoring skills for the fellow. 

Office of Graduate Medical Education

The Texas Tech University Health Sciences Center serves approximately the western half of the state. Core to the mission is developing high quality health care professionals via the schools of Allied Health, Medicine, Nursing and Pharmacy and the Graduate School of Biomedical Sciences. The Health Sciences Center holds a strong commitment to Graduate Medical Education. The School of Medicine hosts 34 residency and fellowship programs with approximately 500 physicians-in-training on campuses in Lubbock, Amarillo, Permian Basin, and El Paso. 

The goal of medical education (residency training) is to become certified by the American Board of Medical Specialties (ABMS) to practice in a medical specialty. The Texas Tech residency programs including the programs that are not currently under the accreditation by the ACGME, are developed in the context of the Physician General Competencies as expressed by the ABMS and the ACGME.  These are:

• Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
• Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
• Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
• Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
• Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

The Texas Tech University Health Sciences Center is a rich and diverse group of physicians, scientists, professionals and support people who share the common goal of learning, caring and healing.

Rationale for Breast Fellowship Program at TTUHSC/SWCC – Breast Center of Excellence

Breast cancer is a nation-wide problem that has been addressed with several educational and research projects, including 32 fellowship programs. However, the National Cancer Institute data presented in December of 2007 revealed that about half of the breast cancers are still being diagnosed with excisional biopsies – not a standard of care. This reflects a need for ongoing emphasis on educational programs and sub-specialty training. 

In Texas, approximately 15,400 breast cancers are diagnosed every year, with a cause-specific mortality of about 2,580. West Texas is a unique region in terms of discrepancies in healthcare delivery systems, geographic distances, and socially isolated populations. This requires unique innovative approaches to provide state-of-the-care. The Texas Tech University Health Sciences Center – Breast Center of Excellence serves, on an annual basis, approximately 1,500 new breast clinic patients and performs 5,000 screening mammograms and treats 350 breast cancers, we believe that this is an ideal set-up for a subspecialty training fellowship in breast disease in the West Texas region. This program is designed specifically to addresses the challenges in West Texas; hence it provides a great training opportunity that exemplifies program building with creative approaches to maximize impact. Geographically, the closest breast fellowship program is 346 miles from Lubbock – a clear indication that wealth of learning resourced in West Texas remains untapped. 

Lubbock and the surrounding area have already established itself as a hub for commerce, technology development and higher education. Providing access to comprehensive healthcare is also a part of this growth and the unique research / outreach role that Texas Tech University Health Sciences Center – Breast Center of Excellence plays is one of the primary reasons that establishing an accredited interdisciplinary fellowship in breast surgical oncology in the Texas Panhandle would be beneficial.  

In terms of clinical services, complete breast screening and diagnostic services are provided within the TTUHSC/SWCC - BCE complement including digital screening and diagnostic mammography, breast ultrasound, image-guided breast biopsies, ductography, whole and partial breast irradiation, oncoplastic surgery and reconstructions and chemotherapy with a full complement of psycho-social and palliative care. 

There are dedicated clinics for cancer risk assessment and prevention, multidisciplinary cancer care planning, and survivorship clinics that provide focused training on each aspect of breast care. This will provide an enormous experience to a growing physician and aspiring instructor with a career focused on breast disease. 

The TTUHSC-BCE is accredited by the national Accreditation Program for Breast Centers (NAPBC) and is diligently engaged in maintenance of 27 quality standards set forth by the NAPBC. The fellow will have a unique opportunity to learn program building and maintenance in difficult circumstances by being a part of this process.

The research program is multi-directional. The center has a prospective database for cancer tracking which will provides an excellent tool for clinical outcomes research. This entails a fulltime data manager position committed to maintaining quality of this tool and generation of reports. The University also provides support for local and national grants for specific projects via the Clinical Research Unit. The database provides a quality assurance measure for our center feedback. The center also partners with the Jerry H. Hodge School of Pharmacy faculty for advancement of translational research. This entails a monthly translational meeting to discuss lab-based projects and clinical questions to come up with translational proposals for future grants. We also report on results of our training modules for the community to assess their reproducibility.

Over the last eighteen months, this program has generated the following research endeavors:

• Women Inspiring, Serving and Educating (WISE) woman program preliminary results of an educational intervention. 34th Annual Symposium. April 2010.
• The Effect of Paget’s Disease on Survival in Breast Cancer. 63rd Annual Cancer Symposium. March 2010. St. Louis MO, USA
• Prevalence of Psychiatric Diagnoses in Breast Cancer patients. 32nd San Antonio International Breast Cancer Symposium. December 2009. San Antonio, TX, USA.
• FACT-B analysis: Quality of life after breast cancer how can we improve survivorship? Submitted to ASCO for October 2010 meeting, New York, NY
• Breast Cancer Staging with Magnetic Resonance for Treatment Planning (B-SMART trial):  funded by Laura W. Bush Institute of Women’s Health - 50 patients enrolled thus far
• In each of the above-listed projects, third year medical students were mentored through scientific and ethical conduct of the research project.

Current Research

WISE Woman Survey
Researchers: Rakhshanda Layeequr-Rahman, MD

Survivorship Program Specific to the Needs of a Particular Population
Researchers: Rakhshanda Layeequr-Rahman, MD

CIS - revamped plan with presentations at Grand Rounds, etc.
Researchers: Rakhshanda Layeequr-Rahman, MD

STRATEGY 1-Discipline Training Strategy:

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.

STRATEGY 2-Academic and Scholarly Activities:

A platform for academic and scholarly activities at TTUHSC / SWCC - Breast Center of Excellence (BCE) – A nationally accredited facility for pursuance of excellent individualized patient care. 

The fellow is positioned in an extremely academic environment with committed mentors in all fields of breast cancer management. Specific academic forums are available to enhance and dissipate the knowledge on the subject. 

Journal Club

The fellow presents articles on recent advances in breast cancer every month at the multidisciplinary tumor board on Thursday. There is a specific document developed by the TTUHSC – Office of Faculty Development to assist in critical appraisal of literature.  The fellow and attendees have access to this document to compile their thoughts; however, fellow is expected to lead the journal club with faculty supervisors. The emphasis is on critical analysis of data for practicability of application in the available setting. 

National Breast Conferences

The fellow will attends at least 2 conferences every year; the annual meeting of the American Society of Breast Surgeons, and the “ SSO Fellows Institute” that is specially designed for fellows. Attendance to other conferences is dependent upon acceptance of abstracts.  The program emphasizes at least 2 abstract submissions every year to national / regional conferences. 

Didactic Series for the practice of Breast Subspecialty

A specific 16 hour didactic series is developed to cover topics from multiple disciplines pertaining to the specialty of breast disease. These topics are presented as hour-long by expert faculty within the disciplines every 3 weeks. Breast Fellows is expected to attend all sessions.

STRATEGY 3-Research Environment

A vibrant environment for basic, clinical and translational research pertaining to breast cancer. 

TTUHSC has designed a course on research methodology that is presented by the office of faculty development. The fellows have access to these resources including the “Clinical Research Institute”. These resources are available on-line and cover Epidemiology, Biostatistics, Basic and Translational Methods, IRB procedures and Grant writing. The fellow will be required to take the Human Subject Protection course and pass test to be certified within the first week of fellowship. 

TTUHSC has an exciting program on clinical and translational research with several labs and expert mentors focusing on breast cancer risk and metastatic potential and drug development. The fellow will have a unique opportunity to participate in these projects. Whereas it is not possible to complete a prospective study in one year along with all the other objectives; these venues provide a unique opportunity to learn methodologies such as banking, cell cultures, and other techniques. These are not mandatory requirements for all fellows. The BCE maintains prospective database on demographics and clinical outcomes of all breast cancer patients by a dedicated research nurse who actively participates in all tumor boards and research protocols to maintain integrity and accuracy of all data. This provides an opportunity to the fellow for clinical outcomes research. The center maintains accreditation with the National Accreditation Program, which requires yearly quality improvement studies – fellow is expected to be involved in at least one of the 2 quality Improvement studies. We expect at least 2 abstract submissions every year by the fellow to major national/regional meetings.

By the end of fellowship training the fellow is expected to have at least 1 accepted publications.