Rotation Specific Goals & Objectives: University Health Network-Princess Margaret Hospital/ Sunnybrook Breast/Melanoma

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1 Rotation Specific Goals & Objectives: University Health Network-Princess Margaret Hospital/ Sunnybrook Breast/Melanoma Medical Expert: Breast Rotation Specific Competencies/Objectives 1.0 Medical History and Physical Examination 1.1 Effectively perform a breast specific patient assessment and consultation including breast history and physical examination 1.2 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) 1.3 Advise patients regarding estimations of risk reduction by screening, medication, and surgery. 2.0 Diagnostic Test Knowledge 2.1 Demonstrate an understanding of the techniques of diagnostic mammography, including the BI-RADS nomenclature, recommendations for additional views, and identifying mammographic characteristics of benign and malignant disease and breast and axillary ultrasound. 2.2 Evaluate the indications for breast MRI in the management of malignant and benign breast disease. 2.3 Select appropriate 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

2 2.4 Discuss the complexities, advantages and disadvantages of breast screening trials in women at different age groups. 3.0 Clinical Diagnosis and Decision Making (analyzes and integrates relevant data) 3.1 Explain and evaluate the benign and malignant pathological aspects of breast disease. 3.2 Understand pathological marking and assessment of breast specimens, including immuno-histochemical stains, cytology, tumor markers, and other indicators of prognosis and their relevance to treatment. 3.3 Stage breast cancer clinically and pathologically. 3.4 Analyze and integrate relevant data to formulate diagnoses and therapeutic strategies (lumpectomy vs mastectomy, extent of nodal dissections) including referrals to genetics team, medical and radiation oncologists, plastic surgeons (breast reconstruction), and psychology when appropriate 3.5 Assess the indications and contraindications for adjuvant systemic chemotherapy, biologic therapies and hormonal therapies in the neo-adjuvant and adjuvant setting. 3.6 Describe the process the patient experiences undergoing radiation therapy to the breast and axilla, including: simulation, treatment planning, treatment delivery, and acute and chronic effects of therapy. 3.7 Assess the indications and contraindications of post breast conservation radiation therapy in both ductal carcinoma in situ and invasive carcinomas, post mastectomy radiation therapy, the management of chest wall recurrences and the inclusion or exclusion or supraclavicular or internal mammary fields and palliative radiation treatment. 3.8 Recognize changing needs for social support systems for patients and their families 2 throughout diagnosis, treatment, and transition to surveillance, and relapse.

3 3.9 Demonstrate an understanding of the role and technical procedures of reconstruction, including tissue expander, implant, and other flap reconstruction techniques for immediate and delayed reconstruction in the setting of post mastectomy reconstructive surgery Demonstrate an understanding of how general breast plastic procedures such as augmentation and reduction relate to total management of women with benign and malignant breast disease Explain and evaluate the interrelationship of adjuvant therapies on planning and timing of plastic and reconstructive surgery Demonstrate proficiency in performing general surgery oncology aspects of a combined case with the plastic reconstructive surgeons (e.g. skin sparing mastectomy) 4.0 Demonstrate proficiency in pre-operative and post operative patient management 4.1 Evaluate and assess patients for suitability for an operative procedure 4.2 Evaluate and manage post op management issues, including wound healing, acute and chronic pain, psychosocial issues and lymphedema 5.0 Recognize urgent situations and intervene quickly and effectively 5.1 Recognize and treat intra-operative and post-operative bleeding 5.2 Recognize anaphylactic reactions to the blue dye from sentinel node mapping 6.0 Technical and Procedural Skills Proficiency 6.1 Assess the indications and contraindications for, and demonstrate proficiency in the performance and interpretation of the results of common in-office procedures, including cyst aspiration, fine needle aspiration, percutaneous core biopsy with and 3 without image guidance, punch biopsy of skin, and nipple biopsy.

4 6.2 Demonstrate proficiency in performing techniques to optimize cosmetic outcome, minimize surgical trauma, and achieve the 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, skin sparing mastectomy, modified radical mastectomy with or without reconstruction, axillary lymph node dissection, and sentinel lymph node mapping. 6.3 Explain evolving surgical technologies such as percutaneous ablation, core vacuum resection, focused ultrasound, ductal lavage and ductoscopy. Melanoma Rotation Specific Competencies/Objectives 1.0 Medical History and Physical Examination 1.1 Effectively perform a melanoma specific patient assessment and consultation including melanoma history and physical examination 2.0 Diagnostic Test Knowledge 2.1 Demonstrate knowledge of when to complete imaging for patients with melanoma, including indication for Ultrasound screening/monitoring, CT scan, MRI and PET scan 2.2 Assess the indications and contraindications for, and demonstrate proficiency in the performance and interpretation of the results of common in-office procedures, including excisional biopsy of skin lesions, fine needle aspiration of palpable lymph node. 4

5 3.0 Clinical Diagnosis and Decision Making 3.1 Analyze and integrate relevant data to formulate diagnoses and therapeutic strategies, including referrals to genetics team, medical and radiation oncologists, plastic surgeons, psychosocial supports when appropriate 3.2 Assess the indications and contraindications for adjuvant systemic therapy for melanoma (neo-adjuvant and post surgery) 3.3 Identify the indications for and techniques of radiation procedures for adjuvant therapy locoregional relapse as well as metastatic foci. 3.4 Identify special pathology issues pertinent to the treatment of melanoma, including molecular markers BRAF, NRAS, CKIT. 3.5 Stage melanoma clinically and pathologically. 4.0 Demonstrate proficiency in pre-operative and post-operative patient management 4.1 Evaluate and manage arm and leg lymphedema as a side effect of melanoma treatment. 5.0 Technical and Procedural Skill Proficiency 5.1 Demonstrate proficiency in performing techniques to optimize cosmetic outcome, minimize surgical trauma, and achieve best oncologic outcome for cancer operations for all skin excisions, including but not limited to wide local excision, local advancement and rotation flaps, sentinel node mapping, axillary dissection (levels I, II, III) and inguinal node dissection (superficial and deep). 5.2 Demonstrate proficiency in DCPC cream application and IL2 injections for intransit metastases 5

6 Communicator: 1.1 Provide clear and thorough explanation of diagnosis, investigation and management in a professional manner and obtain informed consent, providing appropriate therapeutic risk/benefit information for surgical patients and their families 1.2 Deliver bad news in a compassionate and sensitive manner that takes into account the patient s special psychological and social needs. 1.3 Recognize cultural diversity and the different needs for patients and their families with regard to illness and treatment. 1.4 Communicate effectively (timely, concisely and accurately) with physicians (plastic surgeons, medical oncology, radiation oncology, family physicians, referring doctors etc,) in written and oral forms and other health care providers (nurses, genetics) Collaborator: 1.1 Consult and collaborate effectively with other physicians and health care professionals in the multidisciplinary cancer care team (including general surgeons, plastic surgeons, medical and radiation oncologists, nursing staff, social workers and physiotherapists). 1.2 Contribute effectively to other interdisciplinary team activities, including patient review working rounds. 6

7 Manager: 1.1 Utilize resources effectively to balance patient care, learning needs, and outside activities 1.2 Allocate finite health care resources wisely. Health Advocate: 1.1 Demonstrate knowledge of primary and secondary prevention of diseases and advise appropriate interventions, including weight loss, alcohol use, smoking and sunscreen use and use of tanning beds and promote breast cancer and skin screening 1.2 Identify and refer patients to advocacy and supportive organizations Scholar : 1.1 Critically appraise relevant current literature on the surgical management of breast cancer and melanoma. Professional: 1.1 Demonstrate a commitment to excellence to patients, families and their profession in clinical care and personal ethical conduct. 7

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