Curriculum

• 5 months of breast surgery
• 1 month of oncoplastic and reconstructive surgery
• 1 month of radiology
• 1 month of medical oncology
• 1 month of radiation oncology
• 2 weeks of pathology
• 2 weeks of genetics
• 2 weeks of lymphedema
• 2 weeks of high risk

The John A. Ingold multidisciplinary breast surgical oncology and oncoplastic surgery fellowship is designed to educate and train physicians in the multidisciplinary management of breast disease. The purpose of the year-long program is to develop highly competent, inquisitive, responsible, and compassionate breast surgeons. The training curriculum has been constructed to provide the fellow with the skills necessary for success in any type of practice that he or she pursues upon completion of the program.

The educational goals of each individual discipline are integrated and reinforced throughout the year through the fellow’s participation in the bi-weekly Multidisciplinary Clinic, weekly Breast Tumor Board conference, and monthly Breast Journal Club.

The fellow will spend a total of five months engaged in breast surgery, two months with the Program Director and one month with each of the other three attending Breast Surgeons. The fellow will gain experience and develop independence in the ambulatory evaluation of breast patients through the following:

• Clinical assessment utilizing physical examination and examination-directed ultrasound
• Office-based biopsy procedures, e.g. cyst aspiration, palpation-guided core-biopsy, skin punch biopsy
• placement of catheters for partial breast irradiation (PBI) with ultrasound guidance
• Assessment of patient eligibility for neoadjuvant/adjuvant chemotherapies and radiotherapies
• Clinical documentation and treatment planning, including explanation of surgical procedures, risks/benefits, and obtaining informed consent
• Placement of partial breast radiation devices
• Indications and available surgical therapies for palliative management of advanced breast cancer
  

Operative experience will include the following:

• Open and image-guided breast biopsy, nipple/duct procedures
• Mastectomy (including partial, simple, skin-sparing, modified-radical and nipple sparing) with demonstration of indications for breast conservation
• Sentinel lymph node mapping and biopsy
• Axillary lymphadenectomy
• Use of evolving technology such as cryoablation in treatment of benign and malignant breast conditions
• Palliative surgical treatment
• Surgical management of local recurrence following BCT or mastectomy
• Assess patients for eligibility for enrollment into breast clinical trials
• Assess the psychosocial needs and distress, as well as family dynamics and take appropriate action 
• Placement of applicator following partial mastectomy for Intraoperative Radiation Therapy (IORT)

The fellow will spend time with oncoplastic breast surgeon. The fellow will gain proficiency in:

• Appropriate patient selection and preoperative planning
• Local tissue flap closure for acquired defects depending on location in the breast
• Contralateral breast symmetry procedures
• Incision placement
• Prosthetic device placement

The fellow also will spend one month gaining operative experience in the various methods of breast reconstruction under the direction of Michael Meininger, MD and Dr. Lauren Oliver, DO

The fellow will gain proficiency in:

• Evaluation and selection of patients for immediate or delayed post mastectomy reconstruction with implant or autologous techniques
• Indications and use of biologics for reconstruction
• Nipple and areolar reconstruction in ambulatory setting
• Aesthetics and patient counseling regarding the realistic expectations following reconstruction
• Free flap procedures

The fellow will spend four weeks in the radiology department under the direction of Vidya Pai, MD, Section Head of the Breast Imaging Division of Diagnostic Radiology. The fellow will gain experience in the following: Interpreting screening mammograms

• Interpreting diagnostic mammograms and ultrasounds
• 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 will learn how to identify and report four levels of breast density and subsequently recommend follow-up using either 3D digital tomosynthesis or Breast MRI
• The fellow will learn indications for and limitations of breast MRI and 3D digital tomosynthesis. The fellow will observe, assist, and perform stereotactic and ultrasound-guided biopsies as well as wire localization of lesions to undergo surgical excision
• The fellow will be well-versed in the radiology-pathology concordance and recommendations following procedures

The fellow will also attend the twice monthly Breast Imaging Lecture series during which breast imaging topics, original research, and interesting cases are presented and discussed. 

The fellow will spend one month with Naveed Aslam, MD and Laura Nadeau, MD learning about the evaluation and systemic management of patients with breast cancer. Training will focus on the treatment of the patient with newly diagnosed breast cancer as well as the management of patients previously diagnosed with breast cancer. 

Training in radiation oncology is provided under the direction of Joshua Dilworth, MD, PhD, and Peter Chen, MD. The fellow will spend one month in the department to follow patients diagnosed with breast cancer through the radiation therapy treatment. The fellow will participate in the initial evaluation, subsequent simulation, and the patient’s post-treatment evaluation for whole breast as well as partial breast irradiation (PBI), including intraoperative radiation therapy (IORT). PBI training will include observing and assisting with the operative and/or ultrasound placement of strut-adjusted volume implant (SAVI) brachy-catheters, and IORT applicators.

The fellow spends two weeks training in Pathology under the direction of Mitual Amin, MD, Chief of Department of Anatomic Pathology. The fellow will learn to recognize pathologic features of benign and malignant breast disease. The fellow will understand formal techniques for specimen handling, orientation, processing, inking and diagnostic evaluation, as well as technologies in pathologic evaluation such as use of immunohistochemistry, cytology, tumor markers, and other gene-based evaluations.

The fellow will spend two weeks receiving training in Cancer Genetics under the direction of Dana Zakalik, MD. The fellow will demonstrate a thorough understanding of the role of genetic counseling, appropriate indications for recommending genetic evaluation, basic interpretation of genetic testing results, and subsequent recommendations. 

Additionally, the fellow will be able to identify patients at high risk for developing breast cancer, including risk factors such as pathologic, familial, genetic and previous therapies as well as lifestyle and environmental. They will be able to use contemporary risk assessment models and advise patients on risk reduction behavior by surveillance, medication and surgery. 

The fellow will complete a two-week training in senology and high-risk care under the guidance of Ruth Lerman, MD, Director of the Living with Ease program and clinical faculty of the Department of Internal Medicine. The fellow will gain an understanding of the clinical evaluation, risk assessment and management of patients with benign breast disease and make appropriate recommendations for the work up of patients with abnormal imaging studies.

The rotation will provide the fellow with experience in understanding the role of breast wellness, social support systems, cultural diversity, and breast-cancer survivor support group programs. Fellows will learn mentoring techniques for patients in these settings and identify patients at high risk for psychosocial issues, and subsequently utilize social work and other services to assist patients in addressing these issues.

At the completion of the training period, the fellow will be able to recognize the needs of patients and their family regarding illness and treatment, with appropriate attention to existing social support systems, and cultural diversity. During their training, the fellow will participate in existing support groups, and identify local support and advocacy organizations to serve as a physician-patient liaison (e.g. the Beaumont Health Sharing and Caring support group).

The fellow will receive training in Cancer Rehabilitation under the guidance of Justin Riutta, MD. The fellow will be able to:

• Gain an understanding of evaluating common problems after breast cancer treatment such as shoulder dysfunction and post-mastectomy pain syndromes
  • learn to manage these problems using contemporary methods such as compression garments and common desensitization techniques
  • integrate PT/OT resources into management of these cancer treatment related symptoms