I took this yesterday before we left for the airport. Gorgeous sunlight on the soft snow.
I checked in on my patients this morning, and we completed table rounds as well as formal rounds in the hospital. The cardiologist on-call for the weekend is a foreign medical school graduate who came to the US after completing his training in cardiology. Because he did not do residency in the US, he cannot become board certified, even though he is extremely intelligent and a very competent and skilled physician. He did complete a fellowship in the US at a prestigious medical institution, but since he is not board certified, it is exceedingly difficult for him to find a job in his specialty. This could be me someday. American medical school completion doesn't mean a thing if residency isn't completed here; I would have to come back to the US and begin my career again as an intern. So it's obviously a big decision to move out of the states. If I were to fulfill my residency requirements in the US and become an attending after a few years of residency, I could move anywhere in the world and my specialist training will be valid. A part of me wishes to just get my education over with here, so I am free to practice anywhere in the world in the future. But I'm also not one for waiting for life to pass me by, wishing the days away until I'm living where I want and to have my dreams come true. Not only that, but I don't think Mike would ever stick it out over here for another 3-5 years. So the decision has been 99% made, just as long as it's not exceedingly difficult for an American-educated, non-EU citizen to get an internship in England. We'll find that out throughout the coming year. :)
I completed another case study. This one involves Ductal Carcinoma in Situ (DCIS) of the breast, which encompasses the majority of breast cancer. The case has been modified to protect patient confidentiality and privacy.
PL is a 47 year old Caucasian female seen in the oncologist office for 4 year follow-up of Tamoxifen use for Ductal Carcinoma in
Situ. On 7/12/2008, PL underwent a left lumpectomy with satellite lymph node
biopsy which showed 2 foci of invasive carcinoma (0.5cm and 0.05cm) with 0/1
nodes positive. Pathology revealed the
tumor to be ER+/PR+ and Her2Neu -. PL also elected to genetically test for the
BRCA1 and BRCA2 mutations, neither of which were detected in her tumor.
Following the surgery, PL received radiation to the left breast, which has
left a significant amount of fibrosis and is a source of discomfort to the
patient. Annual mammograms have been negative (her last mammogram was December 2, 2011). PL is a nonsmoker, denies alcohol use. Family history is significant
for prostate cancer in her father and a cancer of unknown type in her mother.
Today, PL’s vital signs were stable. Upon physical examination, the heart has a
regular rate and rhythm with a normal S1 and S2, without any murmurs, rubs, or
gallops, the lungs were clear to auscultation bilaterally without wheezes,
rales, or ronchi, and the breast examination was without any appreciable lumps
palpated; an area of fibrotic scarring was noted near the center of the left breast. Current medication includes Tamoxifen 20mg tablet PO daily.
Assessment: Ductal
Carcinoma in Situ, ER+/PR+/Her2Neu-.
Discussion:
The treatment goal of DCIS is to prevent the development of
invasive breast cancer by utilizing tools including surgery, radiation therapy,
and adjuvant endocrine therapy. Local treatment includes mastectomy or lumpectomy
plus radiation. Mastectomy proves to be curative in over 98 percent of patients
with DCIS. Post-mastectomy recurrences may be the result of unrecognized
invasive carcinoma, inadequate margins, or incomplete removal of breast tissue
at the time of mastectomy. However, mastectomy may prove to be more aggressive
of a treatment than is required for most women because survival is comparable
between the two. Continually, women with
unilateral DCIS are at a modestly increased risk of developing invasive or DCIS
in the contralateral breast, and bilateral mastectomy is usually not performed.
Breast conservation therapy is another option for local treatment. A wide
excision of the tumor with negative margins followed by radiation therapy to
eradicate any residual disease is the mainstay in breast conservation therapy.
Studies which have compared breast conservational therapy with mastectomy for
DCIS have shown equivalent long-term survival, although local recurrence rates
are higher in those who opt for breast conservation therapy. Candidates for breast
conservational therapy are the majority of women, and the criteria include:
lesion limited to one quadrant of the breast and whether a cosmetically
acceptable excision is possible (depending on the native size of breast
tissue); achievement of histologically negative margins, as defined by
tumor-filled ducts separated by a measurable distance from the inked surface. While in the operating room, a sentinel lymph
node biopsy is typically performed to assess for microinvasive disease. Following
removal of the tumor by mastectomy or lumpectomy, the specimen is sent to the
pathology lab for determination of histological grade, size and/or extent of
DCIS, to ascertain the presence of contiguous or multifocal distribution, and
to evaluate the margins (1-2mm negative margins). It is also vitally important
to determine the ER/PR and Her2Neu status of the tumor, as it dictates the
choice of treatment. Following lumpectomy, radiation therapy is initiated for
five to six weeks, which reduces the risk of in-breast tumor recurrence by at
least 50 percent as compared to excision alone. The benefit of radiation has
been studied to show improvement of local control and prevention of potentially
fatal invasive in-breast recurrence. Currently, there is research being done to
help decide which patients would best benefit from radiation so as to only
expose those who would find benefit and exclude those patients who would never
have recurrence regardless of radiation use. The final treatment choices involve
adjuvant endocrine therapy. Tamoxifen, which competitively inhibits binding of
estrogen to the estrogen receptor, is used as adjuvant therapy for ER+/PR+
invasive breast cancer to reduce the risk of disease recurrence as well as
contralateral breast cancers and to improve survival. However, the role of
tamoxifen in the treatment of DCIS is less clear, as there have been
conflicting results from large randomized trials. In the most recent studies,
tamoxifen has been shown to be beneficial only in DCIS with ER+ status, which
showed a significant 40% lower risk of invasive breast cancer recurrence when
compared to placebo while there was no benefit among ER-negative tumors.
Following mastectomy, the risks of relapse are minimal, and tamoxifen may not
be warranted. In any case, the risk to
benefits must be balanced for each individual patient before deciding upon the
treatment plan. A few adverse effects associated with tamoxifen (estrogen
receptor antagonist) include hot flashes, endometrial hyperplasia, fibroids,
and polyps, and in postmenopausal women, endometrial cancer, uterine sarcoma,
and venous thrombosis and thromboembolism. The goal of treatment with tamoxifen
is to prevent ipsilateral recurrence and, to a lesser degree, contralateral
breast cancer. Her2Neu + tumors suggest a more invasive nature, and anti-Her2
therapy is being studied in the neoadjuvant and adjuvant treatment for DCIS.
Post-treatment surveillance after treatment for DCIS and early breast cancer
are early recognition and treatment of potentially curable disease recurrences
and second primary breast cancers, evaluation for therapy-related
complications, and detection of symptoms consistent with metastatic disease.
Thus, history and physical exam and routine mammography form the cornerstone of
posttreatment surveillance for DCIS breast cancer patients.
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