Board Review Tidbits

[Music] Welcome back everyone, this is Sam. And this is Karine and we are two octups. This week's episode will be focusing on how we prepared the days leading up to our board exams. We took our boards in 2021 and we both took the hematology as well as the Medicon College board. So the stress leading up to this exams is still fresh in our minds and even those a few years ago, it feels like it was yesterday. Definitely. So each exam is four blocks of 60 questions each for 240 questions. So it's definitely a marathon of a day. And you know, at this point we've all taken the step exams and we are used to sort of the stamina, but it never really gets easier. And in oncology, the top four topics based on the blueprint are GI at 14% breast, 13% GU, 12% and then long 11%. And then we have also for him 35% of the hem exam is neoplasms. So it's because there's cross-covert on onc, very, it's good to know, be familiar with all of those as well. Absolutely. So hematologic malignancies is both high yield for onc day as well as the hem day. So for us, it was back to back days and for you guys that's back to back days this year as well. Although fellows can technically take this in their 30 years, who could break them up one test each year. The day is leading up to the exams, you need to review those cheat sheets, review those high yield topics, do some test out questions and mix up categories. So don't just do 25 questions straight of breast because on test day, you're going to get one breast, one lung, one hem, and just kind of a smattering approach. And so we're going to come over, we're going to cover some of the high yield topics. And so for oncology, we'll get started and lung cancer. Stage 2 to 3 lung cancer. Both Korean and I felt that there were a lot of questions on our boards in how to stage as well as expecting you to stage in the vignette and then how to treat non-small cell lung cancer. And so just as a refresher, stage 1 non-small cell lung cancer is a tumor less than 4 centimeters, lymph node negative, and we treat that with surgery or definitive SBR team. Stage 2 is greater than 4 centimeters but less than 7, or multiple nodules in the same lobe. Lymph node negative or Ipsilateral peribroncular hyalolymph nodes which are considered N1. The way to remember that is that these are the double digit stations. Stage 3 non-small cell lung cancer is a tumor that is greater than 7 centimeters, having multiple nodules in the same or Ipsilateral lobe plus lymph nodes, or being N2, which includes Ipsilateral, medius, stinal, and/or subchrinal lymph nodes. These are designated by the single digit lymph node stations, or you can have a stage 3, which is designated by N3 disease, which are control lateral, medius, stinal, control lateral, hyalur, Ipsilateral, or control lateral, scaling, or superclivicular lymph nodes. And so the treatment, like I alluded to, stage 1a, surgery, or SBR team. For surgery, we're talking about low-bucked me, which is preferred, but you can also talk about segmentectomy or wedge resection in select cases, like when tumors are very small, less than 2 centimeters. The treatment for stage 1b to 3a, so this is a large grouping, surgery, unless not a candidate, but systemic therapy is considered here, either before or after surgery. In 2025, there needs to be a multi-disciplinary meeting to discuss the best approach, because now are perioperative systemic therapy treatments, and we have several options. So we're actually going to be checking for ALC, EGFR, and PDL1 status, to tailor the treatment approaches. And if you find a stage 1b to 3a, EGFR positive lung cancer, you may do surgery followed by adjuvant chemotherapy if a candidate. So if the tumor is a stage 1b greater than 4 centimeters, followed by 3 years of osamertinib. And this is based on the adora trial, which came out a few years ago now. If ALC positive, you're going to be talking about surgery, followed by adjuvant electinib, for two years per the alina trial. If EGFR negative, and it's a stage 1b to 3a, we're not going to be talking about chemo and immunotherapy. So combinations, we have a neoadjuvant approach, which is checkmate 816, and this is exclusively neoadjuvant. So platinum-based chemo therapy plus novelamab for three cycles, followed by surgery. There's also three perioperative treatment regimens, which is a combination of immunotherapy, whether it's nevolamab, durbalimab, or pembro, plus platinum-based chemo-double it. And then that, and then surgery, and the immunotherapy then continues for a full year after. These are new, so this is new in the past few years. The first approval is 2022, so three years ago, so it is now fair game for the boards to be asking us about this. And then the last localized non-small cell lung cancer tidbit you guys need to talk about is unresectable stage 3a or stage 3b and c. And so this is where we're going to be talking about concurrent chemo-radiation, followed by adjuvant electinib, and this is based on the Pacific trial. And if there's EGFR mutations, you're going to be talking about concurrent chemo-radiation, followed by osmertinib indefinitely. Definitely, I sympathize with everyone taking boards in this day and age. Sam and I were just reminiscing it used to be just four cycles of adjuvant chemo-therapy. The easy targets. I know, you know therapies in this space. I know we've talked about we did a special episode on these study for which osmertinib is approved concurrent chemo-rt. So lots of updates, but at this point, it has been approved for a few years, so it definitely could be fair game on the boards. And the last few days leading to the exam, I would open nccn and for the highest yield topics, I would search the word category one and make sure that you're familiar with the regimens that are category one for those highly testable tumors like nonsmeltzl1 cancer, breast cancer, colon cancer, prostate cancer. So for breast cancer, some of the most frequent questions will come in terms of adjuvant systemic therapies. So for her two positive, if there are positive lymph nodes or tumor over one centimeter, you have a neo-adjuvant regimen with chemo and trust to zimab. Remember that all the regimens contain trust to zimab. In smaller tumors, you can get away with just trust to zimab and pachletaxle. But in larger tumors, you're doing the ac followed by the th. So ac remember is a germisin cyclophosphamide and then trust to zimab and then tachsol. And then even larger tumors or lymph node positive, you may favor ac followed by thp, which is the same regimen, but you add per to zimab. And then if there is residual disease, you give TDM one and I think this will definitely be at least one question on your boards. For ER positive in the adjuvant setting, consider the 21 gene PCR assay known as archetype. They're not going to write out archetype, but they're going to call it a 21 gene assay on your exam. Remember the cutoff for the score and age. So for postmenopausal archetype score of under 26, you don't give chemo just undercran therapy for premenopausal under 16. You don't give chemo just undercran therapy. And then those with many positive lymph nodes like if there are N2 and 3, they need chemo for sure. Those includes patients with more than 4 acular lymph nodes clinically detected internal memory lymph nodes in for clivicular or super clivicular lymph nodes. So those are those N2 and 3's higher stage. And then for endocrine therapy, remember for premenopausal to moxifen or aromatase inhibitor with ovarian suppression. And then for postmenopausal aromatase inhibitors are preferred. So those are things like an astrozole. And then for triple negative, you're going to do chemo for lymph node positive or tumors over one centimeter. So ac plus t is remising cyclophosphamide. Pack of taxil is most common, although for smaller tumors, you can get away with TC dosatexyl cyclophosphamide. And then for larger tumors, over 20 millimeters or positive lymph nodes, based on the keynote 522, you add pemberlism at perioperatively regardless of the PDL one status. So remember for those higher risk triple negatives, ad immunotherapy. And then for residual disease, poster drew ad capeside to be. And then in the metastatic setting, remember to give this phosphonator to no smell for bone meds. And then in the metastatic setting for ERPR positive, you're going to do an aromatase inhibitor or full vestryne with a CDK for six inhibitor such as ribocyclib. Although we have extremely recent data for frontline her to positive metastatic for boards this year, trust using my directs again is still the preferred second line. I don't think it, you know, because the guidelines are not updated for frontline, I would still treat this as second line. And remember the side effects of interstitial lung disease for BRCA one or two, when in doubt pick a parpe inhibitor, a lap rib, talazzo perib. Whenever you see BRCA and if there's a treatment option that includes a parpe one in doubt, you know, I would pick any of the drugs that end in parib, PR, PAR, IB. And then for inflammatory localize, you want to give a new adjuvant therapy, which is a preferred option followed by mastectomy. So that's an important pearl that you just ended with with the inflammatory breast cancer because of course they're going to show you that picture of the skin changes and you're going to have to jump to it. So start with chemo and there is no breast conservatory. It has to be mastectomy. And so for hematology, you know, if you're more onc minded like myself, I have to be honest, I focus a lot of my hea board studying on malignant hea because I knew is a large chunk of both exams. So I was studying smart. I was studying one time for both tests, but nine hea topics I actually studied earlier in in the year in July and August. And I made my cheat sheets and then I just did some quick reviews the month to the few weeks leading up just to kind of re refresh that that classical or benign hea topics. I will tell you the day before and actually the morning of my hematology boards I reviewed him. the Globe and Electroferesis. This was probably my weakest point. It still is my weakest point. I get confused. And Dr. Alice Ma did a fabulous free ashboard review. So if you guys are there today and you take your boards this week, just watch it, print that PowerPoint. I know we did an episode on this where we kind of talked through it, but honestly, you need that PowerPoint printed so you could see what she's talking about because there actually were a lot of questions on boards on the Himagaloba and Electroferesis and that truly helped me the most. So very briefly, not putting it to justice, but normal Himagaloba has two alpha chains and two beta chains. Himagaloba and A, which is our majority of our Himagaloba, if you don't have any conditions or Himagaloba nopathes, is alpha alpha and beta beta. Himagaloba and A2 is alpha alpha and delta delta. Himagaloba and F or fetal Himagaloba is alpha alpha gamma gamma. So a normal Himagaloba and Electroferesis. Himagaloba and A, again, that's 95 to 98%. Himagaloba and A2, about two to three percent and Himagaloba and F only one to two percent. You guys need to know that normal so when you start to see things changing, you're thinking through of what is this process. And so Himagaloba nopathes to know how to diagnose on the Electroferesis, you guys should be able to do the thalsemias, all of them. Himagaloba and F, Himagaloba and C, Himagaloba and E, sickle cell trait and disease, Himagaloba and B, Lapor, Himagaloba and B, Constance Springs. And so again, Dr. Alice Ma goes through all of these, print them out, review them. You will absolutely have at least a few questions on them. - Definitely. And then the other thing that comes up all the time, so we have Episodepisod dedicated to Von Willa Brand's disease. But if you want to get the question right, remember type one in three are quantitative defects. One is a partial quantitative and three is a complete quantitative defect. Type two Von Willa Brand are qualitative issues in Von Willa Brand disease. And type two, a large and intermediate size and multimmers are absent. So Sam remembers this by thinking of a type A personality individual folding multimmers, so they will be very small and compact. Type two, B, B bites up platelets or binds platelets, you will see thrombocytopenia as well. Given the binding to platelets, never give DDAVP as it was only cause a release of more defective on Willa Brand factor and worse than thrombocytopenia. Type two N on a test looks like hemophilia A will likely present a female unlike hemophilia A. It's not X-linked that looks like hemophilia A. So remember this by N equals non-male hemophilia. And then type two M is very rare variable bleeding, a pronounced decrease in Von Willa Brand factor activity, but all multimmers are present. Remember this with M equals multimmers normal. The other thing that seems like it comes up a lot on hemboards are congenital bone marrow failure disorders. So I would definitely rewatch the ash lecture for this if you have time to do so. And so all of the congenital bone marrow failure disorders have an increased risk of AML and solid tumors, particularly squamous cell carcinoma of the skin. And then in dyscharytosis congenita, here you have skin and lung issues characterized by pulmonary fibrosis, nail and skin changes arerosis, and it's diagnosed with a telomere length analysis. When here the treatment includes antigen therapy like Danazole, fancone's anemia, gonatal abnormalities, short digits hearing loss, cafeo-lase spots. Here the diagnosis is chromosome breaks and lymphocytes, and the treatment is also antigen. For diamond black fan, you have erythroid deficiencies, and thumb and cranial facial abnormalities, mostly anemia, increased heart defects like VSD, and increased HBF, and the diagnosis with erythrocyte diaminase, and the treatment is steroids but not indigens here, unlike the first two. And do not mix up diamond black fan and shwamen diamond, which is primarily an issue with neutropenia, where you also have pancreatic insufficiency and failure to thrive. So remember that the Chicago black hawks, sounds like black fan and the jerseys are red, so it's an issue with red cells if that helps you. That's the lame. Well, this is very soothing because I know you didn't live in Chicago when you were taking boards, but you do now, Karine. I know, it's true. This is not your black hawks fan, I love it. And so I think our last tidbits that you guys should know walking into test stay this week is know those black box warnings for drug toxicity. These are the big toxicities everyone taking the board should know them, and they're really the most testable. Clinical research methodology, so know how a phase one trial is built, know how to interpret hazard ratios, understanding intent to treat analysis, because this will always be a few questions. And then ethics, general common sense questions, they will absolutely be there. I think knowing the times that we want to recommend surveillance, also when best supportive care and when transitioning to hospices appropriate, that's easily gonna be at least a few questions. I know in all of our episodes, we do highlight the times when surveillance or monitoring is the right answer, because these are the things that the boards love to test about, or at least we feel they love to test about. And then we haven't gotten to this topic either, but supportive care. So things like chemo-related emphasis, how to treat it, how to deal with adverse events, hormone therapy, and then also of course immunotherapies. I do know we have an episode a long time ago about how you treat immunotherapy-related toxicities that is absolutely imperative to know when you're walking into test day. And then just in general wellness, there isn't anyone's first board or board style exam. You guys have gotten here because you've passed many board exams before. And so we all know sleep well, eat well, get regular exercise, regular fresh air. And then there's absolutely no cramming for this. The few days leading up, you guys really should just be relaxing, resting your eyes, because it truly is the marathon of reading after vignette on the computer screen. So don't cram, just kind of stay calm. You don't need to know it all, no one ever does, but you guys will do perfectly fine. And remember the pass rates are really in your favor, and you know more than you think. So if you read a question, you have that knee jerk, this is the answer, go with it. Something is telling you that that is the answer and move on. - So we wish everyone the best of luck on the boards if you're taking them this year. And please let us know if you found any episodes particularly helpful. We will be releasing an episode next week on Bladder Cancer from Esmo, because there were a lot. And then we'll be back with more new content after that. - Yeah. So as always, thank you guys so much for listening. Please feel free to reach out to us with any corrections or comments on our Instagram or our Twitter to onc docs and have a great week.