Heme & Onc Fellow Board Review Tips 2024

[Music] Welcome back everyone, this is Sam. And this is Kareen and we are two Octux. In this week's episode we'll be focusing on final board review tips. We're going to go over our highest yield cheat sheet topics and how we prepare the days leading up to the exam. We took our boards three years ago now, but the stress leading up to the exam is certainly freshener minds. Absolutely, I feel like I can still remember what I did the weeks and the days leading up to boards. And so first you guys need to know the breakdown of the test. It's four blocks, there's up to 60 questions in each of the blocks for a total of up to 240 questions. The top four oncology topics based on the blueprint and use that to your benefit is GI at 14%, breast at 13%, GU at 12 and long at 11%. The top keen topics based on the blueprint is 35% is neoplasms. So be ready for some malignant scheme mostly on your keen boards, but it's also for your game for your oncology boards. Definitely important to remember that. And it is back to back days this year in early October. And as of 2021, fellows can take one of their board exams in their 30 year. So the days leading up to the exams, them and I would review our cheat sheets, or the high yield topics, which we're going to cover some of those. And do test style questions with mix up categories. Definitely. So let's dive into our highest yield cheat sheet topics for oncology first. Mine was stage 23 non small cell lung cancer. Both Karina and I felt there was a lot keyword bolded underlined of these questions on our boards. At one point, I think I had two to three questions on this category in one section. And so first and foremost, you got to know how to stage non small cell lung cancer at its basics. Know the size of the primary tumor, the lymph nodes that are involved. And then you need to know how to treat both resectable and unresectable stage two and three non small cell lung cancer. The landscape of treating this disease is changing quickly. We did an update on these episodes in both metastatic and non-metastatic non small cell lung cancer in 2023. So reference those and will also be redoing new episodes again this year as well as probably every year moving forward. So stage one a these are the tumors that are less than or equal to three centimeters. Lymphno negative you can treat these with surgery or SBRT alone. Stage one B to three a that are resectable you discuss new adgment chemo plus IO. Then surgery versus surgery then chemo followed by IO or osomerniv VGFR mutated. These are new guidelines so they probably won't be seen on your boards today. So again just realize the boards are a little slow for updates. Stage three a three B and three C un resectable disease you treat with definitive chemo RT followed by derailleumab. This is based on the Pacific trial you will be tested on this somehow on your boards. Adjuvant chemo regimens for squamous cell carcinoma is in general cispland plus gem side bean or dose attack cell. And for adnal carcinomas it's this plan plus penetrating. The month before boards I focused heavily on other highest yield solid tumors like GI, GU, breast and of course long. Yes and one of the other things that one of my mentors suggested when I was in fellowship was to open the NCCN guidelines for those most commonly tested cancer types and control certain category one for those categories. So non small cell lung cancer breast cancer colorectal those are the things are going to be tested you on those category two a's and beyond. Those are way less likely to be tested. And so some of the things that I reviewed leading up to the boards was definitely breast cancers so so many questions on breast cancer. And so if you want to review our most recent updates in 2023 we released updates on local life and metastatic breast cancer and we will be releasing another update for this year in October. But those updates from this year probably won't be reflected on the boards anyways. And so some of the things that come up frequently in terms of adjuvant systemic therapy for breast cancer. Is that for her to positive any of the T1 and zeros so those tumors that are under or equal to two centimeters can be treated with surgery upfront followed by a clitaxol and her septin or trust to Zimab or the APT trial and they have a good prognosis with that regiment. And then for the neo adjuvant approach for her to positive breast cancer that's localized if the tumors are larger so over two centimeters or with positive lymph nodes TCHP is the preferred regimen so that is both the HP with her septin trust to Zimab and part to Zimab. And this allows us to tailor the adjuvant therapy plan based on the response and to switch to TDM one if there is not a pathologic complete response or if there is residual disease or the ER positive localized breast cancer in the adjuvant setting consider that 21 gene PCR assay on the type and absolutely remember the cutoff for the score and whether their premenopausal or postmenopausal. So if their postmenopausal and their score is under 26 you can omit chemo if their premenopausal with a score under 16 for note negative you can omit chemo and under 26 for note positive you can omit chemo and those with many positive lymph nodes like N2 or N3 do need chemo for sure and those include women with more than four axillary lymph nodes clinically detected internal memory lymph nodes in freclavicular or so. And then for endocrine therapy remember that for premenopausal it's to moxifen or aromitein inhibitor with ovarian suppression and for postmenopausal aromitein inhibitors preferred. And then for triple negative for those that are over one centimeter or positive lymph node status you're going to give AC plus T so age remites in cyclophosphamide and pack of taxile although for smaller tumors you can get away with just TCE which is dose the taxile encyclophosphamide and for residual disease you can give capesidobene or if there are BRC one or two you can give the premenopausal aromitein inhibitor elaborate. And then in the metastatic setting always remember bsposinates or dino smap for bone meds i feel like there's definitely going to be at least one question on the use of these agents in women with bone meds and breast cancer and also remember that that is the same for metastatic cancer resistant prostate cancer everybody should also be on bone therapy. And then for your positive metastatic breast cancer you're going to give either an aromitein inhibitor or full vestraint with a CDK for six and RB1 mutation or loss confers a resistance to CDK for six inhibitors and then another pearl that change in the last few years for the second line setting of her two positive breast cancer is crest is a memderuxican is the preferred second line agent there is that rare toxicity of special interest with interstitial lung disease so remember that for sure. And then for those with BRC one and two in the metastatic setting remember olapyrib telazopyrib if you see someone BRC one or two basically across tumor types so pancreatic cancer prostate cancer ovarian cancer be thinking about our inhibitors. And finally for inflammatory localized breast cancer I we definitely had a question on that new adjuvant upfront is definitely preferred followed by mastectomy so you can offer breast reserving options. Yeah, I think you hit at least eight questions from boards that I can recall and so switching gears now to he metalligy so if you're more on minded like us and I have to be honest I really focused most of my team board studying on malignant he because I knew that was going to be on both exams so I was kind of killing two birds with one stone for benign he in topics I studied those early in my studying plan so July August for me and I made those cheat sheets and I reviewed them the weeks to days Lee and I was. And so the day before and the actually the morning of my team atology boards I reviewed he Mclobin electrophoresis doctor Alice Ma gave the best ash lecture the three ash borderview lectures that I have ever heard on he Mclobin electrophoresis we will do a full episode on this soon because we have realized we have not yet but honestly Dr. Ma's review is the best thing it is what you need to know walking into board say because there is a lot of questions on this topic but briefly normal he Mclobin has two alpha chains and two beta chains so he Mclobin a that's alpha alpha beta beta he Mclobin a two is alpha alpha delta delta he Mclobin F or fetal he Mclobin is alpha alpha gamma gamma and normal adult he Mclobin is he Mclobin a 95 to 98 percent he Mclobin a two to three percent and he Mclobin F one to two percent he Mclobin apathy is the need to know for the diagnosis based on doctor for recess for board stay is style seniors yes all of them he Mclobin S he Mclobin C he Mclobin E sickle cell trait as well as sickle cell disease he Mclobin LePore and he Mclobin constant springs rent off that PowerPoint review them review them review them and you guys are golden yes and definitely remember medjillary renal cell carcinoma with sickle cell trait they love to ask that and I feel like in the hematology side congenital bone marrow failure disorders were highly tested and unfortunately that's not something we saw commonly in fellowship so I would rewatch that ash lecture a few days before and all of these have an increased risk of AML and solid tumor risk including particularly squamous the miscellic carcinoma of the skin. And for dyscharitosis congenitum, know that skin and lungs are affected. So as characterized by pulmonary fibrosis, nail and skin changes, cirrhosis, it's diagnosed with telomere, length analysis, and the treatment is antigen therapy like danyzol. For fanconis and nomeninia, think about gonadol abnormalities, short digits, hearing loss, phafeolase spots, diagnosed with chromosome breaks and lymphothytes, and the treatment is also antigen. For diamond black fan, these are erythroid abnormalities, and they're gonna have thumb and cranial facial abnormalities. So mostly nomeninia again, because it's erythroid. They will have increased heart defects like VSD, increase hemoglobin F, and it's diagnosed with erythrocyte daminase, and the treatment is steroids, but not to antigens compared to the other two. And then do not mix up diamond black fan and shwaman diamond. So shwaman diamond is primarily an issue with neutropenia. They have pancreatic insufficiency failure to thrive. As an amonic, the Chicago black hogs, like black fan, the jerseys are red, it's primarily an issue with red cells. So diamond black fan, Chicago black hogs, write jersey erythroid abnormality. I love that, I won't forget that. I'll see you get a little PTSD reviewing all these things because I can picture my cheat sheet with all of these words. And so I think the last classical hematology thing that you guys should know walking into board state is definitely Van Leibbrand's disease. Review this, the day is leading up, week's leading up to it. We have covered this topic in a prior episode, but at the basics, if you wanna get these questions right, you need to remember type one and type three are quantitative defects. So type one is a partial quantitative defect in Van Leibbrand factor. Type three is a complete quantitative defect in Van Leibbrand factor. And type two Van Leibbrand is a qualitative. So the quality of the Van Leibbrand is the issue. And so they can ask you about type two A, which has large and intermediate size multiples and those are absent. I remember this by thinking about a type A personality will fold things really tight and tiny and compact so they don't have those large monomers. And so type two B, I remember this by B is being biting up platelets because you'll see thrombocytopenia as well. Given the binding of platelets, you never give DDADP to type two B because you'll cause a release of more defective Van Leibbrand and that will worsen the thrombocytopenia. That is testable. And then type two N on the test, this can look like hemophilia A, but they will present it as a female. And so unlike true hemophilia A, this is not excellent so it's not male, dominant, and family is, but on all of your labs and on the clinical presentation, it'll look like hemophilia A. I remember this by saying 2N is non-male hemophilia. And the last type two is 2N. This is extremely rare. There's variable bleeding presentations, but it has a pronounced decrease in Van Leibbrand factor activity, but all the multiverse are present. So I remember this by M as multiverse normal. N is non-male hemophilia, type two B is biting up those platelets and type two A is missing those large intermediate-sized multiverse. And other tips that you guys need to know about when you're studying in this last month before boards is know the black box worrying for drug taxisities. These are the big taxisities that everyone needs to know because they're the most tested. Also be aware of some clinical research methodology. Know things like what phase one trial methodologies are. Know how into interpret a hazard ratio or an understanding and intent to treat analysis. Ethics is tested on all of our board exams. So this is generally common sense type questions. I think they're give me questions, but be aware that ethics will be tested. And then also know the times that we actually recommend surveillance or observation. And also when we recommend best supportive care. And so this mostly relies on econ performance statuses. So if someone has a poor econ, first do know harmless physician. So best supportive care is probably the right answer. Supportive care including things like risk factors like chemo-related emesis. How to treat that? How to use prophylaxis as well as chemotherapy-related neutropenias, which we did cover on a few episodes. Yes. And we also did infusion reactions recently, which definitely comes up. And one other really important aspect of doing while in your boards is absolutely wellness, snacks, sleep. This is obviously nobody's first board exam when you're getting around to your human exam. So we all know that you need to sleep while eat well, get regular exercise. Fresh air is important. Step out of the prometrich if you can between blocks. And remember that there is no cramming for boards. The day's leading up, it's just reviewing, getting yourself in a good mindset, not trying to cram too much. And remember that the pass rates are in your favor. You know more than you think. So try to relax. Agreed. And so our personal top 10 favorite episodes of our podcast to Young Dox Reboard Review, Colorectal Cancer, the Breast Cancer Series from 2023, the non-small cell lung cancer series from 2023, testicular cancer will be tested because it is curable, even in the metastatic setting, prostate cancer, and then from the hematology side, hemophilia's Von Wolley-Brandt's disease, bone marrow failure disorder, AML as well as stem cell transplant and hot schenslum phoma. And as always guys, thank you for listening and good luck with studying for your boards. Please feel free to reach out to us with any corrections or comments on our Instagram or our Twitter to Young Dox. Have a great week. (upbeat music)