There is a high percentage of questions based on treatment in medical board exams because the reason patients see physicians is to seek appropriate treatment. Three aspects of treatment are tested by specialty board exams:
- Details of specific treatment modalities
- Treatments by disease variant and in particular patient population
- Treatment algorithms
The focus of this post is on choosing the appropriate treatment for a particular population that the patient belongs to, or the disease variant. The writers of the board exams assess your knowledge about different treatment interventions for particular disease variant or within a select group of the patient population. Diseases with well-established guidelines or recommendations are used for such specific questions.
For example, in patients with ovarian carcinoma following primary treatment, an increase in the CA-125 levels are monitored every three months. This is because an increase in the levels precede clinical detection by about three months, and can result in a more effective treatment due to small volume of the tumor.
Another example: postmenopausal women with an endometrial thickness of 5 mm should prompt a further investigation due to increased risk of endometrial carcinoma.
Example Exam Question from Oncology
A 27-year-old woman is scheduled for a routine 16-week ultrasound scan. She is gravida 3, with two normal, spontaneous vaginal deliveries and one miscarriage. The scan detects a multilocular-solid cystic adnexal mass in the right ovary measuring about 7×8 cm, along with a single 16-week fetus. The rest of the pelvic and abdominal scan is unremarkable. There is no significant past medical or surgical history, and there is no family history of endometrial, ovarian, colorectal, or breast cancer. Laboratory workup shows CA-125 levels of 1209 IU/mL. Which of the following is the next appropriate step in the management of this patient?
- Pelvic CT scan should be obtained
- Pregnancy should be terminated
- Surgery with appropriate staging can be performed at 16-18 weeks of gestation
- Surgery should be delayed until the third semester
- Initiate chemotherapy
The above patient should be offered surgery with appropriate staging, as she is already 16 weeks into the gestation, and surgery is considered safe because there is less risk of spontaneous abortion. Corpus luteum of pregnancy is less dependent on hormones, and functional cysts resolve by the second trimester in the majority of the patients. Pelvic CT is contraindicated in pregnancy; however, pelvic MRI with gadolinium injection can be obtained if the ultrasound does not provide sufficient information. Termination of pregnancy is not indicated, as most treatment modalities can be performed without risking the fetal well-being. Surgery should not be delayed until the third trimester, as there is an increased risk of premature labor and poor pregnancy outcome. Chemotherapy is not indicated in this patient as the first-line treatment without confirming the nature of the mass. If chemotherapy is indicated, it should be prescribed after 20 weeks of gestation to decrease the risk of potential fetal toxicity.
Bast RC Jr. CA 125 and the detection of recurrent ovarian cancer: a reasonably accurate biomarker for a difficult disease. Cancer. 2010; 116(12):2850-3. DOI: 10.1002/cncr.25203.
Boussios S, Moschetta M, Tatsi K, Tsiouris AK, Pavlidis N. A review on pregnancy complicated by ovarian epithelial and non-epithelial malignant tumors: Diagnostic and therapeutic perspectives. J Adv Res. 2018; 12:1-9. DOI: 10.1016/j.jare.2018.02.006.