When preparing for medical board exams, it is important to remember that they are primarily testing your clinical knowledge. Therefore, expect to find many questions that will assess your knowledge about treatment modalities and which interventions are the most appropriate for each case. You can be tested on the details regarding a specific intervention, the most suitable treatment in particular populations and disease variants, and on treatment algorithms.
This post will be focusing on treatment algorithms. Treatment algorithms refer to ranking of different treatment interventions according to first-line treatments, followed by second-line, third-line, fourth-line, and so forth until reaching the last line of treatment.
The easier exam questions present a case vignette of a patient who requires a first line treatment, and the response options also contain a first-line treatment. This type of question will be asked in two scenarios. Firstly, if the disease is rare, you are not expected to have more than just the core understanding of the disease and its treatment. Secondly, the disease could be a common one, but one that is from another specialty. This tests your basic knowledge of clinical management, factoring in the history, examination, and assessment of the patient. For example, in oncology, you could be tested on non-neoplastic disorders from hematology. It could even be an extension of an oncology-based question, in which you could be asked to treat a psychiatric condition (depression, anxiety) that develops in a cancer patient.
The more difficult questions will present clinical cases in which you must treat the patient using lower levels of treatment algorithms (second-line, third-line, fourth-line treatment, or even lower). These questions are also presented in two different ways.
Firstly, the question could make it obvious that the patient does not qualify for the first line of treatment, and hence, an alternative treatment must be sought. This could be due to the patient suffering from an adverse reaction from the first-line treatment, or the first-line treatment could worsen the patient’s particular condition due to other medical conditions presented in the patient’s history. You must be vigilant to spot any relevant information that could change the best treatment option to a lower level treatment algorithm.
Secondly, the exam question could simply omit the first line of treatment from the response questions. The question statement may be straightforward, with the patient qualifying for the first-line treatment. However, due to the omission of the first line of treatment, you must choose the next best option presented in the response options.
Example Exam Question from Oncology:
A 35-year-old woman presents with mid-cycle uterine bleeding. Hysteroscopy, sentinel node biopsy, and pelvic MRI are done. She is diagnosed with stage 1 (T1 N0 M0) endometrial cancer based on the histological evaluation. Her medical history shows that she has polycystic ovarian syndrome (PCOS) and a BMI of 30. She does not have any children and has been trying to conceive for the last five years. What is the best initial treatment option for this patient?
- Hysterectomy and bilateral salpingo-oophorectomy
- Hysterectomy and bilateral salpingo-oophorectomy with lymphadenectomy
- Medroxyprogesterone acetate
- Vaginal brachytherapy and external beam pelvic radiation therapy (EBRT)
- Chemotherapy with cyclophosphamide
Type I endometrial cancer is associated with metabolic syndrome, hyperglycemia, hyperlipidemia, obesity, and high estrogen concentrations (as are found in PCOS). The first line of treatment for endometrial cancer is hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy can also be done, depending on the involvement of lymph nodes. The patient does not have lymph node involvement, so it will not be necessary in this patient. However, surgery will leave the patient incapable of reproducing. The patient’s history is indicative of her desire to conceive, and this should be kept in mind when deciding the initial treatment modality. There have been clinical trials showing that vaginal brachytherapy and EBRT can be beneficial to prevent relapses after surgery. However, these measures can only be taken after surgery and cannot be an initial treatment. Chemotherapy can be indicated as a replacement for radiotherapy, or can be used with radiotherapy after surgery, but is also not considered an initial treatment. For fertility preservation, oral progestins like medroxyprogesterone acetate or megestrol acetate are considered the initial line of treatment. The response of the patient to this treatment will be assessed after six months while assisting the patient to conceive by referring to fertility clinic, as pregnancy is associated with a reduced risk of recurrence. If the patient does not respond to conservative management through oral progestins, hysterectomy with bilateral salpingo-oophorectomy will be performed.
Colombo N, Creutzberg C, Amant F, Bosse T, González-Martín A, Ledermann J, Marth C, Nout R, Querleu D, Mirza MR, Sessa C. ESMO-ESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Annals of Oncology. 2015 Dec 17;27(1):16-41.
Morice P, Leary A, Creutzberg C, Abu-Rustum N, Darai E. Endometrial cancer. The Lancet. 2016 Mar 12;387(10023):1094-108.