DIP Episode 309 - The Clutch Breast Cancer Podcast (for all USMLEs)

Okay, welcome. My name is Divine. This is episode 309 of the Divine Intervention Podcasts. And in this podcast, I'm going to be talking about breast cancer and the USM Lids. If you know those podcasts, you'll pretty much be able to get every breast cancer question you see right from you exam. And again, for those of you that are studying for step 2, CK step 3, I have a course actually two courses next week. The first one is an MBME Test Indian Strategy course. It's on Tuesday next week from 2 to 4 30 PM Pacific Standard Time. We basically work on test ticking strategies. And I'm not just going to be teaching you strategies. I'm going to be using actual questions to go over those strategies, right? So you become very good at ticking MBME exams. And then the 20 hours step 2, CK step 3 course will be from Wednesday to Saturday, right? It's from 11 a.m. to 4 p.m. Pacific Standard Time, five hours every day. And basically we'll be covering Peds, Surgery, IMOB Guyne, Psych Neural, Biostat Ethics, those November 2020 changes. And also I'll be focusing on a lot of pathophysiology from step 1 that even cooperated into the new step 2, CK exams and step 3 exams. So if you interested, just shoot me an email through the website. I'll give you information on cost and every other thing you may need. Okay, so let's just jump right into it. Right? So breast cancer, right? So breast cancer is, you know, is bad, right?

And unfortunately, it's probably like the most frequently diagnosed cancer in women, right? Although remember, skin cancer is a more popular, but you know, typically on exams, we're going to go more with breast cancer here, right? Breast cancer. And the thing is breast cancer of all the malignancies that afflict women, right? It's like the second most common cause of cancer death, right? Remember, lung cancer is kind of number one. Lone cancer is bad, right? I mean, like many people, if you get lung cancer, chances are you're going to die. If you get breast cancer, chances are you may die, but there's also pretty good chances you may survive. I mean, we have a lot of really good therapies for this stuff right now, right? So what is the biggest risk factor? So now, and I'll try as much as possible to use like scenarios on this, because the thing is most times breast cancer questions on MBM exams, they show up as scenario questions that kind of messes people up, right? So they're like, mean all these decision trees. I feel like all began as a discipline is a decision tree specialty, right? It's great for people that love decision trees, right? So what is the biggest risk factor for breast cancer? Well, the big, the biggest risk factor for breast cancer is actually age, right? The older person is, the woman is the higher the likelihood of her having breast cancer, right?

But there are some other risk factors that your friends at the MBM me put where they would not put age, right? So say for example, if a person has a family history of breast cancer, that can increase the risk of getting breast cancer, especially like in a first degree relative, right? So they can be mean on a test and put like a history of breast cancer in a second degree relative. If you see that, that is not so much of a risk factor. It's been a first degree relative that increases the person's risk of having of having breast cancer, right? And then one of the things they can also do, let me see in the Q-Stem that, oh, this person in the past has had like a biomemogram with biopsy, like a cornydobyopsy that showed like lobular hyperplegia or like atypical doctor hyperplegia. And then in the Q-Stem they can also put that, oh, the person is like 65 years old and they will say, oh, what is the biggest risk factor for breast cancer in this patient? And then they will put age as an answer and they will put like atypical doctor hyperplegia as an answer. If you see that as an answer choice, go with atypical doctor hyperplegia and then maybe like divine. What are you talking about, dude? You literally just said that age is the biggest risk factor for breast cancer. Yes, I know exactly what I said, right? But the thing is if a person has biopsy proven pre-malignant disease, of course that's going to be a more higher risk factor, right? In that patient compared with each.

Just something to keep in mind for exams, right? And remember there are certain breast cancers that are driven by estrogen and progestin, right? So if for some reason you've had like abnormally large exposures to estrogen in your life, that's going to increase your risk of having breast cancer, right? Like so for example, if a person has like early menarchy, so you start having your period early, right? You're going to be experiencing more follicular phases in your life than the average person, right? So that's going to increase your risk of breast cancer. If a person has late menopause, right? So again, if you have late menopause, let's say you're going to menopause at 60, right? You've had more menstrual cycles than the average woman, right? So that's going to increase your risk of breast cancer, right? Because again, you've had more follicular phases. The more follicular phases you have, the more lifetime estrogen exposure you have, right? And also if you're not liparous, right? Again, if you're not lip... Because remember, whenever you're pregnant, right? And also for about, you know, like roughly six months or so after you've delivered the baby, you're not going to be having periods, right? Because you're in a high-prilactine state. Those high-prilactine states essentially shut down the HPG access, right? So the thing that would happen is if you're not liparous, that means you're spending most of your life having menstrual cycles.

Again, more follicular phases in the menstrual cycle, more estrogen exposure, more risk of breast cancer, right? And then also if you're obese, remember people that are fat, remember, people still contain an enzyme called aromatics, right? And aromatics, its job literally is to convert androgen to estrogen, right? So if a person is fat, right, they will have a ton of aromatics activity, the format ton of estrogen, that will increase the risk of having breast cancer, right? Now, obviously for a person who has breast cancer, right? You know, there are some, there are some genetic things that can cause, that can increase a person's risk of breast cancer, right? So what are those things? Well, typically, you know, we're thinking about like BRCA1 and BRCA2 mutations, and you know, for those of you that are taking the step one exam and you're like, oh, divine, what is some basic science detail they can test with these BRCA mutations? I want you to think about DNA repair, right? Those things are associated with DNA repair, right? So if you have those mutations, they're going to have abnormal DNA repair, that's going to predispose the person to getting breast cancer, right? And the thing is, on MBM exams, they kind of want you to know some things that are associated with these BRCA mutations, right?

So if, for example, they tell you that you see a person that is, you know, they tell you that, oh, they've had like many family members that have gotten like a diagnosis of breast cancer before the age of 50, right? That's definitely something that's also the BRCA mutation, right? Well, if you see like a history of like bilateral breast cancer, so they've had breast cancer in the right breast, in the left breast, that's going to increase, that's likely a person that has some kind of BRCA mutation, right? Well, if you see a person that has a family history of breast and ovarian cancer, you have like both of those cancers together, think about a BRCA mutation, right? Or you see male breast cancer, many people think that, oh, it's only women that get breast cancer, that's not true, men, about 2,000 men roughly every year get breast cancer, right? Because men literally have breast tissue, right? So I remember that breast cancer risk is actually increased in people that have client filters, same from, right? I just thought I should maybe go ahead and throw that out there, right? So if you see male breast cancer in a family, right? That again, those will probably have some BRCA mutation thing going. If a person is also like Ashkenazi Jewish ancestry, right? That's something that's associated with an increased risk of BRCA mutations, right?

And again, if you see just many, many people in the family getting breast cancer, you know, chances are there's probably some BRCA mutation thing going on, right? And typically, if a person is high risk for breast cancer like this, right? Like a person has like this, this high risk factor, you know, it may not be the worst thing in the world to maybe get that BRCA genetic testing, right? Because the thing is, a person has the BRCA gene mutations, it's actually kind of high you to know some things, especially with screening, because we know that for breast cancer, you know, the screening guidelines say USPSTF says started 50, two years, right? American cancer society says started 40, do it every year, right? And you know, USPSTF says, you know, let's kind of cut things off at 75. But I will just tell you this, for purposes of MBM exams, it's not a problem to start screening people at the age of 40. The MBM, they have, I will say in general, they tend to lean more with American cancer society recommendations than the USPSTF recommendations in that regard, right? So that's something to keep in mind. So in other guidelines for normal people, what are the guidelines for who would have BRCA mutations? People would have BRCA mutations, right? Those people need ANOA, mammograms, and breast MR Is. So you need to do a mammogram, but you can just do a mammogram. Those are the, basically, if you see a breast MRI question on your exam, it's going to be these people, right?

People with BRCA mutations, right? And the thing is usually people with BRCA mutations, one thing that's routinely recommended for them on MBM exams is they can say, oh, how can you treat or reduce their risk of developing future malignancy? Well, you just do prophylactic surgery, right? So basically, what's the prophylactic surgery do for these folks? Well, the thing you're usually going to do is you're going to do a bilateral mastectomy, right? So you're going to take out both of their breasts. But then in addition to that, usually these people also can lead this for a THBSO, right? THBSO. Well, what in the world do I mean by THBSO? By THBSO, I mean total abdominal hysterectomy and bilateral salpingo-ufrectomy, right? So you're basically calling out the women's ovaries, calling out the fallopian tubes, calling out the uterus as well, right? In addition to the bilateral mastectomy, right? Just something you want to keep at the back of your mind for purposes of exams, right? And the thing is there is this thing that you may see on the newer MBM exams that may shake you a little bit. And that's this thing called the GAL, G-A-I-L, the GAL risk model, right? The GAL risk model. It's basically, again, you don't need to memorize the things that kind of factor into it, but you need to memorize a number. The number you need to memorize is 1.7%, right? Greater than or equal to 1.7%.

Basically, if according to the GAL risk model, your breast cancer risk over the next five years is like greater than or equal to 1.7%. The thing you're supposed to do on an MBM exam is to go ahead and you can put these people on anti-extrigin therapy, right? So what in the world do I mean by anti-extrigin therapy? Well, I mean a SIRM, especially if you're pre-menopausal, right? If you're pre-menopausal, you're going to go ahead and put these people on a SIRM, right? So what are those SIR Ms? Remember, the classic ones, they're Stomach-Syphen, right? And they're Stomach-Syphen, right? They're Stomach-Syphen and they're Stomach-Syphen. Essentially, these drugs, right? Like Stomach-Syphen, for example, is an estrogen receptor antagonist in the breast, so it's good, right? Because estrogen drives many breast cancers. Stomach-Syphen is an estrogen receptor antagonist in the breast, but remember, it's an agonist in the bone and in the uterus, right? So because it's an estrogen-agonist in the bone, it's actually going to lower a woman's risk for osteoporosis, right? But because it's an estrogen receptor antagonist in the uterus, right? It's potentially going to cause endometriol hyperplasia endometrial cancer, right? Remember, the biggest risk factor for endometrial cancer is having exposure to unopposed estrogen, right? So this is why for the most part, people that are on Tommox-Syphen, once they hit 50, you're going to go ahead and shut that stuff down, right?

And for the most part, people that are placed on Tommox-Syphen on nbim exams, you try to limit it to no more than five years, right? You give within a five-year course of Tommox-Syphen. Remember, there is another agent that's a serum called Rallox-Syphen. It's sort of kind of similar to Tommox-Syphen, but the big difference is it is not an estrogen receptor antagonist in the uterus. So because it is not an estrogen receptor antagonist in the uterus, it does not increase endometrial cancer risk. The only problem though with Rallox-Syphen is that it is not as effective as Tommox-Syphen. So if you are trying to do breast cancer chemotherapy, in a premenopausal woman on nbim exams, go with Tommox-Syphen, not Rallox-Syphen, right? And remember that Tommox-Syphen in addition to that endometrial cancer risk, you know? It also increases risk of like postmenopausal symptoms like hot flashes, right? But it also increases the umand's risk of venostromoboembolic disease, right? It actually also increases the umand's risk of venostromoboembolic disease. These are, again, all reasons that factor into our scene. You know what? When a person is more than 50 years old, cut out the Tommox-Syphen business for breast cancer chemotherapy relaxes, right? So you may be like, okay, divine. What do we use in women that are more than 50 years old in women that are postmenopausal? Well, what you do is you use an aromatis inhibitor, right? You use an aromatis inhibitor.

So what in the world are these aromatis inhibitors? Well, these are drugs like anastrosol, right? Anastrosol, letrosol, examesting, right? Examesting is EXEMES, T-A-N-E, right? Anastrosol, letrosol, examesting, right? So these drugs inhibit aromatis because remember if you're postmenopausal, the primary source of estrogen in you is essentially your fat cells, right? Because remember, fat cells express huge amounts of aromatis. So if you give an aromatis inhibitor, you will convert less androgen to estrogen, right? So the umand will have a reduced risk of breast cancer, right? And one subtle point that is floridly high you to know is like those terms, right? You know, you're going to get hot flashes, right? You're going to get hot flashes because you're essentially creating an estrogen deficiency. But one relatively high you thing to know is that anastrosol, letrosol, examesting, those aromatis inhibitors, they actually do not increase your risk of venostromoembolic disease. I'll say that again, they do not increase your risk of venostromoembolic disease or endometrial cancer. It's a subtle difference, but it's a very high your difference compared with tamoxifen because again, they are creating an estrogen deficiency state. You literally will have like essentially like no estrogen around, right? So you're not going to have anything that's going to be increasing your risk of venostromoembolic disease or driving your endometrial lining to cause endometrial cancer, right?

So again, very high you to keep the stuff at the back of your mind, for example, right? And again, I think I've kind of talked about the screen, right? So again, you know, breast cancer, what are some things you may see with breast cancer on an exam? You know, they may give you a clinical video, they may see all the prison feels are lump in your breast, right? Or the person has like some red nipple discharge or the contelita, oh, the person has like nipple retraction and like skin dimplin, right? Or you know, if a person's breast has like an orange peel appearance, right? The poor orange appearance or probably thinking while along the lines of inflammatory breast cancer. And one thing your friends at the MBM are pretty smart with, with inflammatory breast cancer is typically one thing they love to do is they will tell you that oh, they'll put like my stitis as one of the answers and then they'll they can put like examines as one of the answers, right? Don't don't fall for that stuff, right? So if you see that poor orange appearance, very high fever, it kind of looks like an infection, but they'll tell you that oh, the woman has had the stuff for weeks, right? Again, the timeline is very helpful if had it for weeks, if you see that think about inflammatory breast cancer, right? So think about inflammatory breast cancer. So the thing is, you know, if a person has breast cancer and again, it's ERPR positive, again, you can use those agents that I've talked about, right?

Those either like again, if the woman is primal oposal, you use tamoxifen, if the woman is pusman oposal, you can use an aromatics inhibitor like an astrozole, letrozole or extremist thing, right? Well, remember, another classic receptor that these breast malignancies are, are, you know, can express is this hereto receptor, right? The hereto receptor. So remember, the hereto receptor is a membrane bound receptor, right? And it actually has, you know, a lot of tyrosine kind is activated, right? In fact, sometimes, is there putting hereto receptor as an answer choice to mess with your head, you'll put epidermal growth factor receptor, right? Epidermal growth factor receptor. So if a person has breast cancer that expresses hereto, that's actually like a bad prognostic indicator. However, however, however, right? It's a target of a drug known as Tuzumab, right? Remember, Tuzumab is a monoclonal antibody against the hereto receptor that is very good in a treating breast cancers that have that have that hereto receptor positivity, right? So just something to keep in mind, right? For purposes of mbiming exams, right? And I guess maybe another thing I should say is whenever they give you a question about, because breast cancer, you know, you don't just only treat it with, uh, serms or aromatisine inhibitors, you can also classically use these agents, right? Like drugs like, uh, your anthracyclus, right? Like, doxorobecin, donor becin.

Remember, those drugs can cause diluted cardiomyopathy, right? So sometimes they can give you an mbiming question and say, oh, a patient is about to be started on doxorobecin or something like that. And then they'll say, uh, prior to resuming beginning therapy, what's the next best step in management? And typically on an mbiming exam, you want to pick some kind of echocardiogram, right? Because you just want to check and see what's the ejection fraction like. Because if the ejection fraction stands plummeting, you know what's the cause, right? And you're going to obviously go ahead and stop the drug. So remember that your anthracyclus, like doxorobecin, detain to cause an irreversible diluted cardiomyopathy, right? Because they operate the fencing reaction, right? So you have all these theoretical damage, um, uh, and of the cardiac myocytes, right? And then the pressing gets in trouble. I mean, be like divine, what is it the hard that these things go after? Well, think about it. The heart is one of the tissues in the body that uses like the biggest amount of oxygen, right? And remember, oxygen can be converted to many kinds of free radicals, right? So that's how people can get in trouble with this stuff. And again, remember, it can prevent you with dexrazoxin. Dexrazoxin is an iron key leader, right? That is essentially a fencing reaction inhibitor, right?

So that you don't develop that diluted cardiomyopathy that's associated with using anthracyclus, like doxorobecin, right? So remember, doxorobecin because an irreversible diluted cardiomyopathy contrast is we trust two-zumab that causes a reversible. So when you stop the drug, the diluted cardiomyopathy will reverse because it's a reversible diluted cardiomyopathy, right? And then for purposes of those that are taking the USML exams, remember, one immunologic mechanism your friends at the NBME kind of want you to know about as how trust two-zumab helps with treating her two positive breast cancers is that it uses this thin-cold antibody-dependent cellular cytotoxicity ADCC, right? As one of these killing mechanisms, right? So basically, as a monoclonal, it binds to the antigen, right? And then probably like CD16, you know, like the gamma receptor that you find out some immune systems like NK cells can then binds to the constant region of trust two-zumab and then go ahead and that is essentially destroyed the antigen with a bound to which is a her two positive breast cancer cell, right? So that's just something to kind of keep out the back of your mind for exams, right? So what are some other things that I guess classic scenarios that we pop up on a test that you want to keep at the back of your mind? Well, the first one is what's the most common metastatic location for breast cancer, right? It's going to be the axillary lymph nodes, remember?

Accillary lymph nodes are where breast cancer is love to metastasized to, right? And remember, breast cancer is they can met a stasized to bone and cause hypercarsomy of malignancy, right? They love to metastasized to bone and they can cause both ledic and plastic lesions, right? But typically on NBM exams, they're going to go after the plastic lesions, right? The thing is whenever a person has breast cancer like metastasis to bone, one classic NBM equation is they can see which of the following can be done to reduce the presence risk of pathologic fractures or to reduce the presence bone pain. One thing you can classically do on NBM exams to go ahead and perform radiation on that person's bone, right? Radiation therapy really helps, right? But again, if you don't see that as an answer, one thing you can also consider is giving breast phosphonids, right? You can consider giving this phosphonids on NBM exams, remember? This phosphonids are classically associated on NBM's with jaw austenicosis, right? So if you see a person having trouble with showing after they were recently started on therapy for like hypercarsomy, malignancy, breast cancer, I want you to think about jaw austenicosis with, with a, this phosphonids, right? jaw austenicosis with this phosphonids, right? So how do we have our breast, breast lesions, right? Typically again, if you're less than 30 on a NBM exam, you're just going to go ahead and get an ultrasound, right?

Although if you don't see ultrasound as an answer, if you're less than 30, one thing they can do is they can tell you to tell the woman to return if she still sees the symptoms after like one or two menstrual cycles. That's an alternate answer you may see on a NBM exam. But typically for the most part, if you see a breast lesion in the person on the 30, just get an ultrasound, right? Just get an ultrasound. If it's a solid mass, typically if you notice a solid mass, you're going to do a mammogram after that. And with that mammogram, you're going to do a cornydo biopsy because you want to get some kind of tissue diagnosis, right? But if you notice that it's a cystic mass, you can do like a fine new laspiration, right? And if you see like blood from that, from that fine new laspiration, right? If you see blood or something like that, you're going to send it off for cytology, right? Just to make sure that you're not seeing malignancy. So let me repeat this again. If you notice that you do a one on the 30, right? You want to do an ultrasound first, right? If you see a mass, you see a solid mass, go ahead and refer to a person for a mammogram and a cornydo biopsy, right? Mammogram and a cornydo biopsy. But if you see a cystic mass, do a fine new laspiration, right? You do the fine new laspiration, you'll find, if you see like a like blood right or whatever, you're going to go ahead and send it off for cytology to look for to look for malignant cells, right?

So that's something that's kind of high up to to keep out the back of your mind for on exams. Now one bizarre scenario you miss you on an OB-GYN show of exam is the missing, oh, you know what? A woman on the 30 popular breast mass and we did an ultrasound, we didn't find the breast mass and then they'll see what is your next best stepping diagnosis? Do you know what it is? It's to get a mammogram, right? If you don't see a breast mass on ultrasound, the normal one that is on the age of 30, your next best step on an MDM exam will be to go ahead and get to go ahead and get a mammogram, okay? That's very high up to no, but again for a new man over the age of 30 and she has a poppable breast mass, just go ahead and give her, just go ahead and give her a perform a perform a mammogram, right? Go ahead and perform a mammogram, right? That's your next best step in diagnosis, right? And then I think some other things that may help, right? With some of these, I guess breast fins, remember if a person has unilateral blood-in-ipod discharge, again, don't forget, never get this wrong on an exam, right? That's pretty much almost certainly going to be like some kind of intra-doctor papilloma, right? It's going to be some kind of intra-doctor papilloma. And then what if they tell you that you have a woman that is postmenopausal, right? And she has like a greenish breast discharge, right? So she's postmenopausal and she has a greenish breast discharge.

If you see stuff like that, I want you to different, and you know sometimes you may want to tell you that, oh, when you buy up sick the mass, you found like some kind of lymphoplasmacetic infiltrate, that's like their buzzword. If you see stuff like that, I want you to absolutely, absolutely, absolutely think about something called mammary duct ecthesia, right? Think about mammary duct ecthesia. That's actually something your friends at the MBM love to test quite a bit, right? So think about mammary duct ecthesia in those circumstances. And then one other thing that your friends at the MBM love to test is, oh, what is the most important prognostic factor in a person that has breast cancer? Well, it's obviously going to be like axillary lymph node involvement, right? Is it going to be, you know, like axillary lymph node involvement or like metastasis, right? If you've already seen myths, right? Then that's going to be the biggest prognostic factor in that patient on an MBM exam, right? It's going to be the biggest prognostic factor in that patient on an MBM exam. And then, um, remember, they can also ask you a question, I'm just throwing our random scenarios at this point, they can ask, oh, what is the biggest risk factor for breast abscess, right? What is the biggest risk factor for mastitis or breast abscess? I'll really hope that you're telling me that, you know, essentially being a lactating mother, mother is like the biggest risk factor, right?

Being a lactating mother is the is the biggest risk factor on on an MBM exam, right? And again, don't forget your fibrosistic breast disease. I've talked about this in many podcasts, right? You will see like a lot of nodularity in the breast, like lumpy, bumpy breast can't deal, right? And usually the lesions get more painful as the person is about to hit up their men's ears, right? And then in detail, you, oh, this person has like a mobile, well, so comes, right? Like discrete breast mass, right? You want to think about a fibro, you want to think about a fibroidrenoma, right? Or what if they tell you that, oh, you see a question about a person and you know, she was attacked by some, you know, by some bandits or something, and she was punched in the chest, right? Or the person may have just had like a breast biopsy or breast surgery. And then the person has like persistent pain in a part of the breast and you see like a fluid collection. If you see that, I really want you to think about a breast hematoma, right? I really want you to think about a breast hematoma on an in-beaming exam, right? Think about a breast hematoma on an in-beaming exam, right? And again, one thing I just want to say about breast cancer, right? Like, especially for a person who has like DCIS, right? Like Dr. Casunova inside too, there's really no big difference between, there's really no big difference between doing like breast conservation therapy, right? What do I mean by breast conservation therapy?

I just mean like doing like L'Empactomy Plus Radiation versus doing like a mastectomy, right? There's no difference in a, there's basically no difference in survival, but there's an increased risk of local recurrence when you do that breast-conserving therapy where you do a L'Empactomy with with a with a radiation, right? Just something to keep at the back of your mind for, for exams, right? And again, remember if you're doing a lymph node dissection, you want to do a sentinel lymph node dissection first, right? I mean sendinel lymph node biopsy first because you want to, you know, try to reduce the risk of lymphedema for the woman, right? You want to kind of try to reduce that risk. So you're going to do a sentinel lymph node biopsy first. But if it's what they want for you, they need to do that axillary lymph node dissection. And sadly, that axillary lymph node dissection again can increase the risk of chronic lymphedema of the arm and that those things can actually turn my legnant and become like a lymphangio sarcoma, right? Which is unfortunate, again, definitely happens sometimes, that, uh, at least it's something that your friends at the MBM love to test. And again, like I've said, if a person has metastatic breast cancer, you know, you're going to put them on tamoxifen if they're, if they're, um, uh, if they're, uh, uh, if you, you know, on an MBM test, right?

You're going to put, because chemotherapy is what usually will do if a person has metastatic disease of any sort, right? So if a person has metastatic breast cancer of any sort, just go ahead and put them on, on, on, on tamoxifen, right? But again, if they have bone involvement, right? Like hypercosemia or malignancy, the thing you want to do on a test is again, uh, radiation can help, right? But you can also put those people on bisphosphonites. And again, don't forget the osteoenacruxes of the jaw, right? With, with bisphosphonites, right? Don't forget the osteoenacruxes of the jaw with bisphosphonites, right? Don't forget the osteoenacruxes of the jaw with, with bisphosphonites. And again, one thing that I guess I will say, right? If someone gets like radiation therapy to her breast, and then she starts having like this neck mass a few years later. I hope you're thinking about papillary thyroid cancer, right? Remember, the biggest risk factor for papillary thyroid cancer is a prior exposure to like neck, to like neck radiation. Or the maternity, that, oh, the person's having like shortness or breath, chest pain and all those things, right? The person actually probably has like radiation as associated like pericarditis, right? So again, people can get cardiac issues after getting like radiation therapy to the chest on, on endemic exams. So since I'm running for an engagement, I think I'm going to go ahead and stop here.

But again, if you listen to this podcast and you know everything I've discussed here, you're pretty much set from a breast cancer perspective for purposes of your exam. So, as I do at the end of every podcast, I do a for one or one two to learn for many exams, step one, step two, see, step three, pre clinical medical exams, 30-ish-off exams. And I also do it, you know, I also help people with like ERAS applications for residency, especially if you have like all these red flags or you have like an especially tricky application. So please subscribe to the website, divininterventionpodcast.com, right? If I whenever I make a new podcast, you get an email notification. And I also typically, you know, you can find these podcasts on like Apple podcasts, Google podcasts, Spotify. So, you know, subscribe to those. And again, any little bit of support definitely helps. And then if you want my videos, go on You Tube. I have a You Tube channel, Divine Intervention, USMLE Podcasts and Videos. If you subscribe to that, you'll be able to see the videos that I have made. So thank you for listening to this podcast. I'll see you next time. God bless you. Thank you.

Axillary lymph nodes.

Tamoxifen (a SERM). It provides estrogen blockade in the uterus/breast while being less effective at blocking ovarian estrogen sources compared to A Is.

Orange peel appearance, high fever, and a timeline suggesting symptoms lasting for weeks.

Ultrasound examination.

Osteonecrosis of the jaw (ONJ).

Dexrazoxane; it acts as an iron chelator/free radical scavenger.

Having more follicular phases (e.g., early menarche, late menopause, or non-lactating periods).

BRCA1 and BRCA2 mutations.

Bilateral mastectomy plus THBSO (Total abdominal hysterectomy and bilateral salpingo-oophorectomy).

Tamoxifen (SERM).

Mammogram and Core Needle Biopsy.

Antibody-Dependent Cellular Cytotoxicity (ADCC).

Osteonecrosis of the jaw (ONJ).

Having more follicular phases (e.g., early menarche, late menopause, or non-lactating periods).

BRCA1 and BRCA2 mutations.

Bilateral mastectomy plus THBSO (Total abdominal hysterectomy and bilateral salpingo-oophorectomy).

Tamoxifen (SERM).

Mammogram and Core Needle Biopsy.

Antibody-Dependent Cellular Cytotoxicity (ADCC).

Osteonecrosis of the jaw (ONJ).