SAINT BARNABAS HEALTH CARE SYSTEM Clara Maass Medical Center

R O N A L D J. DEL M A U R O President and Chef Executive Officer Saint Barnahas Health Care System

9/22/05

United States Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 1 9406- 14 15

RE: License # 29-03163 - Notification of Change

I _. . '1

To Whom It May Concern:

Please be advised that Clara Maass Medical Center would like to add Karen E. Borofsky, MD to our radioactive materials license as an authorized user for materials listed in 35.400; and Iridium 192 for uses in a High Dose Rate Remote Afterloading Brachytherapy Device.

Dr. Borofsky's credentials are attached for your review

If you require additional information, please contact us at your earliest convenience.

Sincerely,

Vincent M. Immerso, MS, DABR Radiation Safety Officer

Thomas A. Biga

vvcp

N~JSS/RG?J ?u!ATERIALS-OX ...... ONE C L A R A M A A S S DRIVE 8 BELLEVILI.E, NEW jERSEY u71OY (973) 450-2000 ......

Saint Barnahas 1 Icalth Carr S!.htrm - New jrrsey's hcalth care 1cadc.r.

Karen Loeb Borofsky, M.D. Clara Maass Medical Center

Department of Radiation Oncology 1 Clara Maass Drive

EDUCATION

July 2001 -June 2005

July 2000-June 200 1

July 1996-May 2000

August 1993-May 1996

August 1992- May 1993

WORK EXPERIENCE

August 2005- present

PAPERS

Resident Physician in Radiation Oncology Department of Radiation Oncology Mount Sinai School of Medicine, New York, New York

Chief Resident (January 2004-present)

Internship in Internal Medicine Department of Medicine Columbia University New York Presbyterian Hospital

Doctor of Medicine, M.D. State University of New York at Stony Brook

Chapter President of the American Medical Association

Bachelor of Science, Biology Binghamton University

CumLaude

Washington University in Saint Louis

Clara Maass Medical Center Department of Radiation Oncology

J.A. Cesaretti, M.D., R.G. Stock, M.D., S. Lehrer, M.D.,D.A. Atencio, PH.D., J. L. Bemstein, PILD., N. N. Stone, M.D., S. Wallenstein, PH.D., S. Green, M.D., K. Loeb, M.D.,M. Kollmeier, M.D., M. Smith, M.D., B. S. Rosenstein, PH.D. “ATM Sequence Variants are predictive of Adverse Radiotherapy Response Among Patients treated for Prostate Cancer.” Int. J . Radiation Oncology Biol. Phys., Vol. 61, No. 1, pp. 196-202, 2005

I

Consortium on Graduate Medical Education - Elected to review all aspects of graduate medical education for all members of the consortium including content of curriculums, size of residency programs and all internal reviews. The commipe@dizes a number of subcommittees to carry out its duties. *

House Staff Affairs - Elected to serve on this committee serves as the adjudication body for appeals on adverse actions involving the House Staff.

MEDICALSoclETIES

Amen& Society for Therapeutic Radiation and Oncology American Society of Clinical Oncology American Cancer Society New York Roentgen Society American Medical Association American Brachytherapy Society

LICENSE

New York State 22 1693 New Jersey 25h4A07850700

119

Program Number / Program Name 4303521 1 19/Mount Sinai CityBtate ]New YotkMY

Supplement C 200j!-200~RADIATION ONCOLOGY RESIDENT EXPERIENCE LOG

The completed form should be given to the Program Director by July 1,2002, To be completed by the Program Director:

J

Resident Name Karen Locb-Borofsky lsignaturel fl/&fi b S

- Time Period to be Covered by h g From: 7/1/01 ITo: 6/30/02 c

List institutions used for outside rotations: Dates: From - To 1. 2. 3.

1.

Elmhurst 4/1102-6/30/02

~~ ~~

Adult External Beam Simulated: Primary Site (Non-Metastatic Disease): t&!EEi

33

7

0 0 6 2 0 33 1 0 0

Breast: Intact Breast: Post-Mastectomy BondSoft Tissue Sarcoma Central Nervous System Head/Neck: Intact Hearneck: Post- operative Gastrointestinal: Esophagus Gastrointestinal: Stomach Gastrointestinal: Pancreas Gastrointestinal: Hepato biliary Gastrointestinal: Colon Gastrointestinal: Rectum Gastrointestinal: Anus Gastrointestinal : Other Genitourinary: Prostate Genitourinary: Bladder Genitourinary: Testes Genitourinary: Other

9 3

10 2 1

Gynecologic: Cervix Intact Gynecologic: Cervix Post-Hysterectomy Gynecologic: Uterus

Gynecologic: 0 t h ~ Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma

7 Leukemia / Myeloma

Other Hematologic Malignancies

Skin

Thorax: Small Cell Lung Cancer

6 1 1 0 3 0

a) - 147- Total Primary Site Adult External

Thorn: Non-small Cell Lung Cancer Thorax: Other Benign: Hetcrotopic Bone Benign: Eye Benign: Other (does notj;! in other cutegoria) All Others (Give Examples)

Beam Simulated (total of both columns above) b) -45- Total Secondary (Metastatic) Adult External Beam Simulated p o t Covered Above Under Primary Sire) C) -192- TotaJ Adult External Beam Simulated Cases (Primary Plus Secondary [c equals toial cases e plus b])

2. Pediatric External Beam Simulated: 120

~ ~

Medulloblastoma CNS Won-Medulloblastoma)

on Outside lastitution(s) # Simulnttd

/Leukemia I I

€wing’s Sarcoma / Bone Tumor Neuroblastoma . Retino blastoma ’

.

I

r Hodgkins’s Lymphoma Non-Hodakins’s LvmDhoma

1 I

Wilms’ Tumor I I

Y I

Rhabdomyosarcoma / STS I I I

Surface Applications (moulds, plaque, Sr-90) Unscaled Sourccs (e.g. 1-131 oral, P-32 colloid, Sr- 89,

Other: Describe case(s) for Primary or other institution

4. Specific Rsdlotbenpy Techniques: Cases As Primary Resident in Treatment Planning

# Simulated Mantle 1

Craniospinal Total Body Irradiation 3 Total Skin Irradiation Stcreotactic Radiosurgery: Brain 1 Stcreotactic Radiosurgery: Other

121

Supplement C 122 2002-2003 RADiXTION ONCOLOGY RESIDENT EXPERIENCE LOG

1

The completed form should bk given to the Program Director by July 1,2003. To be completed by the Program Director:

Program Number / Program Name 4303521 1 19/h.lount Sinai City/State New York/NY

Resident Name ' Karen Locb-Borofsky Signature[ fl# -&e--- ,

Time Period to be Covered by Log From: 71 1 /02 To: 6130103 r a

List institutions used for outside rotations: Dates: From - To I . 2. 3.

1. Adult External Beam Simulated: Primary Site (Non-Metartatic Disease): # cases 35 9

2 3 1

8

3

3

4

2 0 43 1 0 0

Breast: Intact Breast: Post-Mastectomy BondSoft Tissue Sarcoma Central Nervous System Hearneck: Intact HeadMeck: Post- operative Gastrointestinal: Esophagus Gastrointestinal : Stomach Gastrointestinal: Pancreas Gastrointestinal: Hepatobiliary Gastrointestinal: Colon Gastrointestinal: Rectum Gastrointestinal: Anus Gastrointestinal: Other Genitourinary: Prostate Genitourinary: Bladder Genitourinary: Testes Genitourinary: Other

0 2

13 2 0

6

OD

0

0

0 3 I

-

Gynecologic; Cervix Intact Gynccologic: Ccrvix Post-Hysterectomy Gynecologic: Uterus

Gynecologic: Other Hodgkin's Lymphoma Non-Hodgkin's Lymphoma

Leukemia 1 Myeloma

Other Hcmatologic Malignancies

Skin

Thorax: Small Cell Lung Cancer

Thorax: Non-small Ce!l Lung Cancer Thorax: Other Benign: Heterotopic Bone Benign: Eye Benign: Other (does noffif in ofher curegotfes) All Others (Give Examples)

4 - 149 Total Primary Site Adult External Beam Simulated (total of both columns above) b) -29- Total Secondary (Metastatic) Adult External Beam SirnuJated (Poi Covered Above Under Primary Site) c) - 178- Total Adult Extcrnal Beam Simulated Cases (Primary Plus Secondary [c equals total cases a plus b))

123 2. Pediatric External Beam Simulated:

Neuroblastoma Retinoblastoma Wilms' Tumor

..

1

Orher: Describe case@) for Primary or other institution

Surface Applications {moulds, plaque, Sr-90) Unsealed Sources :e.g 1-1 3 1 oral, P-32 colloid, Sr- 89, Srn- 153, other) fEndovascular Insertions

I !

,

I

4. Specific Radiotherapy Techniques: Cnses As Primary Resident in Treatment Planning

Mantle Craniospinal Total Body Irradiation Total Skin Irradiation Stereotactic Radiosurgery: Stereotactic Radiosurgery:

# Simulated I

Brain 1 Other

/

'1 24

Supplement C 125

200~-20~RADlATION ONCOLOGY RESIDENT EXPERIENCE LOG I

The completed form should be given to ihe Program Director by July 1,2004. To be completed by tbe Program Director:

Program Number I Program Name 430352 1 1 19/Mount Sinai CityIState N

List institutions used for outside rotations: Dates: From - To

Resident Name Karen Loeb-Borofsky Signature@- 4/4C& / , Time Pcriod to be Covered by Log From:7/1/03 To: 6/30/04

1. 2. 3.

1.

Memorial Sloan Kettering Cancer Center ll3104-313 1 /04

- --

Adult External Beam Simulated: Primary Site (Non-Metastatic Disease): # Cases

13 . 0

2 0 3 0 0 49 0 2 0

Breast: Intact . Breast: Post-Mastectomy BoneISoft Tissue Sarcoma Central Nervous System HeadMeck: Intact HeadMeck: Post- Operative Gastrointestinal: Esophagus Gastrointestinal : Stomach Gastrointestinal : Pancreas Gastrointestinal: Hcpatobiliary Gastrointestinal: Colon Gastrointestinal: Rectum Gastrointestinal: Anus Gastrointestinal: Other Genitourinary: Prostate Genitourinary: Bladder Genitourinary: Testes Genitourinary: Other

3 Gynecologic: Cervix Intact GynecoIogic: Cervix Post-Hysterectomy Gynecologic: Uterus

Gynecologic: Other Hodgkin's Lymphoma Non-Hodgkin's Lymphoma

Leukemia / Myeloma

Other Hematologic Malignancies 0

0

3 3 0

_I__

0 0 1

Skin

Thorax: Small Cell Lung Cancer

Thorax: Non-small Cell Lung Cancer Thorax: Othcr Benign: Heterotopic Bone Benign: Eye Benign: Other (does norfir in other caregories) All Others (Give Examples)

- a) - 1 08- Total Primary Site Adult External Beam Simulated (total of both columns above) b) -1 8- Total Secondary (Metastatic) Adult External Beam Simulated @of Covered Above Under Primary Site) c ) 126- Total Adult External Beam Simulated Cases (Primary Plus Secondary [ c c q u r l ~ l o t l l c ~ ~ P i m w-

2. Pediatric External Beam Simulated:

3ther: Describe case(s) for Primary or other institution

. I- I3 1 oral, P-32 aolloid, Sr- 89,

126

4. Specific Radiotherapy Techniques: Cases As Primary Rcaident in Treatment PGnnlng

## Simulated I Mantle I

Craniospinal 1 Total Body Irradiation 5

Stereotactic Radiosurgery: Brain 2 Total Skin Irradiation

Stereotactic Radiosurgery: Other

127

Resident Experience Report

Program ID: 4303521 119 Program Name: Mount Sinai School of Medicine Program at All Institutes liaren e. loeb

For All %pes in All Areas and All Groups Donc Between 7/1/2004 And 6/21/2005

For Procedures in All Ycars For All Resident Roles

NOTE: Thc Progrm Director i n rcsponsiblc Tor validating thc acouracy of the don in this record. Records signed by both thc resident and Program Di rum must be kept on filc in thc Program OtTm Records scnt to the Residency Rcvicw Committee Oftice MUST bc signed by the Program Dircctor.

GI2 ?‘200! 4

.

~

Resident and Fellow Privileges Granted - Consortium for Graduate Medical Education - ... Page 1 of 2

Back to Searches 1 Bark to list of Residents

Name Hospital Specialty

Privileges Granted:

RT-04-

Application of Radiopaque Clips

RT-OSA-

Catheterlzation and Injection of Inbavesical Co nbast for Simulation

RT-12-

Clinical Determination of Treatment Fltlds

RT-10-

Defining Target Volume and Outlining Blocks on Simulation Films

UT- 14-

Determine the Appropriateness and Carry Out the Planning of A Bnchythempy Procedure

RT-11-

Evaluation of Physics Treatment Plan

RT-09-

Evaluation of Simulation and Portal Films

RT-06-

Injection of Intravenous Contmstfor Simulaaion

RT-03-

Insertion of Vaginal Tube/Rectal Tubes

RT-06A-

Instillation of Intraluminal Contrast for Simulation

RT-21-

Loading and Unloading Ra dioacbive Material

RT-07-

Outiining Tumor Volume and Critical Organs on Ct\Mri

RT-23-

petform ing Survey for Radioactive M aterial

RT-16-

Placement and Removal of Intracavitary Applicators

RT-22-

http://fusion.mssm.edu/privileges/nghtsquery_drilldown.cfm?ResID=5064 5/2 1 I2004

Resident and Fellow Privileges Granted - Consortium for Graduate Medical Education - ... Page 2 of 2

Treatment with A Remote Afterbad-

RT-05-

Venipuncture J

Copyright 0 20%. Mwnt Sinai School of Medicine. Ali RicjbS Reserved. This site is maintained by the Web Develonrnent Office.

http://fusion.mssm.edu/privileges/rightsquery - drilldown.cfm?ResID=5064 512 1/2004

This is to acknowledge the receipt of your letter/application dated

'/z2/bJ , and to inform you that the initial processing which includes an administrative review has been performed.

- c > 3 / 6 3 - c i 3 d There &-Vd were no administrative omissions. Your application was assigned to a technical reviewer. Please note that the technical review may identify additional omissions or require additional information.

0 Please provide to this office within 30 days of your receipt of this card

A copy of your action has been forwarded to our License Fee & Accounts Receivable Branch, who will contact you separately if there is a fee issue involved.

Your action has been assigned Mail Control Number /3 7 755 When calling to inquire about this action, please refer to this control number. You may call us on (610) 337-5398, or 337-5260

NRC FORM 532 (RI)

(6-98)

Sincerely, Licensing Assistance Team Leader