1. FRCS General Surgery exam: tips for breast trainees in line with the new examination format Mr Baek Kim FRCS MD MA ST7 General Surgery Yorkshire deanery Mammary Fold education and training rep 2016

2. Application process Outcome 1 at ST6 ARCP is required for eligibility with use of the ST6 checklist Send up to date CV, logbook, and three references including from the training programme director Part 1: MCQ and EMI questions Part 2: Viva and clinicals

3. Part I Two papers: MCQ paper in the morning and EMI in the afternoon. Tests breath of knowledge in General surgery Few questions on breast surgery Greater emphasis on emergency general surgery Exams conducted in driving centres

4. Recommended books and websites for part I www.efrcs.com www.onexamination.com FRCS general surgery: 500 SBAs and EMIs by Wilson et al (green book) Rush university medical center review of surgery: expert consult- online and print (quite detailed but the online version is useful for question practise)

5. Practise attempting questions in a timed setting In the actual exam there is little time to spare and there will be ambiguous questions with more than one potential right answer Pass mark around 70% at the last sitting in 2015. The marks from the two papers are combined for a final mark.

6. Part two Viva: whole day comprising of 4 sections Emergency/trauma/critical care (30 minutes): x6 questions with about 5 minute per question General surgery (30 minutes): as above Academic viva and principle of surgery/basic science (30 minutes): 30 minutes to read a breast paper. 15 minutes to critique paper followed by 15 minutes testing knowledge in breast surgery (including basic science).

7. Breast specialty viva (30 minutes): x6 questions with about 5 minute per question Clinicals: half day comprising of one long case (20 minutes) and two short cases (10 minutes each) Therefore, 40 minute general surgery clinical and a further 40 minute breast clinical

8. Tips for part two Revise with other registrars and practice answering viva questions (ideally a GI trainee and breast trainee also) Ask consultants for viva practice. Some deaneries have mock viva sessions. Utilise clinics to fine tune history taking and examination skills- significant amount of the clinicals are spent taking detailed history and examination just like in day-to-day clinics. Practice presenting in journal clubs with focus on how to critique breast papers Get used to interpreting CT scans (very common to be shown radiological images during the exam)/ questions on consenting for common procedures Courses are of high value (e.g. Manchester alpine course and Whipps cross course etc.)

9. Reading list for part two Cracking the intercollegiate general surgery FRCS viva by Ball, Walsh, and Tang FRCS: companion cases for the intercollegiate exam in general surgery by Kumar and Phillips NICE guidelines: can be downloaded as an app onto iPad ATLS manual Companion series Surgical critical care vivas by Kanani (used for MRCS- also useful for FRCS)

10. Useful literature on family history Ibis I: RCT including pre and post menopausal women. Increased risk FH patients randomised to tamoxifen versus none. 16 years follow up showed benefit of using tamoxifen with HR 0.71. Ibis II: RCT post menopausal women only. Increased risk FH patients randomised to anastrozole versus none. 5 year follow up showed benefit of using anastrozole with HR 0.5. NSABP P1: Tamoxifen versus placebo for 5 years. 49% reduction in incidence of breast cancer. Greatest benefit seen in pre-menopausal B3 patients. FH01: Investigation of performing mammograms from age of 40-49 in intermediate risk FH group FH02: Investigation of extending mammogram to <40 years old NICE family history guideline

11. Useful literature on axillary management Z11: Patients with T1/2 cancers with one or two positive nodes randomised to WLE + SNB + Radiotherapy vs. WLE + SNB + ANC. 6 year follow up. No difference in DFS and OS between two groups. Higher arm morbidity with lymphodema rate of 12% (ANC) vs. 2% (SNB). AMAROS: Radiotherapy versus ANC in T1/2 cancers after positive sentinel nodes. No difference in local recurrence at 5 years (1 vs. 0.5%). No difference in DFS. Lymphodema rate of 28% (ANC) vs. 14% (radiotherapy). ALMANAC: Reduced arm morbidity in SNB group versus ALND group. Reduced rate of lymphodema and sensory loss (HR 0.37). Better quality of life and arm function. POSNOC: Includes patients receiving BCS and mastectomy. 1 or 2 positive SN then patients are randomised to adjuvant therapy vs. adjuvant therapy and radiotherapy / ANC. Primary outcome axillary recurrence at 5 years. ABS consensus statement on axillary management: http://www.associationofbreastsurgery.org.uk/media/48727/axilla_abs_consensus_stateme nt_16_3_15.pdf http://www.associationofbreastsurgery.org.uk/media/48727/axilla_abs_consensus_stateme nt_16_3_15.pdf

12. Useful literature on endocrine therapy ATAC: RCT post menopausal women. 5 years adjuvant endocrine therapy with Anastrozole superior to tamoxifen (HR 0.87 DFS and 0.86 distant metastasis). ATTOM: 10 versus 5 years of tamoxifen. Benefit seen year 7-9 (HR 0.84) and 9+ (HR 0.75) in terms of disease recurrence. Improved breast cancer mortality HR 0.77 at 9 years plus. Increase in rate of endometrial cancer however. Oxford overview: Tamoxifen versus no adjuvant endocrine therapy. Risk reduction for up to 10 years on recurrence (RR 0.53 and 0.68) and breast cancer specific survival (RR 0.71/0.66/0.68) for up to 15 years. BIG 1-98 (letrozole vs. tamoxifen/ IES (intergroup exemestane study)

13. Useful literature on radiotherapy Oxford overview: Radiotherapy after BCS reduces 10 year recurrence from 35 to 19%. Absolute risk reduction of 4% (25 to 21) for 15 year breast cancer death. Remains same for N0 cancer. Greater benefit seen in node positive patients. One death avoided at 15 years for every four recurrences avoided at 10 years. Oxford overview: PMRT in 1-3 node positive patients. Reduction in recurrence and mortality observed even with systemic therapy. Studies from 1960-1980s however. SUPREMO trial: Investigation of benefit of PMRT in patients with T1/2 N1 cancer (intermediate risk group) after mastectomy and ANC

14. Useful literature on chemotherapy Oxford overview: AC equivalent to CMF but with AC higher dosage achievable. Taxanes added to AC confer benefit- RR 0.86 NICE guideline on adjuvant chemotherapy regime: early and locally advanced breast cancer/ advanced breast cancer (http://pathways.nice.org.uk/pathways/advanced- breast-cancer/advanced-breast-cancer-chemotherapy- and-biological-therapy.pdf)/ indications for Oncotype Dx.http://pathways.nice.org.uk/pathways/advanced- breast-cancer/advanced-breast-cancer-chemotherapy- and-biological-therapy.pdf

15. Further tips Don't forget about benign breast disease (e.g. management of nipple discharge and gynaecomastia) Questions based on management of patients with family history of breast cancer and BRCA mutation common in recent examinations Clinicals have greater emphasis on oncoplastic management of breast reconstructions patients (e.g. strategies to improve symmetry) Pair of examiners ('hawks and doves')- keep composure as the examiners swap after 15 minutes of vivas with contrasting style of questioning. 50% of marks are allocated to breast topics so potentially more advantageous for breast trainees? Previously lesser emphasis on breast surgery.

16. Marks are averaged so you cannot fail on a bad station. You will have bad stations but marks can be made up in other stations. You have to score average of 6/8 overall. Useful further guidelines on the ABS website: http://www.associationofbreastsurgery.org.uk/publications/guidelin es/?page=1 http://www.associationofbreastsurgery.org.uk/publications/guidelin es/?page=1 The questions asked in the exams are common conditions you encounter in your normal clinical practice. Passing both parts of the FRCS at ST7 level is likely to stand you in good position for those applying for the TiG oncoplastic fellowship. Good luck!