Training in the UK All trainees now have 5-6 years undergraduate; 2 - PowerPoint PPT Presentation

3/7/2015 Training in the UK • All trainees now have 5-6 years undergraduate; 2 years postgraduate prior to full registration • Surgical training then 6-8 years (+/- 1-3 years Training and practice of breast MD/PhD research) surgery: international variation • Entry/exit examinations • Oncoplastic breast Fellowships (1 year) Alastair M Thompson (~10) per year in the UK Professor of Surgery • Separation of breast from general surgery as a athompson1 @ mdanderson.org specialty oft proposed, not yet actioned Training in the UK Training in the UK Breast surgery: Surgical training: • Three levels of training • National matching process • Wide variations in oncoplastic/reconstructive • Requirement to pass written and viva examinations training (including Fellowships) (Membership of the Royal College of Surgeons of • Breast screening, family history services, all Edinburgh or England or Ireland or Glasgow); ATLS; breast conditions, benign and malignant. other basic courses (eg endoscopy, laparoscopy) • FNA, core biopsy, breast , ultrasound, IORT, trials • 6 monthly assessments of competency (clinical methodology, translational research /surgical skills, teaching, administration, academic) • [historically breast/endocrine; breast/melanoma; • Intercollegiate “Board” exams in general surgery breast/general/emergency] (with specialist interest possible) 1

3/7/2015 Australia and New Zealand* Who does what elsewhere? Similar training across Europe • Postgraduate surgical training is organized by the • Threat of the European working time directive surgical societies – Breast Surgery ANZ • Fellowship positions are centrally administered, • In Germany, the gynaecologists are the breast though some remain under the control of surgeons institutions and individuals Specialist breast surgery accreditation available in • Willingness to accept international applicants Europe (but not recognised in the UK) who are well trained – different approach to high Globally: quality care • UK aligned models in the British Commonwealth • Some Australasian surgeons chose to do their • In South Korea some breast surgeons give Fellowship abroad chemotherapy *Prof Bruce Mann, Director of Breast Service, Royal Melbourne and Royal Women’s Hospital Who does what elsewhere? Who does what elsewhere? Training and certification of Surgical Oncologists Training and certification of Surgical Oncologists Globally: there is global variation* Globally: there is global variation* • 6 WHO regions: Africa, Americas, Eastern Med, • 6 WHO regions: Africa, Americas, Eastern Med, Europe, SE Asia, Western Pacific Europe, SE Asia, Western Pacific • Life expectancy, education, income: to create • Life expectancy, education, income: to create high, medium or low Human high, medium or low Human Development Index (HDI) Development Index (HDI) countries countries *Chandrakanth A et al Ann Surg Oncol 2015 22:710-718 *Chandrakanth A et al Ann Surg Oncol 2015 22:710-718 2

3/7/2015 Who does what elsewhere*? Training in the UK Breast surgery: Country US S Africa Pakistan China Australia Norway • Three levels of training HDI 0.937 0.629 0.515 0.699 0.938 0.95 • Wide variations in oncoplastic/reconstructive Population 319 M 53 M 188 M 1,365 M 24 M 5 M Inhabitants/ 400 1,000 1,250 526 303 230 training (including Fellowships) physician • Breast screening, family history services, all Fellowship Yes Yes Yes Yes Yes No requirement breast conditions, benign and malignant. Total years 15-17 17-18 15 17 14-17 16 • FNA, core biopsy, breast , ultrasound, IORT, trials training methodology, translational research • Remarkable similarities • [historically breast/endocrine; breast/melanoma; breast/general/emergency] *Chandrakanth A et al Ann Surg Oncol 2015 22:710-718 TARGIT Trial of intrabeam Training in the UK intraoperative radiotherapy Breast surgery: • Three levels of training • Wide variations in oncoplastic/reconstructive training (including Fellowships) • Breast screening, family history services, all breast conditions, benign and malignant. • FNA, core biopsy, breast , ultrasound, IORT , trials methodology, translational research • [historically breast/endocrine; breast/melanoma; breast/general/emergency] *Vaidya J et al Lancet Oncology 2013 3

3/7/2015 Training in the UK Preoperative window trials • In vivo tumor drug/biomarker target testing Breast surgery: • Pre-operative setting: “window of opportunity” • Three levels of training before surgery…….duration? • Wide variations in oncoplastic/reconstructive training (including Fellowships) • Breast screening, family history services, all breast conditions, benign and malignant. • FNA, core biopsy, breast , ultrasound, IORT, trials methodology , translational research • [historically breast/endocrine; breast/melanoma; breast/general/emergency] Preoperative window trials Preoperative window trials • In vivo tumor drug/biomarker target testing • In vivo tumor drug/biomarker target testing • Pre-operative setting: “window of opportunity” • Pre-operative setting: “window of opportunity” before surgery…….duration? before surgery…….duration? • Evidence for biological effects of metformin in • Evidence for biological effects of metformin in operable breast cancer: a pre-operative, window- operable breast cancer: a pre-operative, window- of-opportunity, randomized trial* ** of-opportunity, randomized trial* ** • Pictilisib (GDC0491)*** • 42….70…..140 patients *Hadad et al. Breast Cancer Res Treat 2011;128(3):783-94 *Hadad et al. Breast Cancer Res Treat 2011;128(3):783-94 **Hadad et al. Breast Cancer Res Treat 2015; online 15 th February **Hadad et al. Breast Cancer Res Treat 2015; online 15 th February ***Schmid et al. SABCS 2014, oral presentation 4

3/7/2015 Training in the UK Breast surgery: • Three levels of training • Wide variations in oncoplastic/ reconstructive training (including Fellowships) • Breast screening, family history services, all breast conditions, benign and malignant. • FNA, core biopsy, breast , ultrasound, IORT, trials methodology, translational research • [historically breast/endocrine; breast/melanoma; breast/general/emergency] Some philosophy R R • Multidisciplinary elements to training in breast surgery* • Proud tradition of international surgical leadership in prevention, screening, R neoadjuvant and adjuvant trials • Surgical training never stops – Travelling Clubs, visiting Professorships (King James IVth Society) • Surgeons educating others (never stops!) *Thompson AM What is the future for surgical oncology? Brit J Cancer 2011; 105: 1627 5

3/7/2015 Conclusions • There appears to be “consistency” in training internationally despite differences in requirements for service provision • Breast surgical training is still evolving, as breast services develop and evolve • Enormous opportunities………….and variations around the world 6