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

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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:

SLIDE 1

3/7/2015 1

Training and practice of breast surgery: international variation

Alastair M Thompson Professor of Surgery athompson1 @ mdanderson.org

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

MD/PhD research)

Entry/exit examinations
Oncoplastic breast Fellowships (1 year)

(~10) per year in the UK

Separation of breast from general surgery as a

specialty oft proposed, not yet actioned

Training in the UK

Surgical training:

National matching process
Requirement to pass written and viva examinations

(Membership of the Royal College of Surgeons of Edinburgh or England or Ireland or Glasgow); ATLS;

ther basic courses (eg endoscopy, laparoscopy)
6 monthly assessments of competency (clinical

/surgical skills, teaching, administration, academic)

Intercollegiate “Board” exams in general surgery

(with specialist interest possible)

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]

SLIDE 2

3/7/2015 2

Australia and New Zealand*

Postgraduate surgical training is organized by the

surgical societies – Breast Surgery ANZ

Fellowship positions are centrally administered,

though some remain under the control of institutions and individuals

Willingness to accept international applicants

who are well trained – different approach to high quality care

Some Australasian surgeons chose to do their

Fellowship abroad

*Prof Bruce Mann, Director of Breast Service, Royal Melbourne and Royal Women’s Hospital

Who does what elsewhere?

Similar training across Europe

Threat of the European working time directive
In Germany, the gynaecologists are the breast

surgeons Specialist breast surgery accreditation available in Europe (but not recognised in the UK) Globally:

UK aligned models in the British Commonwealth
In South Korea some breast surgeons give

chemotherapy

Who does what elsewhere?

Training and certification of Surgical Oncologists Globally: there is global variation*

6 WHO regions: Africa, Americas, Eastern Med,

Europe, SE Asia, Western Pacific

Life expectancy, education, income: to create

high, medium or low Human Development Index (HDI) countries

*Chandrakanth A et al Ann Surg Oncol 2015 22:710-718

Who does what elsewhere?

Training and certification of Surgical Oncologists Globally: there is global variation*

6 WHO regions: Africa, Americas, Eastern Med,

Europe, SE Asia, Western Pacific

Life expectancy, education, income: to create

high, medium or low Human Development Index (HDI) countries

*Chandrakanth A et al Ann Surg Oncol 2015 22:710-718

SLIDE 3

3/7/2015 3

Who does what elsewhere*?

Country US S Africa Pakistan China Australia Norway HDI 0.937 0.629 0.515 0.699 0.938 0.95 Population 319 M 53 M 188 M 1,365 M 24 M 5 M Inhabitants/ physician 400 1,000 1,250 526 303 230 Fellowship requirement Yes Yes Yes Yes Yes No Total years training 15-17 17-18 15 17 14-17 16

*Chandrakanth A et al Ann Surg Oncol 2015 22:710-718

Remarkable similarities

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]

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]

TARGIT Trial of intrabeam intraoperative radiotherapy

*Vaidya J et al Lancet Oncology 2013

SLIDE 4

3/7/2015 4

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]

Preoperative window trials

In vivo tumor drug/biomarker target testing
Pre-operative setting: “window of opportunity”

before surgery…….duration?

Preoperative window trials

In vivo tumor drug/biomarker target testing
Pre-operative setting: “window of opportunity”

before surgery…….duration?

Evidence for biological effects of metformin in
perable breast cancer: a pre-operative, window-
f-opportunity, randomized trial* **

*Hadad et al. Breast Cancer Res Treat 2011;128(3):783-94 **Hadad et al. Breast Cancer Res Treat 2015; online 15th February

Preoperative window trials

In vivo tumor drug/biomarker target testing
Pre-operative setting: “window of opportunity”

before surgery…….duration?

Evidence for biological effects of metformin in
perable breast cancer: a pre-operative, window-
f-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 2015; online 15th February ***Schmid et al. SABCS 2014, oral presentation

SLIDE 5

3/7/2015 5

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]

R R R Some philosophy

Multidisciplinary elements to training in breast

surgery*

Proud tradition of international surgical

leadership in prevention, screening, 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

SLIDE 6

3/7/2015 6

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