mammary fold

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_statem
ent_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.

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
• 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!