National Oncoplastic Breast Fellowships: Why plastic surgeons should want to do one and how to successfully obtain one

Rachel Tillett National Oncoplastic Breast Fellow

Training Interface Groups (TIG) National Oncoplastic Breast fellowships have had few plastic surgery trainees apply for the posts, with approximately 10% of all previous fellows being from the specialty of plastic surgery. The TIG committee and senior plastic surgery trainers have actively encouraged and promoted these highly prestigious fellowships to plastic surgery trainees and yet there still appears a reticence to apply, with potential candidates perhaps not appreciating the benefit of a interspecialty training Plastic surgery trainees wanting to specialise in breast surgery feel that they need to gain experience in free flap reconstruction. Whilst this is true, it is possible to gain this experience during training or during a microsurgical fellowship. Breast surgery is evolving rapidly and it is an exciting subspecialty. As plastic surgeons, we need to maintain our presence within breast surgery, so that patients with breast cancer benefit from our highly specialised skills. We need to engage fully in the multidisciplinary team. Completing a TIG oncoplastic fellowship is an excellent way to gain experience within the breast and plastic surgery multidisciplinary team. The National Oncoplastic Breast Interface fellowships are highly competitive and selective. Successful candidates will find that employment potential will improve post-fellowship. Being able to work within the multidisciplinary breast team and perhaps, offer both resectional and reconstructive work to a trust, will make you an attractive proposition. Plastic surgery fellows develop oncological knowledge and practical skills, gain breast MDT experience, learn to speak the same language as breast surgeons, improve communication with patients and colleagues and the fellowships provide excellent networking and mentoring opportunities. Surgeons possessing the complete armamentarium of breast oncological and reconstructive skills will help to provide excellent patient care. So why do an oncoplastic breast fellowship? The new Oncoplastic guidelines Oncoplastic breast Reconstruction: Guidelines for Best Practice state that newly appointed consultants with a breast sub specialty interest, in plastic or breast surgery, should have completed an Interface Oncoplastic Breast fellowship or equivalent1. So if trusts follow the guidelines, it will help you get a consultant post. The new ISCP advanced years curriculum (years 7 and 8) in Plastic Surgery states in the breast reconstruction topic that trainees must understand relevant associated disease and conditions including carcinoma of the breast and its treatment2. This fellowship, along with the MS in Oncoplastic Breast Surgery organised by the University of East Anglia should be a huge encouragement to plastic surgeons wanting to enter the field.

There are very few consultant plastic surgeons nationally who are able to influence the reconstructive decisions that are made by patients diagnosed with breast cancer, since they do not have their own results clinics. Patients are only usually referred onto plastic surgeons if they would like free flap breast reconstruction. It is difficult to present a completely unbiased view of different options available to patients if they are not all available locally. If we want to increase the number of patients who have free flap breast reconstruction we need to collaborate with our breast surgery colleagues, and develop and be present at the breast MDTs. Furthermore, it is not just free flap reconstruction that we are uniquely able to offer patients: volume replacement can be performed using LiCAP and TDAP perforator flaps, which are gaining popularity as reconstructive techniques. We are also ideally placed to perform therapeutic mammoplasty, through our training in different pedicles used for breast reductions. This is plastic surgery at its best: planning and filling soft tissue defects, while maintaining breast aesthetics. To participate fully in these areas in is imperative that plastic surgeons understand breast oncology. Being able to perform a good quality subcutaneous mastectomy when doing free flap breast reconstruction is extremely useful. It reduces the logistical complexity of organising these operations, and ensures that the plastic surgeon is responsible for creating a good envelope. Plastic surgeons who are trained to do their own mastectomies do not feel it hinders the rate of progress of their cases. It can also be argued that plastic surgeons doing resectional work are very aware of reducing the risk of local recurrence and would certainly ensure a good oncological clearance. Understanding the discussions that underpin the indications to give postoperative radiotherapy and the likelihood of this being necessary will also help inform patients when discussing immediate reconstruction. Patients also appreciate plastic surgeons answering some of the oncological questions rather than constantly claiming ignorance and referring patients back to their breast surgeon. The fellowships themselves are extremely well organised and provide a large amount of operative and outpatient experience. The year is accompanied by some valuable courses. There is a 3 day cadaveric course in Newcastle (where there were 13 faculty and 8 fellows, including Prof Hamdi teaching us how to raise a LiCAP flap), a fellow's course in Liverpool, a residential management course (held in Dublin this year), the Politics, Power and Persuasion course to which all fellows are invited and the courses are funded. You are also eligible for 1000 study leave budget. The units offering fellowships are well placed around England and although it might be anticipated that fellows might all want to go to the most prestigious units, practically this is not the case, and many fellows opt to stay closer to home. So how do you get short listed? The first hurdle is to ensure that you are eligible. You need to look at the Severn deanery website under subspecialty posts and tick the box to look at previous posts, please check this with the Severn Deanery and JCST website for the most up to date information 3,4. The website will have details on the application process. You need to have the first part of the exit exam, but not the second part. For my round of applications everyone had completed their exit exams. In order to score well, you need to have relevant breast experience and demonstrate that you are interested in oncology. You

also need to show that you have some breast relevant research and audit. You need to have been on relevant courses and shown some interest in teaching and IT. I spent time attending breast clinics and breast MDTs. I also completed the distance learning breast disease management course organised by the Royal College of Surgeons. I observed mammograms being performed, went to pathology laboratories to watch how specimens were analysed and learnt the basics of breast oncology. I attended the ORBs oncology course for plastic surgeons (one day prior to ORBS). For the last two years I have been to the ABS trainees course in Glasgow which is not only very educational but also provides plastic surgery trainees with a chance to meet high flying breast trainees who are already on fellowships. I have been amazed at how friendly the breast trainees and consultants have been and without their help and encouragement I may not have been successful in gaining a fellowship. How do you perform well at interview? The interviews themselves are challenging. You need to prepare for them as if you were preparing for a consultant interview and some previous candidates have failed to realise this. There are 5 rooms, each with 2 consultants in (usually one breast and one plastic surgeon) and one asks a question, whilst the other marks your answer and then they swap. You need to understand current issues in breast cancer and also have your logbook and portfolio prepared in an organised and accessible manner. The other lines of questioning are along those of a consultant interview: management, teaching, leadership etc. I would like to support plastic surgery trainees applying for these fellowships in same way I was supported by my plastic surgery predecessors: Jo Skillman and Rob Warner. The breast trainees are incredibly well prepared for these interviews and attend residential courses to help them prepare, organised through the Mammary Fold (the breast surgery equivalent of PLASTA). The breast trainees in TIG fellowships that I met on breast courses were very supportive and helpful and talked me through the interview process. There are 9 funded interface oncoplastic fellows each year. This year, there are two plastic surgery trainees undertaking the fellowship, in Exeter and Liverpool. If you would like to be able to offer a comprehensive breast service and work well within the breast multidisciplinary team then please apply for the Fellowship Program. Please contact me for more support. I am really enjoying my fellowship in Exeter, learning huge amounts about oncology and am finding it an incredibly valuable and rewarding experience. I would highly recommend it to any plastic surgery trainee. Contact: racheltillett@doctors.org.uk Acknowledgements: Thanks to Anne Tansley and Joe ODonoghue for their comments References 1. Oncoplastic Breast Reconstruction. Guidelines for Best Practice. Editors: D Rainsbury, A Willett. November 2012 2. www.iscp.ac.uk/surgical/syllabus.aspx 3. http://www.severndeanery.nhs.uk/recruitment 4. www.jcst.org/training_interface_groups/breast_surgery