https://orcid.org/0000-0002-0077-1994
The new General Surgery Curriculum1 has changed the operative requirements for breast trainees in the UK; complex oncoplastic procedures are now included in the indicative numbers required to achieve the Certificate of Completion of Training (CCT). Although a positive step towards recognizing the need for broad oncoplastic training, the impact of this change must be evaluated. To achieve that, the Mammary Fold Academic and Research Collaborative (MFAC) conducted a national multicentre retrospective audit between 2022 and 2024, collecting data from 2018 to 2022. The aim of the audit was to assess the regional variation in oncoplastic breast surgery operative training and the ability of trainees to achieve the new indicative numbers required for the CCT.
All units providing breast surgery services in the UK were eligible to participate and were recruited via professional society e-mails and an advertising campaign during courses, during conferences, via social media, and via regional representatives. Each participating unit obtained local clinical governance approval before data collection. Primary outcome data included the annual number of latissimus dorsi (LD) flaps, chest wall perforator (CWP) flaps, therapeutic/reduction mammoplasties, implant-based reconstructions, lipomodelling procedures, augmentations, and skin-sparing mastectomies (SSMs). Data were collected using the Research Electronic Data Capture (REDCap) platform2.
A total of 26 units from 11 training regions submitted their data. Of these, 22 units (85%) provided screening and symptomatic services for a median of 500 (interquartile range (i.q.r.) 320–655) new cancer patients a year. Each unit had a median of 4 (i.q.r. 3–5) consultants, 1 (i.q.r. 0–3) associate specialist, 1 (i.q.r. 0–4) trainee, and 0 (i.q.r. 0–2) fellows. Only ten units (38%) had direct access to plastic surgery services.
An expected reduction in operative volumes was observed during the COVID-19 pandemic. The median operative volumes of LD flaps, lipomodelling procedures, and augmentations were lower in 2022 than before the beginning of the pandemic. The median operative volumes surpassed the pre-pandemic volumes for CWP flaps, mammoplasties, and implant-based reconstructions (Fig. 1). A wide variation in operative volumes was observed between centres for all procedures. In 2022, the following annual median operative volumes were recorded: 4 (i.q.r. 1–9) LD flaps, 4 (i.q.r. 1–15) CWP flaps, 39 (i.q.r. 28–62) mammoplasties, 39 (i.q.r. 24–50) implant-based reconstructions, 9 (i.q.r. 4–17) lipomodelling procedures, 1.5 (i.q.r. 0–4) augmentations, and 0 (i.q.r. 0–17) SSMs.
Annual procedure volume data
Data are presented as median (interquartile range). Circles indicate significant outliers. LD, latissimus dorsi; CWP, chest wall perforator; SSMs, skin-sparing mastectomies.
Data suggest that adequate volumes of implant-based reconstructions and reduction mammoplasties were performed within participating institutions to facilitate training. However, achieving the requisite number of local flaps (25) and SSMs (40) may prove difficult for some trainees because of the low number of these procedures being performed, even in the higher-volume units.
The generalizability of these results is limited by the proportion of participating units and the complete absence of representation for some regions, and the results may be subject to participation bias. An indirect observation of this project is an apparent lack of access to plastic surgery services and some operative procedures, suggesting inequality of service provision across regions, a finding similar to conclusions drawn by the Breast Cancer Now report3.
These results indicate the need for a careful assessment of achievability of indicative operative numbers for breast trainees within the scope of training. Achieving the indicative number of procedures does not necessarily correlate with competence4 and the threshold set is not always evidence-based5. This national audit highlights a significant gap in the operative data for breast cancer surgery, which could be addressed through the implementation of national registers, such as the National Bowel Cancer Audit, or utilization of data from the Model Hospital.
Collaborators
Mammary Fold Academic and Research Collaborative
Nick Abbott (Raigmore Hospital, Inverness, NHS Highland); Brenda Anena (Luton and Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust); Soofiyah Ayaani-Vaughan (Worcestershire Royal Hospital); Sadaf Batool (Chesterfield Royal Hospital); Jessica Bennett (North Tees and Hartlepool University Trust); Cristina Croitoru (Altnagelvin Area Hospital); Urszula Donigiewicz (Torbay and South Devon NHS Foundation Trust); Rasheed Elayyan (James Paget University Hospital NHS Foundation Trust); Sahar Elzein (Northumbria Healthcare NHS Foundation Trust); Nikki Green (Great Western Hospital); Grant Harris (Queen Elizabeth Hospital, Gateshead); Sadaf Jaffferbhoy (University Hospitals North Midlands); Natasha Khan (St Richard’s Hospital); George Lane (Leeds Teaching Hospital); Grace Hui Chin Lim (Queen Elizabeth Hospital, Gateshead); Sankaran Narayanan (University Hospitals North Midlands); Shonnelly Novintan (Colchester Hospital); Ashish Patel (Gloucestershire Royal Hospitals NHS Foundation Trust); Francesca Peters (Northumbria Healthcare NHS Foundation Trust); Tim Rattay (University Hospitals of Leicester); Tom Richardson (University Hospitals North Midlands); Lucia Sepesiova (Whiston Hospital, St Helens and Knowsley NHS Trusts); Soni Soumian (University Hospitals North Midlands); Yan Yu Tan (Northumbria Healthcare NHS Foundation Trust); Megha Tandon (University Hospitals North Midlands); Joseph Vance-Daniel (Royal United Hospital Bath); Jamie Vatish (Leeds Teaching Hospitals); Annabelle White (St Richard’s Hospital); Myat Win (St Helens & Knowsley Teaching Hospitals NHS Trust); Obafemi Wuraola (Barnsley Hospital).
Funding
The authors have no funding to declare.
Acknowledgements
The authors acknowledge: Nick Abbott (Raigmore Hospital, Inverness, NHS Highland); Ruth James (Luton and Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust); Rachel Bright-Thomas (Worcestershire Royal); Julia Messey (Chesterfield Royal Hospital); Dave Fung (North Tees and Hartlepool University Trust); Brendan Skelly (Altnagelvin Area Hospital); Michael Green (Torbay and South Devon NHS Foundation Trust); Sue Down (James Paget University Hospital NHS Foundation Trust); Alice Townend (Northumbria Healthcare NHS Foundation Trust); Samantha Williams (Great Western Hospital); Sunil Amonkar (Queen Elizabeth Hospital, Gateshead); Douglas Ferguson (Royal Devon and Exeter Hospital); Sekhar Marla (University Hospitals North Midlands); Mustafa Al-Sheikh (St Richard’s Hospital); Brian Hogan (Leeds Teaching Hospitals NHS Trust); Naren Basu (University Hospitals Birmingham); Clare Rogers (Doncaster and Bassetlaw NHS Trust); Sunita Saha (Colchester Hospital); Richard Hunt (Gloucestershire Royal Hospitals NHS Foundation Trust); Alice Townend (Northumbria Healthcare NHS Foundation Trust); Monika Kaushik (University Hospitals of Leicester); Tamara Kiernan (Whiston Hospital, St Helens and Knowsley NHS Trusts); Sankaran Narayanan (University Hospitals North Midlands); Richard Sutton (Royal United Hospital Bath); Raj Achuthan (Leeds Teaching Hospitals); and Julia Dicks (Barnsley Hospital).
Author contributions
Alona Courtney (Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Visualization, Writing—original draft, Writing—review & editing), Natasha Jiwa (Conceptualization, Methodology, Project administration, Writing—review & editing), Alex Humphreys (Conceptualization, Methodology, Project administration, Writing—review & editing), Jenna Morgan (Conceptualization, Methodology, Project administration, Writing—review & editing), Louise Merker (Conceptualization, Methodology, Project administration, Writing—review & editing), Rachel X. N. Lee (Project administration, Writing—review & editing), Katherine Fairhurst (Project administration, Writing—review & editing), Thomas Hubbard (Conceptualization, Methodology, Project administration, Writing—review & editing), Rajiv Dave (Software, Supervision, Writing—review & editing), and Mammary Fold Academic and Research Collaborative (Investigation, Data Curation)
Disclosure
The authors declare no conflict of interest.
Data availability
Data reported in this paper cannot be found on publicly available databases.
References
Cook T, Lund J. General Surgery Curriculum From August 2021. https://www.iscp.ac.uk/iscp/curriculum/general-surgery-curriculum/1-introduction/ (accessed 23 March 2023)
Author notes
Members of the Mammary Fold Academic and Research Collaborative (MFAC) are co-authors of this study and are listed under the heading Collaborators.
A summary of the results was presented to the Mammary Fold Pre-ABS Meeting, 2024.
