It’s been a long time since I updated this blog and I’ve just finished Part2 exams in 2023. A lot of things are different: I’m older, I have a toddler, I’m now training in the West Midlands (with luckily fantastic breath of clinical exposure) and exams frankly matter less. Nevertheless, they must be done, they’re stressful and they’re insanely expensive. I’ve put together my notes here for the benefit of others. (They will probably be out of date rather quickly so if anyone is interested in updated them in 2024 drop me an email on nhs.net or leave a comment on the blog.)

Some notes are free to access, many of these are an update on freely available notes by Dr Vanita Gandhi that have been in circulation since 2019. You can access these via shared google drive folders from your department colleagues and use those if you prefer of-course. Some site specific notes which are updates of aforementioned freely available notes are free to access. Other general notes such as staging and OAR tables are free to access too. However currently other site specific notes that are largely an original compilation of data have a minimal fee associated with them that grants you access for a year. Why do you have to pay for full access? – simply because keeping this site uncluttered and free from adverts costs, and I’ve been paying out of pocket for a few years now. Additionally, I really need to recover a small fraction of my generous donations to RCR as exam sitting fees! Eeks.

FRCR PART2a is essentially an MCQ exam

FRCR PART2b is a fast-paced viva with cases including skin and palliative session at least, and a total of 10 case stations (no matter how well you’ve practiced, the real exam feels a 10x faster than any practice session). 1 contouring station and 1 communication station. See RCR website for details.

Part2b is held 6 weeks after Part 2a (approximately). DO NOT leave studying for PART 2b till after passing PART 2a unless you expect to give them at separate sittings. A lot of the information overlaps so studying for PART 2 as a joint exercise is efficient. (but of course might not be the right thing practically for individual circumstances and that’s okay too). If you do plan to give them in the same sitting, study for ALL of it together.

HOW TO APPROACH EXAM Preparation : General principles

In my opinion, 6-9 months of dedicated study is required if done alongside a full time job. The exams do force you to study all cancer sites at the same time, and it can be quite rewarding to see it all make sense as a whole in your brain. It’s still very very painful simply due to the volume of data.

1. The good news is that the exam for the most part tests grey cases, clinical judgment and cancers you would tend to see in clinic. Esoteric knowledge is not going to the tripping point (except a few questions in the miscellaneous section of FRCR Part2a). But grey cases and clinical judgement is the tricky bit to navigate. Hence a basic understanding of the evidence, the relative merits of each treatment and risks vs benefits reasoning is crucial – basically a complex clinic!
2. Radiotherapy is increasingly an important part of the examination material tested, understanding immobilsation, what radiographers do practically, how gaps are managed, how on treatment problems are approached, familiarity with CBCT images, re-irradiation etc are all very important principles to fully understand. Do spend time in treatment room and mould room (mould room particularly for skin treatments and limb immobilisations)
3. Do make a set of notes ; type or write or draw – whatever works for you. But putting thoughts down in a definitive format helps and provides an easy reference to go back to. Other peoples notes are excellent starting points. They are grossly ineffective on their own though. Only when you’ve adapted others notes to make a set that makes sense to you will it eventually help.

RESOURCES to build notes and concepts:

Disclaimer: The most valuable resource remain your patients. Seeing patients in clinic, making decisions and defending them with a clear rationale is the best way to learn. Second, colleagues – peers/consultants/associate-specialists and everyone else who teaches and trains you to make decisions with patients and thirdly – the treatment room and radiographers.

Textbooks: I did not study any text book for this exam. I haven’t read a text book in years. I am aware there are many good ones out there e.g Practical Radiotherapy and this approach might work for you. I am simply detailing my experience here though and there is certainly more than one way to approach exams and to learn. Review articles, Guidelines, publications are the main text I use. And of course, you can use the notes here as a basic text to edit and make your own.

Trial information: InstantOncology by Lei Wang on Instagram is great for pictorial memories. Trial summaries also published in Clinical Oncology. ARRO Cases studies often summarise data and evidence well. ASCO posts comes out with updates and commentaries on trials that are often helpful. (both ARRO cases and ASCO posts can be found with a simple google search). While it would be nice to read ALL the original trial papers, often impossible. Do read the sites that interest you more, landmark studies, controversial studies to improve clinical reasoning and general oncology training. However, exact trial statistics and data will NOT be asked in the exam.

Part 2a tips: Notes on the miscellaneous sections are particularly important as you might not have enough clinical experience to rely on your experience to choose your answer. Do not neglect this: Sarcoma, paediatrics, Thyroid, Lymphomas/Plasmacytomas are the main tumour sites to study in this section. Also make a note on DVLA rules, opioid conversion, Toxicity management of IrAE, General concepts on toxicities and dose reductions for different chemotherapy agents. I wouldn’t personally bother learning the exact percentage reduction for a Bilirubin of 35 umol/L level for irinotecan for example. It might pop up in the exam but the effort to reward ratio is poor. I would know it is hepatically metabolised, doesn’t require dose reduction in renal disease and does require dose reduction for deranged LFTs, and a normal bilirubin is approximately up-to 21umol/L and thus in this question some dose reduction (50%? 75%?) might be needed. In real life you would check the rota. Perhaps remembering some common examples (for example 5FU preferred to capecitabine in renal disease or Cr <50 umol/L) though can help eliminate options and make a good judgement call on the right MCQ answer.

RESOURCES FOR QUESTIONS FOR PART 2a

Sometimes testing ourselves and practical problem solving is the best way to consolidate information. There are UK based question banks that are commonly presumed not fully up -to-date and include Oncopaedia (Wales – I didn’t use this) and Cambridge Clinical Medicine Online (that quite eagerly took my money, didn’t reply to any correspondence and as far as I know the website has never actually worked!) I wouldn’t recommend either. There are 2 fantastic resources in medical oncology that are up-to-date and I would highly recommend. Unfortunately there isn’t an equivalent that is radiation oncology specific.

1. Heme-Onc Questions https://hemeoncquestions.com by Dr Ravin Garg who is a community oncologist in the USA and treats all cancer sites. He regularly updates the questions are there are >2000 questions on here! Ignore the haematology sections for UK exams but it covers all the solid tumours very well with detailed explanations. If the aim is consolidating your knowledge – this is it. Do be wary of some variations in UK-US practice – e.g. adjuvant chemoradiotherapy vs chemotherapy alone for high risk endometrial cancer, chemotherapy alone vs chemoradiotherapy as adjuvant treatment for biliary cancers. If some answers don’t link in with your clinical experience – check UK guidelines – NICE, RCR to clarify. This is a minor problem though given the sheer volume of questions available.
2. 500 SBAs for the Medical Oncology Specialty Certificate Exam (500 Single Best Answers for the Medical Oncology Specialty Certificate Exam). Its available on AmazonUK and also available as an e-book for international candidates. It was published in 2022 so still fairly up-to-date but I imagine it won’t be in a few years. Excellent explanations again that help with consolidation of learning.
3. The Leeds SBA course (see courses below) has mock questions and the RCR website has some mock questions too. However, their educational value is limited on their own. Questions and answers without explanations do not help you revise the rationale or confirm your reasoning. To benefit from Leeds SBAs you need to be on the course really. Nevertheless, the other two resources above provide plentiful of questions!

RESOURCES for Part 2b

Radiotherapy concepts

1. Anatomy (Head and Neck in particular) : AVARO project https://www.avaroproject.net. A free online platform by TATA memorial Kolkata, designed in a structured course-like format that is brilliant for head and neck anatomy. I haven’t looked at other sites but probably excellent too. Very helpful for contouring station and being confident with normal structures and extent of invasion of disease as you describe MRI images or CT scans
2. E-contour: https://econtour.org. If you’re not already using this you need to start asap. A whole library of contoured cases with OARs, targets, normal anatomy and clinical pearls. It is American so know your local procotols and evidence base to understand where American and UK practices diverge. Not very different but brain contouring for example diverges. Turn off the contours drawn for you, take screenshots, practice contouring random slices on power point and compare against the gold standard. Fantastic Part2b practice for the new contouring station.
3. Radiotherapy protocols: Important for Part 2b. EVIQ is an Australian/NZ based site with a summary of radiotherapy protocols. https://www.eviq.org.au/radiation-oncology. West Midlands have also published their radiotherapy protocols online for many sites (not all) and can be found here https://wmcanceralliance.nhs.uk/professionals-area/operational-delivery-network/radiotherapy/protocols. Each UK department will have their own set of protocols – know how to access these.

Oral presentation Tips: Part 2b is FAST. Insanely fast. You really don’t have time to waffle and only a few seconds to think. Practice Practice practice. Speech has to be concise, fluent and rapid. I think it certainly penalises those with English as second language simply due to how time-constrained the exam is – but it is a UK Royal College exam. I won’t discuss the merits vs demerits of this here but it’s important to be prepared.

• a) Read the Question and take a few seconds to collect your thoughts if needed (needless waffle wastes more time than a 3 seconds of silence).
• b) Give the answer with the most important information first followed by the explanation or details. Announcement or Headline First, Body after. This way if the examiner already has the information they need from you, they’ll move you on. Also examiners can get lost in verbose answers. They’re listening out for some key words and lots of speech makes it harder for them to find those important words.
• c) Reading scans – practically just say the most obvious malignant abnormality, then look around for nodes or invasion into surrounding structures, and lastly anything else obvious (stoma, drain, pelvic cyst). Summarise your readings of the scan by saying this is most consistent with x cancer – e.g. locally advanced cervical cancer. I found it quite hard to even to introduce the scan with “this is a saggital section of a T2W MRI” in the exam due to time pressures but launched straight into the tumour I could see.
• d) Have prepared scripts that you practice in front of a mirror.
• What is your management approach? – this question needs to include holistic patient care. Example scripts include: “I would refer for nutritional, swallowing and dental assessment and consent for radical intent chemotherapy for oropharyngeal cancer, at X Gy, N fractions with weekly chemotherapy at Z dose” OR “I would manage pain, discuss referral to palliative care and discuss palliative chemotherapy with xyz regimen”. OR For a patient who has lost weight on CBCT scan in head and neck cancer: “I would ensure nutritional and swallowing support, deformable registrations of CBCT with original planning scan and request physics to re-calculate dose to the target and OAR, looking for hot spots/geographical misses/dose to cord (whatever is relevant in your case). I would then either – 1. continue radiotherapy with monitor unit correction or 2. Urgent rescan in new shell and replan (while patient may or may not continue RT on old plan until replan available – agains depends on your case).”
• What is your radiotherapy dose and fractionation : Literally just give this information and move on
• What is your radiotherapy management plan: Start with “I would treat with Radical/Palliative INTENT, with X Gy in N Fractions (dose and fractionation) with or without chemotherapy with 6MV photons IMRT” – This is the Announcement or Headline! Then launch into immobilisation, bladder and rectal filling, CT planning scan, fusion images and details of Target contours (GTV, CTV and PTV) etc

COURSES: There are many excellent courses run throughout the UK/internationally. I can’t really comment on all of them. I would recommend one Part 2a course and one Part 2b course. Multiple courses probably have decremental additional value. You do also need time to practice and there isn’t any substitution for this. Others might disagree – but just my 2 cents. Additionally all the courses are really expensive!

• Leeds FRCR PART 2a course – Run once a year in the UK and once a year in India. UK one was online (run around May for August sitting) but the winter course in India is apparently face to face in 2023. Might be something to keep in mind!
• Wales FRCR Part2b course – Online pre-recorded lecture, live online lectures and then an in-person course with a mock exam. It’s really really really good. Highly recommended. Run once a year only though in time for August-October sitting (Sept 2023 for example).
• Other courses: Derby, Christie, Liverpool and many others run courses. No personal experience or comments.