What is a surgical oncologist?

Although I've mentioned before that I am a surgical oncologist, but I recently noticed that, in nearly five months of blogging, I've yet to explain exactly what that is or what it means. I've written about all sorts of things, ranging from alternative medicine, to the evolution-creationism conflict, to the Holocaust, to even trying my hand at reviewing music.

True, I've discussed a fair number of anecdotes based on patient stories. Certainly those stories can give a feel for what I do in the clinical part of my duties, but they don't really explain what my specialty is. I've also spoken about the difficulties of combining a research career with a clinical career, but the emphasis was usually on the research and not so much on the actual clinical work that I do. I've never actually talked about what my specialty is. I find that somewhat odd. It just never occurred to me. Perhaps I just assumed that everyone knows, even though I know better than that.

In my experience, there is a fair amount of confusion among lay people about what exactly a surgical oncologist is. Basically, a surgical oncologist is a surgeon who specializes in the surgical treatment of cancer and malignant diseases. The reason that there is confusion over what a surgical oncologist does is because there is considerable overlap between what we do and what general surgeons do. Indeed, I am a general surgeon, because most surgical oncologists do a general surgery residency first and then a surgical oncology fellowship. It's a long haul, because a general surgical residency is at least five years. If one opts to do research during residency (more or less mandatory to get accepted by a good fellowship program), then the general surgery is more like six or seven years. Then, the surgical oncology fellowship is three more years.

The fellowships for surgical oncology are quite competitive to get into, as there are only 18 training programs in the U.S. approved by the Society of Surgical Oncology. What does this additional training provide? First, it educates the surgeon in the state-of-the-art care of common malignancies that can be treated surgically, such as breast, lung, and colon as well as providing extensive exposure to complex and unusual cancer problems. Second, the training includes considerable experience in management of complex disease involving endocrine pancreas and in surgery for benign and malignant tumors of the thyroid, parathyroid, adrenal, and ovary. However, perhaps the most important additional skills and knowledge provided by a surgical oncology fellowship are the understanding of the multidisciplinary management of the major cancers that are primarily treated with surgery, such as breast cancer, colorectal cancer, melanoma, stomach cancer, pancreatic cancer, and liver cancer. The surgical oncologist takes rotations in medical oncology, radiation oncology, and pathology. In addition, the surgical oncologist is expected to complete a research project on malignant disease during the fellowship. This additional experience prepares the surgical oncologist to take the lead where appropriate in the multidisciplinary management of solid tumors and to develop either a clinical or translational research program into his cancer of interest.

A surgical oncologist is different from a medical oncologist or a radiation oncologist, with whom we are sometimes confused. Medical oncologists do not so surgery; they treat cancer by administering chemotherapy. This makes them the primary doctors who treat hematologic malignancies, such as lymphoma and leukemia, for which surgery is not helpful, other than for the occasional diagnostic lymph node biopsy. They also administer adjuvant chemotherapy, which is chemotherapy given after surgery with curative intent that is designed to decrease the rate of recurrence. Cancers for which adjuvant chemotherapy has been shown to improve survival and disease-free survival include breast cancer, colorectal cancer, and several others. They also have the very difficult and emotionally draining job of treating patients with metastatic solid tumors, for whom cure is not possible. Radiation oncologists, on the other hand, are more like surgical oncologists in that they treat local disease, this time using radiation, rather than surgery. Radiation oncologists sometimes are the primary treatment for some cancers with or without chemotherapy (Hodgkin's lymphoma, anal cancer, for example), but most of the time they give adjuvant therapy after surgery, as in breast cancer and rectal cancer.

We should get one thing straight here. Most cancer surgery for the common abdominal malignancies (excluding prostate or gynecological malignancies) is still done by general surgeons and is likely to continue to be done by general surgeons for the foreseeable future. Breast cancer and colon cancer, for instance, the two most common cancers surgical oncologists deal with, are primarily dealt with by general surgeons, particularly when they are uncomplicated cases. There are a fair number general surgeons even do advanced cancer operations, like the Whipple pancreaticoduodenectomy or liver resections. Surgical oncologists are more highly trained, but a lot of what a surgical oncologist learns and brings to the table can be learned outside of a fellowship through experience taking care of cancer patients, and many general surgeons have done so. However, these days, as for many specialties, fellowship training is becoming more important, and among younger surgeons who want to take care of cancer patients not completing a surgical oncology fellowship is becoming less of an option. There will probably never be enough surgical oncologists to take care of all of the cancer in this country, and general surgeons will probably still take care of the bulk of the common cancers that surgery can cure, like breast or colorectal cancer. However, for cancers that require a complex operation to remove, such as pancreatic cancer requiring a Whipple pancreaticoduodenectomy or liver tumors requiring large liver resections, you are probably better off with the specialist. (Of course, this can be confusing to patients as well, because colorectal surgeons do a fine job of taking care of colorectal cancer, and there are many liver surgeons or liver transplant surgeons who do liver resections for cancer, mainly because, except of very busy transplant programs, there are not enough liver transplants at most hospitals that do them to keep a liver transplant surgeon busy.)

As a career, surgical oncology has many advantages. One of the great joys of surgical oncology is that you can actually cure your patient. If most of your practice is breast cancer, as is mine, you can actually "cure" your patients a fairly high percentage of the time (one of the key reasons that altie testimonials for "breast cancer cures" from patients who eschew chemotherapy and radiation therapy proliferate). For such patients, chemotherapy and radiation therapy are the "icing on the cake" that decreases the rate of recurrence, but surgery was the primary therapy. That is not to say that some patients with tumors that should have been curable don't sometimes relapse, but most of the time they do not. Another great advantage of surgical oncology as a specialty is that it tends to lend itself better than many surgical specialties (trauma, for instance) to basic and translational research, which is the path I have taken. If, as a surgical oncologist, you work at an academic cancer center (as I do), the opportunities for collaboration and research that makes a difference in the lives of cancer patients is great. And depending upon the diseases you take care of, the lifestyle can be not so bad, as much of the time you don't have to take trauma or general surgery call. Of course, one disadvantage of being a surgical oncologist is that you become the general surgeon for the medical oncology service. That means that, whenever patients with cancer get general surgical problems (cholecystitis, appendicities, bowel obstructions), the medical oncologists usually call you, not the general surgeon. Bowel obstructions are seldom the easy kind where you operate and cut a couple of bands to fix the problem. No, the bowel obstructions we see are usually in patients with carcinomatosis (diffuse tumor deposits all over the abdominal cavity), for whom our best efforts are unlikely to relieve their obstruction for long or to do it well enough to enable them to eat solid food again. We don't see straightforward cases of appendicitis or cholecystitis; the patients we see with these diseases usually have very low white blood cell counts (meaning they're immunosuppressed) and/or low platelet counts (meaning that operating on them has a much higher risk of causing bleeding).

Overall, surgical oncology as a specialty is evolving and becoming more defined. There are now subspecialties of even surgical oncology. The most common one is breast surgery, and there are now a number of breast fellowships for surgeons who want to specialize in breast surgery. I only see this trend proliferating, as it has in so much of medicine. Nonetheless, for common cancers, both surgical oncologists and general surgeons with a strong background in treating these cancers can provide excellent, state-of-the-art care. For more uncommon or complicated cancer problems, however, a surgical oncologist is usually the better bet.

This post originally appeared in the original Respectful Insolence blog on May 9. 2005.