What is Surgical Oncology ?

Historically, surgery was the only treatment for cancer with pioneering surgeons pushing the boundaries of knowledge down through the millenia [1]. Only in the last century have non surgical means provided an adjunct or more rarely, an alternative to surgery [1]. Despite the advances in medical and radiation oncology, surgery is still the only modality with the potential to cure most solid cancers. Surgeons have a pivotal role in cancer treatments and research, leading the diagnostic and treatment pathways for most cancers from counselling patients about their diagnosis through to surgery and aftercare. They have also led many of the great advances in cancer research.

However, cancer care has evolved very rapidly over the last few decades and therefore a new type of surgeon is needed to keep pace with these changes. No longer is surgery alone the only treatment for most solid malignancies but a combination of surgery and multi-modal therapies (with highly focussed radiotherapy, targeted molecular therapies and poly-chemotherapy) becoming the modern standard of care.

As a result, the surgeon, who 40 years ago would often be the only specialist to have contact with most cancer patients, can no longer work in isolation but must lead a multi-disciplinary team. They must be more than just a technician and must understand the biology and natural history of the disease as well as the contributions made by other disciplines to the cancer patients’ treatment. It is at this point that the surgeon becomes a surgical oncologist.

Examples include:

  • Collaboration with radiation and medical oncologists on the use of neoadjuvant chemotherapy or radiotherapy to enhance or permit surgery possible and on the indications for adjuvant therapy after surgery.
  • Collaboration with radiologists to plan surgery or optimise resection margins.
  • Collaboration with pathologists to ensure appropriate primary and adjuvant therapies, (tumour immunophenotyping and mutational analysis to optimise treatment) and to quality assure surgery (e.g. assessment of circumferential resection margins following TME)
  • Collaboration with geneticists in hereditary cancers to optimise treatment,  prevention or screening strategies (BRCA1, FAP).

The technical side of surgery has also been transformed in the past few decades with advances including:

  • Minimally invasive cancer surgery, (laparoscopic [2-4], Natural Orifice Transluminal Endoscopic Surgery (NOTES5), Transanal Endoscopic Microsurgery (TEMS [6])
  • Improved understanding of  surgical margins (the TME in rectal cancer for example [7])
  • Sentinel node biopsy [8]
  • Robotic surgery,
  • Intraoperative chemotherapy and radiation therapy (limb perfusion, HIPEC, IORT)
  • Reconstructive surgery (breast oncoplastics, head and neck surgery, bladder replacement techniques),
  • Enhanced recovery programmes [9]

The main argument against a specialism of surgical oncology is that it would not be possible for a single surgeon to have the expertise to perform a full range of oncological procedures ranging from liver resection to breast reconstruction, radical prostatectomy to radical neck dissection. This is indeed the case and is a situation which will become more marked with further technological advances. However within each subspecialist area there is much shared knowledge and expertise (basic biology of cancer, radiotherapy effects, contra-indications and uses, targeted molecular therapies) and in many cases, cross fertilization of techniques and ideas between site specific disciplines has much to offer.

One of the strongest arguments in support of surgical oncology as a specialist discipline is to help raise standards across Europe where at present there is huge variation in outcomes from cancer [10-11] by helping to establish pan European quality standards.

Some procedures should only ever be undertaken in highly specialised centres. Examples include cytoreductive surgery with HIPEC, sarcoma surgery, isolated limb perfusion, liver resection and laparoscopic cancer surgery. Understanding of these more complex procedures is essential for any surgeon dealing with a cancer site to prevent patients being denied access to these modalities. For example, the massive advances in the boundaries of liver resection mean that an inexpert surgeon might deny surgery to a patient which a super-specialist would offer surgery to after neoadjuvant chemotherapy and portal vein embolisation. Clearly not every surgeon will be able to offer these advanced techniques, but if they work in that field they have a duty to be fully aware of what is possible with appropriate expertise and resources. This is only possible if all surgeons who deal with cancer have training and exposure to advanced surgical oncology.

It is envisaged that the ‘Advanced Surgical Oncologist’ will have a broad base of relevant knowledge that transcends site specialisation, supplemented with a high level of advanced knowledge and technical expertise in the conduct of the surgical procedures relevant to their main disease site of interest.

Outside of Europe progress towards specialist ‘Surgical Oncology’ accreditation has been greater: in the USA, Advanced Surgical Oncology was provisionally recognised as a sub-specialty area with its own proposed certification by the American Board of Surgery (2009) [12]. A specific board-certifying examination on “Complex Surgical Oncology” will soon run alongside designated training programmes in US Institutions. At present in the USA, the majority of oncological procedures are still performed by generalists with no specific oncology training. It is hoped that this new sub-speciality recognition, enhanced training and examination will improve the situation.

In the USA, all training and accreditation is standardised by National Examinations at both medical graduation (USMLE) and sub-specialisation (American Boards of Medical Specialties). In Europe, the situation is more complex. Most European member states have their own professional bodies which regulate medical graduation and specialisation.  These are mutually recognised across Europe [13] but the fact that many different bodies are involved and National legislation varies widely means that harmonisation of practice and setting pan-European quality standards is difficult.

The Union of European Medical Specialists (UEMS) was established in 1958 to ensure the highest standards of medical care across Europe and to promote standardisation. It contains 37 specialist sections and includes the European Board of Surgery (EBS) which runs a number of Specialist Examinations including, in partnership with ESSO, one in Surgical Oncology. The aim of this qualification is to provide evidence of expertise in the subject at a level that would be acceptable in all European Countries.

The European Society of Surgical Oncology (ESSO) is committed to the full development of Surgical Oncology in Europe. By providing a forum for exchange of knowledge and expertise, via its web site, its Fellowships, its international congresses, master-classes, board exams  and other educational resources it  helps to improve European cancer care.  The development of a new Core Curriculum  to help guide trainee surgeons will also help define requisite levels of knowledge. Furthermore, ESSO´s concern and commitment on quality of cancer care across Europe, embodied in the EURECCA Project (pioneered by this society) will serve to homogenize cancer treatment and make an invaluable contribution to European Oncopolicy.


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