EDITORIAL

Are We Ready to CertifySurgical Oncologists?

WALTER LAWRENCE, JR., MD*Division of Surgical Oncology, Massey Cancer Center, Virginia Commonwealth University,

Richmond, Virginia

Twenty years ago, a few years after the formation ofthe Society of Surgical Oncology (SSO), the question ofcertification for surgical oncology was a hotly debatedtopic. In 1979, the Council of the SSO specifically in-structed me, as their then current president, to advise theAmerican Board of Surgery (ABS) of the strong interestof the SSO in certification, but neither this nor the iden-tification of “special competence in surgical oncology”has come to pass over the ensuing years. The identifica-tion of this area of special interest within general surgeryhenceforth has relied primarily on the achievement ofmembership in the SSO, a society that has gained in bothnumbers and prestige over these last few decades. Therecent establishment of a certification process for vascu-lar surgery within the domain of general surgery and ofan Advisory Council for Surgical Oncology within theABS again raises the issue of some form of certificationfor surgical oncologists. Has the political climatechanged enough for surgical oncologists to have theirspecial interest, training, and competence officially cer-tified in some way? Has the long-standing opposition bysome to this certification now been weakened enough toallow an official recognition of expertise in surgical on-cology? This editorial commentary will argueagainstachange in the status quo.

One of the first problems in this consideration of cer-tification is the definition or the actual identification ofthe scope of activity of the surgical oncologist. The term“surgical oncology” did not come into wide usage untilthe 1960s, when the two major attributes of surgicaltrainees from cancer centers with this special interestwere the capability of performing radical head and neckcancer surgery and the ability to conduct the more ex-tensive operations for gynecologic cancer, particularlyfor the more advanced lesions. Head and neck canceroperations, except for thyroid and parotid surgery, hadlong been a weakness for most practicing ABS-certifiedgeneral surgeons, and most otolaryngology training pro-grams did not include major head and neck cancer sur-

gery until recent years. General surgeons had includedthe standard but not the radical gynecologic proceduresin their practices for many years, but gynecologic surgi-cal training in earlier years, as well as general surgicaltraining, had never included operations of the magnituderequired for advanced gynecologic cancer. However,both of these fields (otolaryngology and gynecology) be-gan to develop special advanced training in oncologicsurgery for these two anatomic areas in the late 1960s,the same time that the concept of surgical oncology wasevolving within the field of general surgery. As the trendtoward specialization in oncology developed over thenext couple of decades, both of these anatomic areastraditionally served by the surgical oncologist (or “cancersurgeon”) became a specific focus for other specialtygroups.

In both gynecologic and head and neck surgery, theoncologists with additional training were able to focustheir efforts entirely on the specific anatomic sites asso-ciated with their specialty. In gynecologic oncology, thisincluded the development of expertise in the administra-tion of chemotherapy in addition to performance of thespecialized operative procedures required. In head andneck oncology, the total focus of the specialized otolar-yngologic surgeons has been on the performance of ex-tensive resections in the head and neck area along withthe reconstructive surgery required after such radical re-sections. Despite both the complaints and the territorialclaims of the general surgical establishment, these twoemergingspecializedsurgical oncology areas of greatinterest have been slowly removed as major activitiesfrom the purview of both the practicing general surgeonand the emerging general surgical oncologist. Over thelast three decades, surgical oncology has come to beprimarily management of breast disease, gastrointestinal

*Correspondence to: Walter Lawrence, Jr., MD, Massey Cancer Cen-ter, Virginia Commonwealth University, Room 403, 1200 E. BroadSt., Richmond, VA 23298. Fax No.: (804) 828-4808.Accepted 4 February 1999

Journal of Surgical Oncology 1999;71:74–75

© 1999 Wiley-Liss, Inc.

neoplasms, melanoma, and soft tissue sarcomas, al-though many nononcologic general surgeons with stronginterest and special competence in these same areas havelimited their activity to only one of these disease pro-cesses to the exclusion of the others. There does notappear to be a precise definition of exactly what is to beincluded in “surgical oncology.” Thus, although we candefine the general surgical oncologist in general terms,our definition is usually one of a concept, or an approach,rather than a description of a surgeon with a clearly de-fined specific set of technical skills. From the outset, thishas been a major problem in the consideration of thecertification process for surgical oncology as opposed toa more clearly defined technical specialty.

A second issue in this discussion of certification isrelated to the basic premise of certification, that of theprotection of the health care consumer. Our hope is thatoptimal surgical care is provided in all surgical special-ties by those surgeons who are identified as being themost competent individuals to provide specific surgicalservices. For this reason, most hospitals should and even-tually will utilize certification as a guide to the award ofhospital privileges. Let us examine the expected subse-quent train of events if we do formally certify surgicaloncologists, from the standpoint of the major diseaseprocesses now being managed by the usual general sur-geon. Both breast surgery and operations for gastrointes-tinal cancers are major activities in the broad field ofgeneral surgery as well as being a major emphasis for thesurgical oncologist. Malignant melanoma is a less com-mon clinical problem, but one for which fully trained,board-certified general surgeons justifiably feel fully ca-pable of care. A major concern, therefore, is the use of asurgical oncology certification process for unfairly lim-iting the practice of those fully qualified and certified(ABS) general surgeons who do not achieve specific cer-tification in surgical oncology. The formal certificationof surgical oncology could become a franchise, to beused at the local level, and one designed to give an out-right monopoly to surgical oncologists for all generalsurgical cancer problems. I submit that this would be amiscarriage of justice if one views the certification pro-cess primarily as a means of protecting the public, asopposed to giving some personal advantage to a subset ofsurgeons.

Do these negative views toward a certification processfor surgical oncology diminish the importance of thisarea within general surgery? I certainly hope not since Ihave spent almost 50 years focusing my own efforts inthis special area. The surgical oncologist, in my view, isactually a much needed surgeon both to contribute to thecancer education of undergraduate and postgraduate stu-dents and to provide leadership to regional colleagueswho are practicing general surgery. I believe he or shemust be a well-qualified and certified general surgeonwho has obtained additional training and experience in

the cancer field and then has devoted his or her profes-sional work almost completely to oncologic problems.This skill in surgical oncology includes the capability of,and experience in, performing the less frequently utilizedor more complex operative procedures for neoplastic dis-ease that are not usually employed by the “standard”general surgeon. However, this additional specialized ex-perience often relates as much to the proper selection ofpatients for these operations, rather than the performanceof the actual procedure itself. The surgical oncologistviews all operative procedures for cancer in the perspec-tive of the total care of the patient by all disciplines,rather than operation as an isolated treatment method.Another major contribution of the surgical oncologist isan in-depth understanding of the natural history of thewide range of diseases we know as cancer, and this giveshim or her the ability to provide consultation and lead-ership to both surgical and non-surgical colleagues in alarge variety of circumstances. This help to others isaccomplished in a fashion similar to that of general sur-geons who have focused their own professional activitieson some other area of general surgery, such as trauma,burns, endocrine surgery, or inflammatory bowel disease.As with all of these surgical “hobbies,” the general sur-geons in the medical community continue to perform themajority of operative procedures that are required bycancer patients. Establishing a sub-board or a similartype of certification for surgical oncology would prob-ably alter this practice situation to the detriment of boththe recipients and the providers of oncologic care.

As noted at the outset, surgical oncology has notachieved formal certification over the last several de-cades despite the interest expressed in this possibility bymany. Nevertheless, with time, surgical oncology hasbecome firmly established as a special interest areawithin general surgery. The development of formal divi-sions of surgical oncology in university departments ofsurgery, the continued growth and strengthening of thenational and well-recognized organization representingsurgical oncology (SSO), the development of competi-tive training programs and training grants in surgical on-cology, and the special identification (through coursesand lectures in surgical oncology) by the American Col-lege of Surgeons attest to the progressive growth andsuccess of this field. ABS has given attention to this areaof special surgical interest by establishing the AdvisoryCouncil for Surgical Oncology this past year. This coun-cil will report to the board of the ABS regarding surgicaloncology training and potential certification proceduresas well as addressing the question asked in the title of thiscommentary. Surgical oncology has been identifiedclearly as a significant activity by the “powers that be” insurgery and in oncology. However, there seems to belittle justification, to this writer, for a separate certifica-tion process forthis area of special interest that is so im-portant to us all.

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