Journal of Surgical Oncology 2007;96:1–2

GUEST EDITORIAL

Organ-Based Subspecialization in Surgical Oncology:Fragmentation as a path to progress?

MONICA MORROW, MD*333 Cotman Avenue, Philadelphia, Pennsylvania

It is difficult to believe that less than 30 years agosurgical oncologists were being asked to justify therationale for their existence as a subspecialty withingeneral surgery. Today, the role of the surgical oncologistin the management of the cancer patient is wellrecognized, and the Society of Surgical Oncology’swebsite lists 14 approved training programs in generalsurgical oncology. Initial concerns that the developmentof surgical oncology would deprive the general surgeonof the ability to treat cancer patients have not proven to betrue, although the proportion of cancers treated bysurgical oncologists is difficult to determine since thereis no board certification or certificate of added compe-tence in surgical oncology. In a population based study of29,666 breast cancer patients reported to the Los AngelesCounty Surveillance, Epidemiology, and End Results(SEER) Program between 1990 and 1998, membershipin the Society of Surgical Oncology was used as asurrogate to identify surgical oncologists. Using thesecriteria, 90% of breast cancers were treated by non-surgical oncologists [1]. In contrast, the vision of theleaders in surgical oncology in the 1970s and 1980s ofthe role of the surgical oncologist as one who engages inthe total care of the cancer patient, performs unusualoperations for the treatment of malignancy, and takes aleadership role in educating colleagues about the biologyof neoplasia has proven to be remarkably accurate.

Training in surgical oncology has traditionally beenbroad based, with rotations on head and neck, thoracic,and gynecologic oncology services as well as ‘‘tradi-tional’’ general surgical services treating gastrointestinal,hepatobiliary, breast, and soft tissue tumors. Over time,the population of surgical oncologists who treat the entirespectrum of malignancies encompassed by this traininghas dwindled and there has been an increasing trendtoward organ-based subspecialization. This is reflected inthe organization of the surgical services at the major freestanding cancer centers in this country along anatomiclines and by the proliferation of organ-based subspecialtyfellowships. In contrast to the 14 general surgical

oncology fellowships approved by the Society of SurgicalOncology, there are 33 breast fellowships in theirmatching program.

Ironically, the specialty of surgical oncology now findsitself asking the question ‘‘Is subspecialization good forsurgical oncology?’’ One way to address this issue is toask whether subspecialization improves cancer care.There are a plethora of studies which indicate that cancertreatment outcomes ranging from survival to quality oflife are improved when surgery is performed by highvolume surgeons. While it is reasonable to argue thatvolume may be a surrogate for improved processes ofcare, multidisciplinary management, or some less easilydefined variable, it is an inescapable corollary that theorgan-based subspecialist is most likely to be a highvolume surgeon by virtue of performing procedures inlimited areas of the body, and also more likely to have theinterest, energy, and expertise to build a multidisciplinaryteam and keep up to date with advances in his/her area ofexpertise. When surgeons refer family and friends forcancer care, they seek out an expert, not the bestgeneralist, regardless of any qualms they may have aboutthe methodology of volume/outcome studies.

Does organ-based subspecialization hurt surgicaloncology as a discipline? Organ-based specialization isa natural outgrowth of the explosion of knowledgeregarding the pathogenesis and treatment of cancer thathas occurred over the past 20 years. The evaluation ofgenetic predisposition, the use of prophylactic surgery,and chemoprevention are clinical realities for manydisease sites. Participation in patient care in thisarena requires a much more in depth understanding ofepidemiology and genetics than was traditionally part of

*Correspondence to: Monica Morrow, MD, 333 Cotman Avenue,Philadelphia, Pennsylvania. Fax: 215-214-4035.E-mail: monica.morrow@fccc.edu

Received 24 January 2007; Accepted 1 February 2007

DOI 10.1002/jso.20798

Published online 18 April 2007 in Wiley InterScience(www.interscience.wiley.com).

� 2007 Wiley-Liss, Inc.

surgical oncology training. Advances have occurred inimaging, screening, and diagnostics. The indications foradjuvant and neoadjuvant chemotherapy continue toexpand, both in terms of disease sites for which activedrugs are available and stage of disease within individualorgan sites for which treatment is appropriate. Molecularclassification of tumors and targeted therapy are part ofeveryday practice. All of these advances have increasedthe body of knowledge that a surgical oncologist mustacquire for each disease site enormously. Is it reasonableto expect that after a typical rotation of 2–4 months on anorgan-based service that a trainee will have acquired asignificant amount of this knowledge base, and moreimportantly, will be likely to maintain and expand it formultiple organ sites over time? I think not.While I believe that organ-based subspecialization is

necessary to maintain the surgical oncologist’s role intotal care of the cancer patient and eduction of colleaguesabout cancer biology, there is an important role for thosetrained in general surgical oncology to play to ensure thefuture of the discipline as organ-based subspecializationevolves. Training programs for organ-based subspecialtyfellowships are at vastly different stages of development.For example, the breast fellowships certified by theSociety of Surgical Oncology have a list of learningobjectives for each required rotation which is so lengthythat I have often wondered whether an individualreally needs to complete not only a breast fellowship,but a medical oncology fellowship, a radiation oncologyresidency and a mammography fellowship to meetthem. In contrast, although gastrointestinal fellowshipshave initiated a matching program, a program for thedevelopment and certification of quality guidelines fortraining programs has just begun and will not be

operational for several years [2]. The American Associa-tion of Endocrine Surgeons has developed objectives anda curriculum for fellowship training, but complianceappears to be voluntary [3]. General surgical oncologyshould take a leading role in defining the fundamentalprinciples of cancer biology and management whichare not organ site specific and should be part of thetraining experience regardless of subspecialization.General surgical oncology societies should also act asumbrella organizations to bring the perspectives ofsurgical oncologists of all types to larger organizationssuch as the American College of Surgeons and theNational Cancer Institute.Organ-based subspecialization is inevitable. It has

already taken place at cancer centers and universityhospitals for many disease sites, and is seen in the care ofthe breast cancer patient in the community. Generalsurgical oncology training will continue to be necessary,and will increasingly provide surgeons for communitiesnot large enough to support organ-based subspecialists.By embracing organ-based subspecialty training andusing the experience gained during the development ofgeneral surgical oncology as a subspecialty, we willultimately improve the quality of cancer care that weprovide.

REFERENCES

1. Skineer KA, Helsper JT, Deapen D, et al. Breast cancer: dospecialists make a difference? Ann Surg Oncol 2003;10:606–615.

2. Swanstron U, Park A, Arregui M, et al. Bringing order to chaos.Developing a matching process for minimally invasive andgastrointestinal postgraduate fellowships. Ann Surg 2006;243:431–435.

3. http://www.endocrinesurgery.org/fellowships/objectives.html

Journal of Surgical Oncology DOI 10.1002/jso

2 Morrow