Surgical Oncology

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illixir

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Hi, I'm a second year resident interested in Surg onc among other specialties. I want to get a sense of what surgical oncologists are doing at other people's institutions and what direction people think this specialty is headed. Surgeons are continuing to specialize in certain types of procedures, I find at my institution most of the colon cancers are being done by colorectal, pancreatic cancers by HPB, breast cancers by breast, thyroid by endocrine/ENT. All these fellowships do indirectly give exposure to non-surgical treatment of these cancers, and the surgeons with the best outcomes are those from the anatomically oriented specialties(at my institution). There may be these complex tumor cases that are fit for surg onc, but they are rare. I'm also not at the most academic place.

The surgical oncologists we do have: one does some cases that don't really fit a mold, melanoma/sarcoma cases, gastrectomies/esophagectomies(what he does most frequently), another does again some oddball cases and here and there the occasional colon, liver, gastrectomy, esophagectomy, whipple or adrenal. They also have less volume overall then the other specialties despite their breadth of surgical offerings.

Clearly its a specialty lending itself to academics, their fellowship requires experience with all the different types of oncology therapy and in a big center they're probably doing more of the stuff with peritoneal chemo but overall, it seems like they are doing a broad range of cases without really mastering any of them unless their practice is built towards focusing on a certain one. Nowadays with a 2-3 year fellowship including research and time with medical/radiation oncology it seems hard to imagine mastering many of these cases if one didn't come close in residency, and if their mentors dont have high volume. Gastrectomies and melanoma/sarcoma seem to be the main operations/areas they end up controlling and mastering, but maybe that's just what I'm seeing.

A bigger question then is what will really be the role for these types of surgeons with the continuing trend, the random complex tumor case requiring peritoneal chemo or enbloc radical resection with other random cases and time supervising the lab? Or should they too focus on a certain type of cancer/procedure.

What are other people's experiences with this department and thoughts on the utility of such a fellowship?

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Surg onc is an interesting field. Because as you pointed out, it is one of very few fields that is not anatomically based, but rather it is mitotically based.

As you point out, at big academic centers, things get exceptionally compartmentalized - it is very uncommon actually for a hospital to have a colorectal, HPB, endocrine, and surg onc division - that's something you really only see in the big big centers. The impression I've gotten is that at even medium sized academic centers, to say nothing of private practice, there is more variety in their practice.

A lot of discussions have gone on about what the best training route is if you want to do HPB (which seems to be what a lot of med students and young residents considering "surg onc" think they want to do). The transplant guys will tell you they get the best technical training to do those operations. The HPB guys will tell you that since they focus their whole training on it, they are the best. The surg onc guys will tell you they are the best at cancer care and the operation is only one part of that.

But as someone pointed out at AHPBA this year, at the current rate in 10 years we are going to have something like 1000 HPB fellowship trained surgeons out there. They joked that eventually we will have more HPB surgeons than whipples. In other words, the marketplace is tight - the likelihood that you're going to be a whippleologist a la Cameron these days is quite low.

To me, I think I'm pulled to surg onc because I DON'T necessarily have one organ system that I'm drawn to. I like the (potential, at least) for more variety in the practice. Also, one of my mentors (not a surgical oncologist) put it:

If you do an HPB fellowship and can't find an HPB job, what do you do? (answer: general surgery)

If you do a Surgical Oncology fellowship and can't find an HPB job, what do you do? (answer: surgical oncology)

My other draw to oncology is that I am very strongly considering a research heavy career. Doing surg onc gives me "street cred" to do broad based outcomes research on all cancer types, and the practice can lend itself to a lot of research time if you do end up doing a lot of melanoma and breast.

Anyways, those are my stream of consciousness thoughts.
 
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I'm not really equating it to HPB, I think if you want to do whipples in practice, you should be doing them pretty regularly. Though that's part of the reason I ask this question because traditionally it may be associated with that.
I'm at essentially what amounts to a community hospital, by no means an academic center though we do have an affiliation and are heading that way now, half of our attendings are private practice and the other half employed by the hospital. We of course don't have separate services for all those fields, in reality we have one surg onc service which includes 2-3 surg onc attendings, a HPB attending, and an endocrine attending. Their practices are completely separate though despite having the same service of residents rounding on their patients. General surgeons at my institution also do a fair number of gastrectomies and colectomies for cancer.
The surg onc attendings here actually probably don't mind their practice as I mentioned above and have the experience to do the variety of occasional operations as they're more senior. But again, outcomes are not as good as those doing several of them a week, though this may not be true everywhere. And I think trying to obtain the necessary experience to perform such a variety now would be difficult, but I suppose that argument is being made for surgery in general. If a surg onc attending is going to be pursuing research(which most of them tend to) they will want to be at an academic center which lends itself to the compartmentalization. If you're in the community or small hospitals, I don't know that a surg onc fellowship is even as helpful except maybe to show to your patients given general surgeons do many of those operations there.

It sounds like you're at a larger place, what cases are your surg onc attendings doing?
 
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