Walter Lawrence

History of Surgical Oncology

The history of the special interest area within general surgery that is now called surgical oncology began long before this nomenclature was conceived. It seems fair to say that the therapeutic approach to cancer, or “oncology,” has been intimately linked to the field of surgery since ancient times. Certainly, it is only in the last 100 years that there has been any useful treatment to offer the cancer patient other than an operation. Even though the effect of radiation was discovered just before the turn of the last century, this modality was only of limited clinical value until about 50 years ago. As the anticancer drugs and various hormonal alterations appeared on the scene as therapy at about the same time, we must consider all but the most recent history of oncology to be a purely surgical story.

Technologic innovations in surgery: a philosophic reflection on their impact on operations for cancer.

Technologic advances this past half‐century have clearly had a positive effect on our ability to both diagnose and treat human cancer as well as on the operative treatment of other diseases. However, the impact of these innovations on the surgical treatment of cancer is not as clear as it is for many other problems that are managed surgically. This review is an “opinion piece” that attempts to assess the successes and failures of technologic innovations that have been introduced for the purpose of improving the operative treatment of cancer. J. Surg. Oncol. 2009;100:163–168.

Special certification for general surgical oncology: concerns of a curmudgeon.

The possibility of some form of official recognition for the general surgeon who has expertise in surgical oncology has been discussed ever since the evolution of the Society of Surgical Oncology (SSO) from the James Ewing Society back in 1975. The Council of the SSO concluded in the late 1970s that this recognition should definitely take the form of certificates for those who had additional competence and experience in the surgical and overall management of patients with cancer for whom general surgery operations played some role. After all, our fellow disciplines of medical oncology and radiation oncology had established such a process and it seemed logical for surgeons participating in multidisciplinary care of cancer patients to have similar recognition as experts in oncology. Since I had the privilege of serving as SSO President then, I was instructed to relay this message from our SSO Council to my colleagues on the American Board of Surgery (ABS). Due to a general reticence for such subspecialization at that time among members of the ABS, and possibly for other reasons, this proposal from the SSO fell on ‘‘deaf ears’’ and nothing happened. Three decades later, much has changed in terms of the maturation of the field of surgical oncology within general surgery. Also, the attitudes of our general surgical leaders regarding the suitability of formal certification of general surgeons with special competence in surgical oncology and other specialized areas has changed. The ABS now seems poised to endorse official recognition for general surgeons who have had specialized training in surgical oncology. They propose this by establishing special competence through training guidelines and a formal examination process. Since the leadership and the majority of the SSO have been urging these developments over several decades, there is considerable jubilation about these recent developments despite a few negative views expressed by some of us. Some potential adverse effects of formal certification are not completely dismissed by those favoring this process, but the statement often made at present is that the positives outweigh the negatives. My purpose for writing this opinion piece is to suggest the opposite—that the negatives of this development may overwhelm possible advantages achieved by certification of general surgical oncologists. Regrettably, we health care providers are becoming more and more an industry and less and less an altruistic profession. For this reason, we are beginning to discuss ‘‘professionalism’’ in our education and training programs much more often, but the focus of medical practice has been ‘‘market share’’ and other business practices despite our lofty discussions of the importance of team efforts in patient care. It is for this reason that I strongly believe any certificate of special competence in a clinical health care environment can, and possibly will, be used by some hospitals through their bylaws to restrict the performance of patient care procedures to the ‘‘chosen few’’ with special competencies. It is clear that this is a good thing in many instances, particularly where craniotomy or prostatectomy is required, or even a technically demanding vascular operation. However, the overwhelming number of disorders that are appropriately cared for by surgical oncologists are procedures for which we routinely provide training and establish competence for surgeons completing approved general surgical training programs. Most of us agree that the well-trained general surgeon can deal with the overwhelming majority of these and the benefits provided to society by surgical oncologists are more in the leadership and cognitive areas, and much less in the technical sphere. We do need surgical oncologists’ leadership in clinical trials and for the overall management of very challenging Society of Surgical Oncology 2011The possibility of some form of official recognition for the general surgeon who has expertise in surgical oncology has been discussed ever since the evolution of the Society of Surgical Oncology (SSO) from the James Ewing Society back in 1975. The Council of the SSO concluded in the late 1970s that this recognition should definitely take the form of certificates for those who had additional competence and experience in the surgical and overall management of patients with cancer for whom general surgery operations played some role. After all, our fellow disciplines of medical oncology and radiation oncology had established such a process and it seemed logical for surgeons participating in multidisciplinary care of cancer patients to have similar recognition as experts in oncology. Since I had the privilege of serving as SSO President then, I was instructed to relay this message from our SSO Council to my colleagues on the American Board of Surgery (ABS). Due to a general reticence for such subspecialization at that time among members of the ABS, and possibly for other reasons, this proposal from the SSO fell on ‘‘deaf ears’’ and nothing happened. Three decades later, much has changed in terms of the maturation of the field of surgical oncology within general surgery. Also, the attitudes of our general surgical leaders regarding the suitability of formal certification of general surgeons with special competence in surgical oncology and other specialized areas has changed. The ABS now seems poised to endorse official recognition for general surgeons who have had specialized training in surgical oncology. They propose this by establishing special competence through training guidelines and a formal examination process. Since the leadership and the majority of the SSO have been urging these developments over several decades, there is considerable jubilation about these recent developments despite a few negative views expressed by some of us. Some potential adverse effects of formal certification are not completely dismissed by those favoring this process, but the statement often made at present is that the positives outweigh the negatives. My purpose for writing this opinion piece is to suggest the opposite—that the negatives of this development may overwhelm possible advantages achieved by certification of general surgical oncologists. Regrettably, we health care providers are becoming more and more an industry and less and less an altruistic profession. For this reason, we are beginning to discuss ‘‘professionalism’’ in our education and training programs much more often, but the focus of medical practice has been ‘‘market share’’ and other business practices despite our lofty discussions of the importance of team efforts in patient care. It is for this reason that I strongly believe any certificate of special competence in a clinical health care environment can, and possibly will, be used by some hospitals through their bylaws to restrict the performance of patient care procedures to the ‘‘chosen few’’ with special competencies. It is clear that this is a good thing in many instances, particularly where craniotomy or prostatectomy is required, or even a technically demanding vascular operation. However, the overwhelming number of disorders that are appropriately cared for by surgical oncologists are procedures for which we routinely provide training and establish competence for surgeons completing approved general surgical training programs. Most of us agree that the well-trained general surgeon can deal with the overwhelming majority of these and the benefits provided to society by surgical oncologists are more in the leadership and cognitive areas, and much less in the technical sphere. We do need surgical oncologists’ leadership in clinical trials and for the overall management of very challenging Society of Surgical Oncology 2011

Criteria of Operability in Advanced Breast Cancer

Radical resection of the breast, pectoral muscles, and regional lymph nodes for breast cancer was popularized by William S. Halsted late in the nineteenth Century, and became the mainstay for treat-ment. The lack of benefit from this Operation for some patients was first appreciated by Haagensen who, in classic publications with Stout in 1942 and 1943, described clinical features that were predictors of a shortened life expectancy after radical mastectomy (Haagensen and Stout 1942, 1943). Based on a series of 640 patients treated by radical mastectomy, they defined what they called “specific criteria of clinical inoperability” in patients who were considered technically resectable at the time of initial clinical presentation but who experienced early recurrence after surgery. Haagensen and Stout concluded from their thoughtful analysis that other treatment strategies for the management of these patients with locally more advanced breast cancer had to be found.

The Changing Face of Surgical Oncology

In 2015, the Society of Surgical Oncology celebrated a historical milestone, the details of which Dr. Charles Balch and his colleagues have recorded in a three-part treatise in Annals of Surgical Oncology. At this writing, there is some agreement on the meaning of the term ‘‘surgical oncology’’ among general surgeons. However, the slow but continuous change in the actual meaning of this term has continued to intrigue me. Some historical observations may be of interest and could have some effect on the evolving board certification process for this relatively new subspecialty of general surgery. When I was first involved in surgery as a medical student in 1945, surgical resection was the only effective cancer treatment for most ‘‘solid tumors.’’ General surgeons usually performed the cancer operations in various anatomic locations, except for the genitourinary and central nervous system sites, for which surgical subspecialists had established jurisdiction. Lung cancer was in the overall purview of general surgery because cardiac surgery was not yet developed. Otolaryngologists and gynecologists in that era generally deferred to general surgeons for major oncologic surgical procedures because their training programs did not often include operations required for cancer. University hospitals and some private hospital training programs in general surgery were mainly responsible for preparing surgeons to perform operations on most cancer patients with solid tumors, except for the occasional patients managed in ‘‘cancer hospitals.’’ Roswell Park Memorial Institute in Buffalo, Memorial Sloan Kettering Cancer Center in New York, the Ellis Fischell Cancer Hospital in Missouri, and M.D. Anderson Hospital in Houston existed, but they did not have many surgical trainees or significant ties to major surgical training programs at that time. They had fellowship training programs, but these were generally outside the mainstream of surgical education. Clinicians in these cancer hospitals provided cancer patients with both operative and radiation therapy care and would have been known as ‘‘surgical oncologists’’ rather than ‘‘cancer surgeons.’’ They were the multidisciplinary clinicians of that era. By the early 1950s, the aforementioned cancer hospitals were gaining legitimacy in the field of academic general surgery through some highly respected surgical leaders, including Allen Whipple (New York), Eugene Bricker (Missouri), and R. Lee Clark (Houston). Not only were these surgeons focusing only on cancer patients, but they also were performing extensive operations, earnestly believing that these were likely to result in a cure. This more radical surgical approach was used particularly for patients with cancers in the gynecologic anatomic area (e.g., pelvic exenteration) and in the head and neck (radical resections with extensive lymphadenectomy, craniofacial resection, and so on), as well as for patients with melanoma, for which extensive elective lymphadenectomies became the rule. Although this approach was termed ‘‘cancer surgery,’’ it actually was the surgical oncology of that time, and it included considerably more of the human anatomy than surgical oncology does currently. My personal observations came from my post-residency fellowship training at Memorial Sloan Kettering Cancer Center (1951–1952, 1954–1956), and then from serving the subsequent 10 years as a staff surgeon at this same institution. Although the cancer surgeons there (later called surgical oncologists) often specialized in specific anatomic areas, as a group, they covered cancers from head and neck to breast, to lung, to bone and soft tissue sarcomas, to gastrointestinal cancers, and to all pelvic cancers (including gynecologic malignancies). In those years, postresidency trainees leaving for surgical practice outside the cancer hospitals focused their subsequent practices on Society of Surgical Oncology 2017