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Surgical Oncology in the 21St Century Presidential Address

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Surgical Oncology in the 21St Century Presidential Address Surgical Oncology in the 21st Century Presidential Address Charles M. Balch, MD advances in oncology research are now taking The increased empha¬ Substantialplace that will clearly benefit patients with cancer as we sis on multidisciplinary approach the 21st century. These research advances range cancer care raises the im¬ from those involving molecular biology to results of pro- portant question about spective clinical trials involving multimodality treatments. which physician spe¬ These advances will produce some fundamental changes cialty will coordinate that will affect our surgical practice and the expertise we cancer care in the fu¬ bring to the care of patients with cancer in the next century. ture. It is already evi¬ I chose this topic for three reasons. First, multimodality dent that cancer care will cancer treatment will be used for the vast majority of pa- involve two or more tients with cancer in the future. This, in turn, will require treatment modalities for a profound change in the coordination of cancer treatment most patients in the fu¬ by a team of specialists instead of the surgeon alone. Sec- ture; in fact, it already ond, I am concerned that some patients with cancer may does in many cases. not have access to optimal surgical care in the future. My The traditional se¬ experience on the American Board of Surgery as well as quence of cancer man¬ conversations with surgeons in the community make it agement has involved Charles M. Baldi, MD very clear that many surgical trainees and practicing sur¬ either surgery alone or geons are having a difficult time keeping pace with oncol¬ surgery as the first of a series of multimodality treatments, ogy advances because too many are not equipped educa¬ with the surgeon being the patient's entry point into the tionally or are not willing to be fully engaged in care system because we establish the diagnosis and give partnership with other oncology specialists. Furthermore, the first treatment. However, by the 21st century it is pos¬ any void left by surgeons in decision making is being filled sible that only a minority of patients with cancer will have by medical oncologists who have had little exposure to surgery alone as a single modality of treatment. It is more surgery as a treatment for cancer. likely that chemotherapy and even radiation therapy will Third, the Society of Surgical Oncology and its members be used as the initial cancer treatment for many patients, are the most appropriate group to provide leadership while surgical treatment for some types of cancer will be within both the surgical community and the oncology relegated to a secondary or even a tertiary level. community to represent the value of surgical care for pa¬ For example, preoperative chemotherapy has been used tients with cancer. To do this, we will have to broaden our for an increasing number of tumors, either to reduce tumor vision as a society by boldly adopting an even more pro¬ size (to facilitate the surgery) or to determine drug sensi¬ active role in cancer education and research as it relates to tivity in individual patients. This approach has been used the surgical patient with cancer. successfully in patients with some stages of breast cancer, osteogenic sarcoma, testicular cancer, anal carcinoma, rec¬ A GLIMPSE INTO THE FUTURE OF CANCER CARE tal carcinoma, gastric carcinoma, soft-tissue sarcoma, and carcinoma. On the other hand, there will be an our care for esophageal While the centerpiece of specialty is surgical increased role for excision of distant metastatic the with the of our is surgical patient cancer, uniqueness specialty disease as a means to achieve more responses in Both are but the latter complete oncology management. important, patients already responding to chemotherapy and/or ra¬ will be the emphasis of this talk. As we approach the 21st diation therapy. century, advances in oncology will have a major impact on the multidisciplinary treatment of the surgical patient with cancer as well as surgical education and cancer research. COORDINATION OF CANCER CARE As multimodality cancer treatment becomes standard Accepted for publication July 25, 1992. for a larger number of patients, a central question is, "Who From the Division of Surgery, University of Texas M. D. Anderson will coordinate the care of the patient with cancer?" Until Cancer Center, Houston, Tex. recently, this has exclusively been the surgeon, but in¬ Presented as the address at the 45th Annual Cancer presidential Sympo- it will involve a team of sium of the of New York, NY, March 15,1992. creasingly oncology specialists. Society Surgical Oncology, This team will be of Reprint requests to the Division of Surgery, University of Texas M. D. composed surgeons (both specialist Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 and generalist), medical oncologists, and radiation oncol¬ (Dr Balch). ogists. What are their respective roles? Downloaded From: http://archsurg.jamanetwork.com/ by a Johns Hopkins University User on 12/26/2014 The surgeon and the surgical oncologist should continue Table 1.—Oncology Staffing to have the symbiotic relationship that we have had for decades. In general, surgical oncologists will work in No. of in institutions No. of Training tertiary-care hospitals, primarily teaching Specialty Physicians Programs with surgical residency programs, while board-certified surgeons will continue to be the cancer surgery specialists Surgical oncology 1000 12 in local hospitals. Both groups of surgeons have tradition¬ Medical oncology 6000 166 been care of their ally involved in the overall surgical pa¬ Radiation oncology 2500 75 tients, including the coordination of multidisciplinary cancer care. All surgeons must therefore incorporate new knowledge from oncology advances that now extend well beyond the technical aspects of surgery if we are to main¬ have incorporated the rigor of clinical trials into every as¬ tain a viable partnership with other oncology specialties. pect of their patient care, at university medical centers, in The American Board of Surgery has sanctioned this their training programs, and in community practice as concept by formally incorporating surgical oncology as well. We should compliment them on their foresight and one of its primary specialty components and defining it to ask the question, "Why shouldn't surgeons be more include the broader components of oncology management involved in shaping the future of cancer through clin¬ in addition to cancer surgery (ie, coordinated multimodal¬ ical trials?" ity management of the cancer patient by screening, sur¬ Radiation oncologists provide an important form of lo¬ veillance, surgical therapy, adjunctive therapy, rehabilita¬ cal and regional cancer therapy. Often, radiation therapy tion, and follow-up). is used after surgery to improve local disease control rates To do this, surgeons must address educational and (eg, rectal cancers and breast cancers) or even before sur¬ practice issues that incorporate oncology principles to a gery to reduce tumor bulk (eg, some head and neck can¬ greater degree than we have in the past. While this should cers). Sometimes, irradiation is used as an alternative to not be a problem for most members of the Society of Sur¬ surgical excision of a cancerous organ (eg, gastric lym- gical Oncology, I am very concerned that the practice of phoma or laryngeal carcinoma). Radiation oncologists cancer care by community surgeons will not succeed un¬ usually work closely with medical oncologists and sur¬ less there are fundamental changes in surgical residency geons, but more often, in general, with the former. training programs and continuing education that more fully incorporate oncology principles. ONCOLOGY MANPOWER ISSUES Surgical oncologists have the dual responsibility, indeed We also need to examine manpower issues if we are go¬ the obligation, to be role models and consultants in both ing to ask the question, "What is the surgeon's role in co¬ surgical care and oncology care. In addition, we must teach ordinating cancer care in the 21st century?" other surgeons and surgical residents how to incorporate The first thing we can say is that surgical oncologists will oncology principles into their practices. Are we doing that not directly provide cancer care for the majority of patients well enough? Recently, I analyzed the topics most fre¬ with cancer. After all, there are only 1000 members of our quently failed on the American Board of Surgery's oral ex¬ society, and if one adds the membership of all other spe¬ amination and found, much to my dismay, that oncology cialty societies of surgical oncology, the number still would topics were the least understood by recent graduates of not exceed 2500. Our surgical oncology specialty is about surgical training programs. These data corroborate my one eighth the size of our medical oncology and radiation impression, after examining hundreds of candidates for therapy counterparts (Table 1). Shouldn't we at least the American Board of Surgery, that a significant number consider increasing the number of surgical oncology have only a rudimentary knowledge of oncology. Some of specialists? these candidates could not address such straightforward Let me see if I can graphically illustrate this issue by ex¬ issues as when to give tamoxifen in patients with node- amining the number and distribution of oncologists in positive breast cancer. A frequent reply to such a question Texas. Figure 1 shows the locations and number of surgi¬ was, "I would refer the patient to a medical oncologist for cal oncologists who are members of the Society of Surgical all those decisions." Oncology. There are 76 members in Texas, of whom 80% Medical oncologists, by their practice and training, are are located in Houston. Clearly, these members of our so¬ positioning themselves to coordinate cancer treatment ciety cannot provide all the cancer surgery needed by the from the time the diagnosis is first established.
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