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From the Department of Surgery, Ocean Medical Center, Brick, New Jersey.
Correspondence: Address correspondence to: John S. O’Shea, MD, FACS, Department of Surgery, Ocean Medical Center, 204 Jack Martin Boulevard, Suite C-3, Brick, NJ 08724; Fax: 732-840-3499; E-mail: jsoshea{at}comcast.net
Since at least the second half of the 19th century surgery has played a prominent role in the treatment of neoplastic diseases. As specialties and subspecialties proliferated during the 20th century, it was reasonable to think that the need would arise for a surgeon whose focus and training were geared exclusively toward the care of the patient with cancer. As we continue our efforts to deliver the best possible surgical care to the greatest number of patients with cancer, it is important to be aware of the historical complexities of specialty development as it relates to surgical oncology.
Historians of medicine have pointed out that the process of specialty development is in no way inevitable and it is subject to social, political, financial, and even personal influences that cannot be easily predicted or regulated.1 State licensing boards have avoided the issue of the standardization of specialists and, although certification is widely recognized as demonstrating proficiency within a chosen discipline, it remains a voluntary endeavor on the part of the physician. Certifying boards and specialty organizations set educational standards and provide guidelines for scope of practice, but they are not licensing bodies. Hospital credentialing committees also tend to be vague in their definition of specialty qualifications when deciding on delineation of privileges.2
The specialties of radiation oncology and medical oncology grew essentially de novo, around the technologies of radiology and chemotherapy as their defining point. The development of specialization in cancer surgery has been much less straightforward and, over the past several decades, surgical oncology has at times struggled to define its role.3–5
The roots of surgical oncology can be traced to Memorial Hospital in New York City and its association, beginning in 1912, with noted pathologist James Ewing. The James Ewing Society, begun in 1940 as an alumni association of Memorial Hospital, was renamed, in 1975, the Society of Surgical Oncology6 and since then has set guidelines for fellowship training programs. In 1998, the American Board of Surgery appointed an advisory council for surgical oncology to make recommendations on all relevant issues, including training in oncologic surgery. Opposition to separate American Board of Surgery status for surgical oncology has centered on the issue of the "fragmentation" of general surgery and a desire to maintain general surgical core competencies.7 As of 2004, there were 14 approved surgical oncology fellowship training programs in the United States, with approximately 35 graduates per year. As of May 2003, the roster of The Society of Surgical Oncology, Inc. numbered 1839 members.8 In 2001, 164 physicians in the American Medical Association (AMA) physician master file listed surgical oncology as their self-designated practice specialty (SDPS).9
As with general surgery, surgical oncology has had to face the issue of fragmentation, making the delivery of surgical care to patients with cancer increasingly complex. A brief look at the evolution of subspecialties involved in the surgical treatment of certain cancers (e.g., head and neck cancer, breast cancer, colorectal cancer) will indicate the irregular nature of specialty development.
The first "Head and Neck" service was established at Memorial Hospital in New York in 1915 with Henry Janeway as Chief of Service. In the 1940s, Hayes Martin and Grant Ward helped to define the parameters of this developing surgical specialty and in 1954 the Society of Head and Neck Surgeons (SHNS) was founded. Membership of this organization consisted primarily of general and plastic surgeons. The American Society for Head and Neck Surgery (ASHNS) was established 4 years later, by otolaryngologists with a particular interest and involvement in head and neck oncologic surgery. Because organized training programs were not available at that time, most of the graduate training in head and neck surgery occurred in unofficial "apprenticeship" or "preceptorship" arrangement, with mentors coming from the fields of general surgery, plastic surgery, and otolaryngology. Committees from the ASHNS and the SHNS collaborated to create the Joint Council for Approval of Advanced Training in Head and Neck Oncologic Surgery and, by 1977, the Council had approved a course curriculum for training in head and neck surgery.10 The two societies eventually merged in 1998 to become the American Head and Neck Society which, as of 2004, listed 15 approved programs in head and neck surgery training a total of 21 fellows. These programs vary in length from 1 to 3 years and applicants need to be eligible for examination by the American Board of Surgery, the American Board of Otolaryngology, or the American Board of Plastic Surgery.11 In 2001, 265 physicians listed their SDPS as head and neck surgery.12
In response to mounting clinical evidence and accelerated by social changes resulting from the Women’s Movement, the surgical treatment of breast cancer had a major paradigm shift in the second half of the 20th century and interest in breast cancer in general increased correspondingly.13 By the 1980’s, some surgeons began to limit their practice to breast surgery, following additional training that varied in length and quality. In addition, graduates of surgical residency programs entered more formal postresidency breast surgery fellowships. In 2003, in collaboration with the American Society of Breast Diseases and the American Society of Breast Surgeons, the Society of Surgical Oncology (SSO) developed comprehensive guidelines for fellowship training programs in breast surgery. As of 2004, 23 of 27 existing fellowship programs in breast surgery confirmed that they meet the requirements outlined by the SSO.14 The American Society of Breast Surgeons was founded in 1995 and, as of 2004, listed more than 1700 members. As of 2001, the AMA physician master file did not include a separate SDPS listing for breast surgery.
The American Board of Proctology was organized in 1934 and incorporated August 13, 1935, 2 years before the incorporation of the American Board of Surgery. In 1947, the Advisory Board for Medical Specialties supported a petition from the Central Certifying Committee of Proctologists of the American Board of Surgery for recognition as an independent board. The Board of Proctology would issue two certificates, one for candidates seeking recognition as colorectal surgeons and another for those candidates who wished to limit their practice to anorectal diseases. The latter group would not be required to pass the general examination given by the American Board of Surgery.15 After prolonged discussion and some degree of compromise, the American Board of Proctology agreed to withdraw its application for independent board status and it currently remains a subsidiary of the American Board of Surgery.16 In 1961, the American Board of Proctology changed its name to The American Board of Colon and Rectal Surgery, Inc. In 2003, 1177 physicians listed their SDPS as colorectal surgery.17
The unpredictable nature of specialty development, in addition to its historical interest, presents genuine questions regarding the delivery of surgical care to the patient with cancer. Should the patient with colorectal cancer, for example, be operated on by a general surgeon, a colorectal surgeon, or a surgical oncologist? A number of outcome studies appear to support the concept that a benefit to patients exists, in terms of in-hospital mortality18 and possibly survival,19,20 when specialists perform cancer surgery. Evaluation of the data in these studies becomes problematic, however, when we consider that the definition of a specialist remains inadequate.
It appears likely that surgery will maintain its prominent role in cancer treatment for the foreseeable future, with the number of patients needing oncologic procedures projected to increase significantly by the year 2020.21 As knowledge about neoplastic diseases and their surgical treatment progresses, it is also likely that specialization in surgical oncology will continue to evolve. Historical perspectives should not be overlooked as we endeavor to devise a healthcare system that provides competent, measurable, and affordable surgical care to meet the projected need of cancer patients.
Received for publication February 11, 2004. Accepted for publication March 1, 2004.
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