Job Outlook of Surgical Oncologists

[Dr.CCM]

With all the new minimally invasive procedures and therapy being used, what is the job outlook of surgical oncologists?

By that I mean, is there any chance in the next 20 years for this specialty to go the way cardiovascular surgery is suffering now--other specialties encroaching and treating their patient base with cheaper, intervening procedures?

Any input would be great. Thanks.

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[ESU_MD]

I wonder if cancer surgery and minimally invasive should be used in the same sentence?

 

[JackADeli]

I wonder if cancer surgery and minimally invasive should be used in the same sentence?

Yes

 

[SLUser11]

I wonder if cancer surgery and minimally invasive should be used in the same sentence?

They should absolutely be used in the same sentence.

 

[ESU_MD]

OK, so maybe any self-respecting young surgeon can take out a R colon cancer via the scope just as fast as an open procedure with similar oncologic results. the prototypical minimally invasive cancer operation.

What about the more traditional big-whack procedures of surg onc- like whipple, retroperitoneal sarcoma, stuff like that? Does anyone think its worth it to develop a minimally invasive whipple? The morbidity of the procedures probably isnt from the size of the scars in these cases. Isnt cancer surgery all about destruction anyway?

 

[JackADeli]

To name a few going ~ "top down":

Neurosurgery is using lapscopes for transnasal approaches to pituitary and other things
ENT is using robotics for trans-oral resections & Thyroid/parathyroid
Thoracic is using VATs with lung and esophageal cancer resections
General MIS folks do abdominal nodal sampling for some cancers
Hepatobiliary folks are using lap and/or robotics for gastric resections, liver resections, and experimentally pancrease resections.
SurgeOnc is doing any combinations of above and below this list
Urology is using lap and/or robotics for nephrectomies and adrenals.
Gyn is doing lap and/or robotics for uterine CA, ovarian CA
Colo-rectal is doing lap colons
Then, you have GI med doing esophageal mucosal stripping and ampullary resections.
Let's not forget the budding NOTES arena..... There may be lots of overlap between all of these fields and procedures.


Yes, MIS is integral to modern surgical oncology and you either get on-board or get out of the way.

PS: so WS doesn't get mad at me, breast surgery and conservation and implanting radioactive things, etc... all geared towards limiting resection to limit morbidity.

 

[JackADeli]

...What about the more traditional big-whack procedures of surg onc- like whipple, retroperitoneal sarcoma, stuff like that? Does anyone think its worth it to develop a minimally invasive whipple? The morbidity of the procedures probably isnt from the size of the scars in these cases. Isnt cancer surgery all about destruction anyway?

There are probably some lesions that are going to require major resections and amputations. However, we are gaining more control of the collateral damage. We are developing dyes and special luminescence to loacalize the extent of tissue.... similar to the limitied resection object of Mohs micrographic surgery.

 

[ESU_MD]

To name a few going ~ "top down":

....
Colo-rectal is doing lap colons

poor colo rectal- always at the bottom..😀

Dont get the wrong idea, I think the MIS stuff is pretty cool, but it all comes down to pt selection and outcomes- specifically in this case late oncologic outcomes.

Maybe I'm hypersensitive because I tend to think of doing procedures fast, efficient and simple. Or maybe I never got to work with a crew who could set up a nice lap case without having to call biomed to white balance the camera, get new cords, etc...

 

[surg]

No issues from my perspective. As we go further into the future, I think the real question will be, what does an MIS trained person bring to the table? They are being trained to be expert in the use of a set of instruments that will become commonplace to every other specialty. The knowledge of either a disease process or an anatomic region will still be the real thing that defines the basis of surgery. "It's not whether you can operate, it's whether you should." There is nothing in the MIS armamentarium that a surg onc couldn't learn if it became what needed to happen to take care of their patient. There is nothing magic about the scope or the robot that is covered only in MIS fellowships. (BTW, I've seen the video for a lap whipple, not planning on trying that any time soon; and quite frankly with me down to a 2cm incision for my parathyroids, I'm having trouble understanding why I should fire up the robot, although one of my friends did it successfully recently just for fun.)

The biggest threat to surg onc is not other surgeons, but that someone will develop a pill for cancer or perfect percutaneous ablation/etc where surgery will only be for salvage and failures. This will definitely crimp volume. Don't see this happening any time soon though. Cancer is a diverse disease and if one cancer goes away, we'll move on to something else.

 

[JackADeli]

...Dont get the wrong idea, I think the MIS stuff is pretty cool...

Maybe I'm hypersensitive because I tend to think of doing procedures fast, efficient and simple...

I understand where you are coming from... I just encourage you to keep an open mind. New tech is developed everyday. Its ability to be used fast and efficiently ALWAYS takes a learning curve. We saw that with open to lap-choles. The question is will you be sitting on the sidelines, uninvolved or actively participate in pushing forward the future.

No procedure will be introduced as immediately ready and perfect. GI ~owns the endoscopy because GSurgeons failed to get involved early, cardiologists own coronary cath because CT/CV refused to accept and laughed at the national presentations for about 10yrs. Plenty of "old time" surgeons made arguments of their small transverse incision for cholecystectomies and now do no cholecystectomies. Thoracic folks poopoo'ed VATS lobes..... Vascular was ~little late and has endured some years of up hill fighting to gain back endovascular from cards & IR.

You can be Mulholand and poopoo the place for MIS whipples. You can be any of the numerous jobless thoracic guys that poopoo'ed VATS. etc, etc.... Yes, new tech is painful. Yes, you need to time your entry into new tech carefully. But, the longer you wait to enter the fight the more risk is taken by the pioneers and so too is more money & glory taken by them. Also, you are often then stuck with the designs and solutions they developed... even if it seems to you a better alternative could have been developed. A parallel is how healthcare management was taken over by HMOs/politicins/etc... cause we didn't get as involved. It is very easy to sit back and let others charge.

...The biggest threat to surg onc is not other surgeons, but that someone will develop a pill for cancer...

Yep

...The biggest threat to surg onc is not other surgeons, but that someone will ...perfect percutaneous ablation/etc where surgery will only be for salvage and failures. This will definitely crimp volume...

Only if surgeons allow ablative and percutaneous techniques to be developed by the non-surgeon specialties. I have met with the industry reps. They come to the surgeons & surgeons disregard them. They then turn to IR/GI/Pulm/etc.... who then becomes the provider of this therapy.

You may like open procedures but be very cautious about what techniques you disregard/fail to learn. You may be giving your work to someone else. Consider rads doing breast cores, ablations, tumor Tx via seed placement, gamma knife (with non surgery specialties placing the fiducials), GI moving into NOTES, GI doing zenkers, esoph mucosa stripping, etc.... That all may be fine with you. But, you are then relagating yourself to just the salvage and complication procedures.

 

[thedrjojo]

No issues from my perspective. As we go further into the future, I think the real question will be, what does an MIS trained person bring to the table? They are being trained to be expert in the use of a set of instruments that will become commonplace to every other specialty. The knowledge of either a disease process or an anatomic region will still be the real thing that defines the basis of surgery. "It's not whether you can operate, it's whether you should." There is nothing in the MIS armamentarium that a surg onc couldn't learn if it became what needed to happen to take care of their patient. There is nothing magic about the scope or the robot that is covered only in MIS fellowships. (BTW, I've seen the video for a lap whipple, not planning on trying that any time soon; and quite frankly with me down to a 2cm incision for my parathyroids, I'm having trouble understanding why I should fire up the robot, although one of my friends did it successfully recently just for fun.)

The biggest threat to surg onc is not other surgeons, but that someone will develop a pill for cancer or perfect percutaneous ablation/etc where surgery will only be for salvage and failures. This will definitely crimp volume. Don't see this happening any time soon though. Cancer is a diverse disease and if one cancer goes away, we'll move on to something else.

I agree with this entirely...

you have to consider, surgical oncology as a field essentially encroaches upon many other specialties as it is... name one cancer that entirely belongs to surgical oncologists? In fact, many "surgical oncologists" are just general surgeons who decided to focus on cancer, but never got any additional training (go to Tisch, NYU's private hospital, and see who is doing the whipples there... its not Berman (board member of the SSO), or Roses (who was one of the lead authors on the sentinal lymph node biopsy for melanoma), or any of the other surgical oncologists, its Pachter, the chairman and a general surgeon who has focused his career on the Pancreas). Surgical Oncologists is the representation that treating/mastering the disease process and not the anatomy is what is important, and really the first and only type of surgical subspecialty designed in this mold (Transplant is the only other field I can think of that is disease/treatment process based and not anatomically based, and MIS is skill set based). As was stated above, surgical oncologists already do MIS procedures, all surgical residents must be proficient in MIS, and if anything, the MIS fellowship might be in jeopardy as the "skills" taught in the fellowship become more and more par for the residency course (my particular residency is, so I have heard, doing away with the fellowship and instead incorporating that into the residency... but I don't have all the details so I am not entirely sure).

 

[SLUser11]

Surgical Oncologists is the representation that treating/mastering the disease process and not the anatomy is what is important, and really the first and only type of surgical subspecialty designed in this mold (Transplant is the only other field I can think of that is disease/treatment process based and not anatomically based, and MIS is skill set based).

Trauma/Critical care

Pediatrics

MIS (it's hard to argue the semantics of this not being disease/treatment based)

Endocrine (maybe your argument works here)


I don't know, it seems like there are several surgical subspecialties that are dedicated to a certain pathology: Trauma, cancer, etc....or to a certain patient population: MIS, peds......not all specialties are entirely based on anatomy.


As far as laparoscopy for cancer, every time I open the blue journal or Am J Surg there's a new article about laparoscopy having non-inferior oncologic outcomes for some new cancer: Adrenals, rectal, colon, LIVER, lung, kidney, prostate, uterus, ovary......I'm sure pancreas will work its way in there eventually......

 

[SLUser11]

and quite frankly with me down to a 2cm incision for my parathyroids, I'm having trouble understanding why I should fire up the robot.....

I'm arguing semantics here, but your parathyroid surgery would be considered minimally invasive by most endocrine surgeons.....

Otherwise, I can't agree with you more about adjuvant therapies being the real threat to our livelihood.

 

[thedrjojo]

Trauma/Critical care

Pediatrics

MIS (it's hard to argue the semantics of this not being disease/treatment based)

Endocrine (maybe your argument works here)


I don't know, it seems like there are several surgical subspecialties that are dedicated to a certain pathology: Trauma, cancer, etc....or to a certain patient population: MIS, peds......not all specialties are entirely based on anatomy.


As far as laparoscopy for cancer, every time I open the blue journal or Am J Surg there's a new article about laparoscopy having non-inferior oncologic outcomes for some new cancer: Adrenals, rectal, colon, LIVER, lung, kidney, prostate, uterus, ovary......I'm sure pancreas will work its way in there eventually......

Trauma and Peds... forgot about them... they do fit the mold...

MIS, i did mention as more of a skill set... surgically wise, there is no major difference in lap procedures compared to open procedures, just the skills used to complete them. Surgical oncologists take a team approach to cancer, working with the medical and radiation oncologists for a complete treatment plan, and the basis of the training is that approach to the treatment of cancer... transplant deals with the immunological therapy, and more time is spent with managing rejection than it is preping and doing the surgery...

I do agree with you that MIS is the future of pretty much all types of surgery, including oncology. One major one you didn't mention that is a real hot advance is Minimally Invasive Esophagectomy. We had a grand rounds on that last year (one of the thorasic surgeons from Pitt, an alumni of our program, came and gave the presentation... boy was it impressive). As an aspiring surg onc (as PGY1, really aspiring here 😉 ), I am looking forward to all the minimally invasive procedures, and still feel a surg onc fellowship will be the best preparation to doing these procedures and treating cancer patients on a whole.

 

[SLUser11]

As an aspiring surg onc (as PGY1, really aspiring here 😉 ), I am looking forward to all the minimally invasive procedures, and still feel a surg onc fellowship will be the best preparation to doing these procedures and treating cancer patients on a whole.

I'd keep an open mind during your rotations. You might find that one area of surgical oncology interests you the most, e.g. colon and rectal cancer, thyroid cancer, breast cancer, lung cancer, liver and pancreas cancer, where a different fellowship may serve you equally or better.

As for Surgical Oncology, most people do 2 years of research, so I guess you can't keep an open mind for too long. My experience has been that oncologists find a small area of interest, like melanoma or breast, that ends up being a large portion of their practice.

 

[Winged Scapula]

I'd keep an open mind during your rotations. You might find that one area of surgical oncology interests you the most, e.g. colon and rectal cancer, thyroid cancer, breast cancer, lung cancer, liver and pancreas cancer, where a different fellowship may serve you equally or better.

As for Surgical Oncology, most people do 2 years of research, so I guess you can't keep an open mind for too long. My experience has been that oncologists find a small area of interest, like melanoma or breast, that ends up being a large portion of their practice.

Good point.

All of my attendings in fellowship were Surg Onc trained. And they all had 1 area of expertise; the ones doing breast admitted they did less than 2 months of breast during their fellowship and probably did not benefit much from the remaining training, except in terms of the research, multidisciplinary training and covering the Surg Onc service.

So keep your mind open (as always).

 

[thedrjojo]

I'd keep an open mind during your rotations. You might find that one area of surgical oncology interests you the most, e.g. colon and rectal cancer, thyroid cancer, breast cancer, lung cancer, liver and pancreas cancer, where a different fellowship may serve you equally or better.

As for Surgical Oncology, most people do 2 years of research, so I guess you can't keep an open mind for too long. My experience has been that oncologists find a small area of interest, like melanoma or breast, that ends up being a large portion of their practice.

Oh, I am keeping an open mind... thats why I qualified it as im only a pgy1...

Your point of another area might serve me equally or better is the contention of the surg onc fellowship/ideology. Currently im looking at liver and pancreas (but having never actually operated on them, its all just fanciful thinking). I know that there are 3 ways to really focus on it (Surg Onc, Transplant, or HPB) and each claim to be the best approach to focusing on the area, and it will be a challenge over these next 5-7 years to figure it out and narrow it down.

Tracked Surg Onc fellowships (meaning you focus your surg onc fellowship time on one area more than the others if that is what you want to be doing) might be coming in the future, or so it would make sense to do... its a newer fellowship and still working on its board, so i can see it, and the whole training paradim, shifting in the future (more tracked residencies - gone with be the general surgery and possibly even the internal medicine residencies, in will be residencies for each type of surgery, each type of medical specialty, shaving a year off or so off residency/combining it with fellowship)...

 

[SLUser11]

Oh, I am keeping an open mind... thats why I qualified it as im only a pgy1...

...Currently im looking at liver and pancreas (but having never actually operated on them, its all just fanciful thinking).

Well, I can tell you from experience that liver and pancreas cases aren't always as fun as they may sound. There's a reason why transplant and hepatobiliary fellowships are considered less competitive.....

 

[45408]

Well, I can tell you from experience that liver and pancreas cases aren't always as fun as they may sound. There's a reason why transplant and hepatobiliary fellowships are considered less competitive.....

Some people are gluttons for punishment though. Peds doesn't sound fun to me either...

 

[thedrjojo]

Well, I can tell you from experience that liver and pancreas cases aren't always as fun as they may sound. There's a reason why transplant and hepatobiliary fellowships are considered less competitive.....

It isn't necessarily that the procedures sound fun, its that I enjoy the pathology and the physiology of oncology/transplant more than anything else... and as a former tournament chess player, the long cases don't scare me too much...

I thought HPB fellowships were fairly competitive

 

[SLUser11]

I thought HPB fellowships were fairly competitive

Traditionally, that fellowship was not very competitive. It is possible that the difficulty in matching has increased. I wasn't able to find much info on it just now, but here's the closest thing to an answer.

As for transplant, not competitive.

But, as I've said before, most fellowships are not that hard to get into, which is why such a large % of general surgery graduates can go on to fellowship. My experience is that for CT/Vascular/Trauma/MIS/Breast/Transplant/HPB/burn/Hand, it is still a buyer's market. Of course, every year people will say "it's getting really competitive this year" but the numbers don't lie.

It seems like Plastics is still by far the hardest match, based on overall interest (# applicants) and quality of applicants. Peds and Surg Onc are still very competitive, but tend to be a self-selecting group, and then colo-rectal is just sort of floating around in the wind out there, and I can't really tell where it belongs on that list....probably below the main 3 but above the first group I mentioned.

Of course, you need to do what makes you happy, and the competitiveness should be a non-factor in your career decision.

 

[thedrjojo]

Traditionally, that fellowship was not very competitive. It is possible that the difficulty in matching has increased. I wasn't able to find much info on it just now, but here's the closest thing to an answer.

As for transplant, not competitive.

But, as I've said before, most fellowships are not that hard to get into, which is why such a large % of general surgery graduates can go on to fellowship. My experience is that for CT/Vascular/Trauma/MIS/Breast/Transplant/HPB/burn/Hand, it is still a buyer's market. Of course, every year people will say "it's getting really competitive this year" but the numbers don't lie.

It seems like Plastics is still by far the hardest match, based on overall interest (# applicants) and quality of applicants. Peds and Surg Onc are still very competitive, but tend to be a self-selecting group, and then colo-rectal is just sort of floating around in the wind out there, and I can't really tell where it belongs on that list....probably below the main 3 but above the first group I mentioned.

Of course, you need to do what makes you happy, and the competitiveness should be a non-factor in your career decision.

the link didn't really tell much of anything... there are so few HPB spots, and a good majority applying for that also apply for surg onc (hence the combo match with surg onc now) that I lumped it in the competitive level of surg onc, maybe a little lower... who knows... I have 5-6 years to worry about it (assuming I am going to do research, transplant is a 4th year application, surg onc/hpb is early 5th year application)... the landscape will probably change by then (especially if Surg Onc gets boarded and then starts accepting new programs again

 

[Guile]

It isn't necessarily that the procedures sound fun, its that I enjoy the pathology and the physiology of oncology/transplant more than anything else... and as a former tournament chess player, the long cases don't scare me too much...

I thought HPB fellowships were fairly competitive

A right hepatectomy is a great case.

It seems like Plastics is still by far the hardest match, based on overall interest (# applicants) and quality of applicants. Peds and Surg Onc are still very competitive, but tend to be a self-selecting group, and then colo-rectal is just sort of floating around in the wind out there, and I can't really tell where it belongs on that list....probably below the main 3 but above the first group I mentioned.

Of course, you need to do what makes you happy, and the competitiveness should be a non-factor in your career decision.

I always thought that peds surgery was the most competitive, but that may have just been the conventional wisdom that gets passed along from year to year and isn't current. It's competitive due to the low number of spots and somewhat insular group is my understanding. Plastics is competitive for obvious reasons of course, although I hear the job market is pretty tough right now with the economy being down and oversaturation.

 

[SLUser11]

A right hepatectomy is a great case.


I always thought that peds surgery was the most competitive, but that may have just been the conventional wisdom that gets passed along from year to year and isn't current. It's competitive due to the low number of spots and somewhat insular group is my understanding. Plastics is competitive for obvious reasons of course, although I hear the job market is pretty tough right now with the economy being down and oversaturation.

The updated Peds match statistics show that it was a brutal year for Peds (54% match rate for US MDs vs. 71-75% in recent years). I think of Peds as a self-selecting group....small # spots for a small # of interested people....but it would suck to jump through all those hoops, research etc, and then still not match.

Personally, I didn't like peds surgery all that much...or vascular, or transplant, or hepatobiliary. If I had to pick a specialty besides colorectal, I might just pick good old-fashioned general surgery.

 

[deleted89854]

I'm aiming for peds right now, and the match seems pretty brutal. Everybody interviews everywhere, and it seems like you're lucky to get a match in your top ten. Apparently there are programs that take a fellow every other year, so the number of spots vary. Everybody has research and absites above the 70th percentile, and someone told me the average matched applicant has about 15 publications (total). My program has sent people to Hopkins and Chicago the last couple of years, so that's a little reassuring.

It was my understanding that Surg-Onc was another field that basically required research. One of the fellows told me if I was interested I should try to get my PhD. Plastics is doable without dedicated research time, although some papers probably help. Of course, all this is based upon the scientific method of "some guy told me once" so take it for what it's worth.

 

[Guile]

My program has sent people to Hopkins and Chicago the last couple of years, so that's a little reassuring.

For peds? Did these guys do two years in the lab? Bench research or clinical?

 

[deleted89854]

One had 2 years bench research, the other was doing mostly outcomes research. I'm in a clinical lab myself.

 

[SouthernSurgeon]

. I think of Peds as a self-selecting group....small # spots for a small # of interested people....but it would suck to jump through all those hoops, research etc, and then still not match.

Esp once you see the people who try to match, don't, do the year of peds cc hell to try and boost their app, and STILL don't match...

 

[45408]

Esp once you see the people who try to match, don't, do the year of peds cc hell to try and boost their app, and STILL don't match...

Yeah, I know a girl who did that. That's why I tried to find a field that didn't rely on getting a specific fellowship in order to hit my career goals.

 

[surgoncforya]

To name a few going ~ "top down":

Neurosurgery is using lapscopes for transnasal approaches to pituitary and other things

SURGONC doesn't touch the brain.

ENT is using robotics for trans-oral resections & Thyroid/parathyroid

SURGONC is doing transoral robotic resections. And robotic/MIS thyroid.

Thoracic is using VATs with lung and esophageal cancer resections

SURGONC is doing plenty of VATS, and 3-hole minimally invasive esophagectomy.

General MIS folks do abdominal nodal sampling for some cancers
Hepatobiliary folks are using lap and/or robotics for gastric resections, liver resections, and experimentally pancrease resections.

SURGONC is doing laparoscopic hepatectomy, radical cholecystectomy, and laparoscopic whipple, not to mention laparoscopic upper GI/gastric/spleen/adrenal, distal pancreas, etc.

SURGONC is doing single port colectomy, single port LAR, robotic LAR, robotic APR, etc.

SURGONC is still the master of all things open

 

[SLUser11]

To name a few going ~ "top down":

Neurosurgery is using lapscopes for transnasal approaches to pituitary and other things

SURGONC doesn't touch the brain.

ENT is using robotics for trans-oral resections & Thyroid/parathyroid

SURGONC is doing transoral robotic resections. And robotic/MIS thyroid.

Thoracic is using VATs with lung and esophageal cancer resections

SURGONC is doing plenty of VATS, and 3-hole minimally invasive esophagectomy.

General MIS folks do abdominal nodal sampling for some cancers
Hepatobiliary folks are using lap and/or robotics for gastric resections, liver resections, and experimentally pancrease resections.

SURGONC is doing laparoscopic hepatectomy, radical cholecystectomy, and laparoscopic whipple, not to mention laparoscopic upper GI/gastric/spleen/adrenal, distal pancreas, etc.

SURGONC is doing single port colectomy, single port LAR, robotic LAR, robotic APR, etc.

SURGONC is still the master of all things open

Well, at least you're not biased.

Besides, we both know that Surgical Oncology is not the leader in the majority of innovative procedures you just mentioned.

 

[JackADeli]

Well, at least you're not biased.

Besides, we both know that Surgical Oncology is not the leader in the majority of innovative procedures you just mentioned.

I'm not sure why my name has been tagged to the quoted comment... that was not what I posted. What I posted is:

To name a few going ~ "top down":

Neurosurgery is using lapscopes for transnasal approaches to pituitary and other things
ENT is using robotics for trans-oral resections & Thyroid/parathyroid
Thoracic is using VATs with lung and esophageal cancer resections
General MIS folks do abdominal nodal sampling for some cancers
Hepatobiliary folks are using lap and/or robotics for gastric resections, liver resections, and experimentally pancrease resections.
SurgeOnc is doing any combinations of above and below this list
Urology is using lap and/or robotics for nephrectomies and adrenals.
Gyn is doing lap and/or robotics for uterine CA, ovarian CA
Colo-rectal is doing lap colons
Then, you have GI med doing esophageal mucosal stripping and ampullary resections.
Let's not forget the budding NOTES arena..... There may be lots of overlap between all of these fields and procedures.


Yes, MIS is integral to modern surgical oncology and you either get on-board or get out of the way.

PS: so WS doesn't get mad at me, breast surgery and conservation and implanting radioactive things, etc... all geared towards limiting resection to limit morbidity.

 

[Guile]

I'm not sure why my name has been tagged to the quoted comment... that was not what I posted. What I posted is:

Your name is attached to that reply because surgoncforya messed up the reply function. He tried to separate your comments and reply to them individually. See above.

 

[surgoncforya]

Well, at least you're not biased.

Besides, we both know that Surgical Oncology is not the leader in the majority of innovative procedures you just mentioned.

Yes, very true for both.

I am biased,
and surgical oncology is not the leader in MIS. Late but strong adapter.