Surgical Oncology=Colorectal?

[SLUser11]

http://www.acgme.org/Portals/0/Defined_Category_Minimum_Numbers_Complex_General_Surgical_Oncology.pdf?platform=hootsuite



In many areas, a turf war still exists between surgical oncologists and colorectal surgeons for the surgical treatment of colorectal cancer. At national meetings and in casual conversations, I’ve heard surgical oncologists opine that they are either equally or more qualified to remove colorectal cancer than we are.


I just saw this link today, which shows the case minimum for “gastrointestinal not HPB” surgery to be 50…over a 2 year fellowship. My understanding is that this would include foregut as well, with no specific minimum requirements for colectomies and pelvic dissections.


Thoughts? Should modern graduates of surgical oncology fellowships be doing colorectal surgery? Should they venture into the pelvis?

SLUser

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[SLUser11]

http://www.surgonc.org/training-fellows/fellows-education/surgical-oncology/program-requirements

These must be the old, pre-ACGME rules, but I'm not sure. They require at least 10 combined colon and rectal cancer surgeries during the 2 year fellowship.

http://www.absurgery.org/xfer/CGSO-QE.pdf

This suggests that 10% of the new exam is small bowel and colorectal, so at least they are expected to understand it.

 

[doc05]

let's not pretend that a 1 or 2 year fellowship makes you an expert in anything. that requires real-world experience, whatever the
label on your fellowship certificate. so it really doesn't matter.

 

[vhawk]

http://www.acgme.org/Portals/0/Defined_Category_Minimum_Numbers_Complex_General_Surgical_Oncology.pdf?platform=hootsuite



In many areas, a turf war still exists between surgical oncologists and colorectal surgeons for the surgical treatment of colorectal cancer. At national meetings and in casual conversations, I’ve heard surgical oncologists opine that they are either equally or more qualified to remove colorectal cancer than
I just saw this link today, which shows the case minimum for “gastrointestinal not HPB” surgery to be 50…over a 2 year fellowship. My understanding is that this would include foregut as well, with no specific minimum requirements for colectomies and pelvic dissections.


Thoughts? Should modern graduates of surgical oncology fellowships be doing colorectal surgery? Should they venture into the pelvis?

SLUser

Well I've done about 60 colons during my fellowship with 10 months to go (though no further CRS rotations so I'll maybe do 10ish more) and I can basically say that I would feel ok doing routine lap rights and sigmoids and some super easy lap LARs (like at 15cm) and I would probably feel comfortable doing open LARs but only down to like 6-8 cm or so I definitely am not doing any ultralow nonsense. That being said the type of practice I'm looking to join probably isnt gonna have any role for me to do CRS stuff anyway, which is more than fine by me.

 

[SLUser11]

Well I've done about 60 colons during my fellowship with 10 months to go (though no further CRS rotations so I'll maybe do 10ish more) and I can basically say that I would feel ok doing routine lap rights and sigmoids and some super easy lap LARs (like at 15cm) and I would probably feel comfortable doing open LARs but only down to like 6-8 cm or so I definitely am not doing any ultralow nonsense. That being said the type of practice I'm looking to join probably isnt gonna have any role for me to do CRS stuff anyway, which is more than fine by me.

That's a pretty high volume of colon surgery compared to what other programs advertise.

Is there a place where I can find average numbers/case logs from surg onc fellowship graduates? I tried pub med yesterday with no luck.

let's not pretend that a 1 or 2 year fellowship makes you an expert in anything. that requires real-world experience, whatever the
label on your fellowship certificate. so it really doesn't matter.

I agree 100%. The same can be said about anything. If you are doing 1-2 LARs/APRs per year, you're not going to be proficient over time. The best subspecialty surgeries are performed by surgeons who do them all the time. There are plenty of surgical oncologists who have a high volume of colorectal surgery and are great at it.

However, you have to have some foundation to work from, and I'm not sure if that is universal in surg onc fellowships.

A question for you both: When you were in surg onc fellowship, were you being taught colorectal surgery by colorectal surgeons, or by surgical oncologists? Were there competing learners (i.e. chief residents or colorectal residents)?

SSO fellowships seem to place much more emphasis on the cognitive and decision making aspects than purely on technical training.

Is this different from other fellowships? Don't colorectal fellowships and HPB fellowships place emphasis on the cognitive and decision making aspects of their specialty?


I'm not questioning the innate talent or capabilities of surgical oncologists. The best technical surgeon I know is a surgical oncologist, and he does an outstanding open APR that belongs in a textbook. I'm wondering if the fellowship's structure is adequate for us to assume that board-certified (new concept) surgical oncologists are experts in colorectal surgery. Expert is the key word, as I believe colectomies are appropriate for general surgeons and beyond.

 

[vhawk]

For me it was a bit of a mix but mostly it was CRS fellowship trained surgeons. The surg onc people will do the odd lap right for like an appendiceal cancer or TI carcinoid or something but for the most part they defer colorectal cancers to the CRS people. They reciprocate with all their CRC liver mets etc.

 

[SLUser11]

For me it was a bit of a mix but mostly it was CRS fellowship trained surgeons. The surg onc people will do the odd lap right for like an appendiceal cancer or TI carcinoid or something but for the most part they defer colorectal cancers to the CRS people. They reciprocate with all their CRC liver mets etc.

I certainly did my fair share of hepatectomies as a resident, but would never feel comfortable doing them now. I use the surg onc team routinely for anything more than a simple wedge biopsy.

Appendiceal cancer is an area of controversy as well, as I feel that surgical oncologists should be doing HIPECs rather than CRS. I do tend to do quite a few lap right colectomies for goblet cell carcinoids and beyond, but I don't mess with carcinomatosis.

Do the other fellowships require you to log that many nonoperative multidisciplinary cases? I honestly don't know, but I'd always gotten the impression that surg onc pretty uniquely focuses on the multidisciplinary aspects of care.

As for case volumes - there is no publicly available data that I know of. The top programs avg 100 or more CRS cases per fellow pretty comfortably, but there is a lot of variation (eg Hopkins seems particularly CRS light).

Whether the attendings are SSO or CRS trained really seems to vary by program.

I'm not sure that logging non-op cases somehow makes their approach more cognitive, etc. Colorectal surgeons obviously participate in MDTs, and are not simple technicians. I would opine that colorectal surgeons are more in tune with the colorectal cancer literature than their surg onc colleagues, but my opinion isn't necessary as there is a ton of literature on the matter.

I think 100 colorectal cases is pretty impressive, but I'm not sure that number is truly the average at "top" programs. That would require at least 2-3 months of a dedicated colorectal rotation, but realistically it would probably require 4-5 months, assuming there are roughly 20 elective OR days per month, which is also a pretty aggressive estimate.

Where are the surg onc fellows averaging over 100 colorectal cancer cases? How many of these are pelvic dissections? How many are laparoscopic or robotic?

Whether the attendings are SSO or CRS trained really seems to vary by program.

I am most interested in This. Who is doing the colorectal cancer at these top programs? Are there programs in the US that are considered the "top" for colorectal cancer where the bulk of the colorectal cancer surgery is being done by surgical oncologists? Can anyone name a place? I can't think of any.

What programs do you guys think of when you think of the "top" places to receive surgery for colorectal cancer? Mayo? MSKCC? MD Anderson? KU Wichita (jk)?

 

[vhawk]

Mayo doesnt have a surg onc fellowship though they do have an HPB fellowship, but I'm pretty sure they dont do any colons as I'm good friends with their current fellow. I think at places like MSK and MD Anderson there are so many fellows and so much volume that if you have a specific interest in colons you could probably do that many. I think 100 is well above average and I'm a little skeptical that anyone is doing that many regularly, as you are correct that would be like a 4-5 month experience at minimum which just seems like a ton. I mean you did a 1 year CRS fellowship, and if you exclude anorectal and scopes, did you even do significantly more than 100 colons? I do know that for many surg onc fellows they are only doing a handful of months of HPB services and getting very minimal cases, so there is some free time for that I guess but I'd be shocked to hear that anyone program was ROUTINELY getting 100 CRS cases

 

[SLUser11]

I mean you did a 1 year CRS fellowship, and if you exclude anorectal and scopes, did you even do significantly more than 100 colons?

I did over 200 colectomies, but I was at a very high volume center, and that really only averages out to about 4/week. They were definitely not all for cancer, and I did plenty of diverticulitis, IBD, precancerous polyps, etc. About half were laparoscopic, which is important because the learning curve in studies is over 50 lap colectomies. I can say with certainty that I continued to ascend the learning curve for laparoscopic CRS after graduation, so the true number to achieve proficiency is probably higher.

This is part of my point, though. I have a thriving cancer practice, but I only have this because my benign practice is thriving. I find cancers when people are sent to me for rectal bleeding, and I do TAMIS or colectomy when polyps are not amenable to endoscopic removal. I have ongoing relationships with the GI docs, who are looking for one person to whom they can send all of their colon cases, benign and malignant.

Well at least the pretense of neutral discussion is gone.

Please don't be upset, as I value your opinion. I apologize if I framed this as a neutral discussion, as I'm clearly biased in favor of CRS. I shouldn't have been so dismissive of your volume estimate, as I know you are guessing and there are no good resources to give us an answer. The websites for the "top" institutions do not give any information about CRS volume, nor does the SSO website.

Doc05 is the only practicing surg onc on this forum that I know, but plenty of you guys are in fellowship or considering fellowship, and I really want to hear what residents think as well, not just attendings. My recent inner monologue has focused on whether or not the residents at my home facility can tell the difference between the two specialties.

Surgical oncology is a great field, and because it is so competitive, it likely attracts some of the best surgical residents. However, in 2016, I don't think it's best for residents to choose surgical oncology if they plan on having a big colorectal practice, especially in regards to rectal cancer.

 

[surg]

I have seen case logs from back when SSO controlled all the surg onc fellowships, and what what I remember, all programs were exceeding the minimums by fairly substantial numbers. Some programs are heavier in CRS than others, but even the lower GI volume programs that I knew of were well above the minimum lines. Without checking everyone's rotation schedule, I would guess that most fellowships that did confined rotations have between 4-6 months of non-HPB GI surgery time plus coverage for other fellows for vacations/research presentations, etc. (a few places you were basically on "gen surg onc" for extended periods of time). It is a 2-3 year fellowship after all so we have more time to get it all done.

The attendings that I know at different programs are a mix, some programs are mostly surg onc trained, and some use almost exclusively CRS trained surgeons for the colorectal surgery. As you say, over the long haul it is probably volume and interest that matter the most. In my fellowship I had both surg onc trained folks and CRS trained folks (probably about 60/40 in terms of volume). When I was faculty for a fellowship we also had some Surg Onc trained and some CRS trained faculty doing CRS cases (probably closer to 20/80, so the reverse) . This included robot cases, straight lap, and open. Having said that, this does vary with some fellowships having higher volumes than others. In fellowship, though you are also getting pelvic cases from doing exenterations, sarcoma resection, carcinomatosis cases as well as combo cases (liver and colon case does in the case case), etc, so the actual trips into the pelvis is higher than CRS cases exclusively and may be booked under different codes for case logging purposes. I don't know of anyone that graduated in my cohort or the cohorts in the few years above and below me that would have felt uncomfortable doing any oncologic CRS case. Tell them to do a complex Crohn's case though and watch most of them claim ignorance fast!

I think each type of training has their roles and there is definitely overlap. The usual difference for most ends up being what you do when you are not doing colorectal cancer, other cancers or benign colorectal disease? For those that have a nearly 100% colorectal cancer practice, the two specialties converge on each other pretty quickly. For those that aren't 100% Colorectal Cancer, the higher the technical complexity of the case (e.g. super low rectal that you aren't planning an APR), probably the more surgical volume you have the better. The higher the complexity of the case in terms of multidisciplinary coordination (e.g. possible other metastases, coordinating neoadjuvant clinical trials, etc), the probably the more cancer volume you have the better. Coming out of fellowship without taking extra steps to fill in the gaps, I would guess that CRS trained have a head-start on the technical, and Surg Onc trained probably have a head start on the cancer, but either group can "catch up" if there is interest.

 

[thedrjojo]

It's interesting you think surg onc shouldn't be the main focus for colorectal but fine with surg onc doing liver resections instead of transplant or dedicated hpb. I know that it's all institution specific, but our site doesn't have a crs, so surg onc does all the colon cancer, but our transplant guys will do the majority of liver resections (both surg onc and transplant split the panc cases)

Surg onc has this problem with turf wars with most of what they do (head and neck, endocrine, hpb, colorectal) and everyone thinks their way is the best. I think organ system approach is preferable and being able to do the malignant and benign cases is important.

 

[Pir8DeacDoc]

As a point of curiosity and hopefully not to derail the thread, what type of head and neck surgery do Surg Onc guys do? The surg onc guys in my residency seemed to do melanoma on the face and the occasional parotid tumor. But we did all the tongues, etc. Just haven't seen it

 

[surg]

You are right in that just about everyone feels like their own way is better. Probably just trying to justify our own life choices I guess. As I said before, in many areas, surg onc starts to converge, but the reason I chose to pursue the disease based approach (I would lump surg onc, endocrine, maybe vascular into this approach), is that I liked having front to back knowledge about what was going to happen. Where I have seen the occasional regional specialist (I lump colorectal, HPB, etc into this approach) sometimes lack is the emphasis on the technical ability to get the case done and losing the forest for the trees. The regional specialists who really like cancer cases tend to do very well on the cancer cases, but I have occasionally bumped into ones that only do the occasional cancer sometimes forget about things like what the appropriate staging should be and how that would impact the overall survivability, etc. or are less willing to engage in all the aspects of a multimodality approach such as preoperative chemotherapy or radiation therapy in favor of just getting their "part" done and letting the other specialists handle the disease.

As to Head and Neck, most surg onc fellowships have reasonable endocrine neck experience as well as melanoma experience. Most also provide some small modicum of experience in other head and neck cancers. Most would feel comfortable I think doing a neck dissection since we get it for thyroids and melanoma, but how comfortable someone would be doing a tongue cancer or any intraoral cancer for that matter, would be very dependent on which fellowship they did and their personal interest, but I would venture to say that this would be the small minority of currently trained surg onc fellows. A generation ago, that sort of training was much more common, but with the proliferation of H&N oncology fellowships, I suspect that the numbers done by surg onc fellows have gone down for most places

 

[vhawk]

It's interesting you think surg onc shouldn't be the main focus for colorectal but fine with surg onc doing liver resections instead of transplant or dedicated hpb. I know that it's all institution specific, but our site doesn't have a crs, so surg onc does all the colon cancer, but our transplant guys will do the majority of liver resections (both surg onc and transplant split the panc cases)

Surg onc has this problem with turf wars with most of what they do (head and neck, endocrine, hpb, colorectal) and everyone thinks their way is the best. I think organ system approach is preferable and being able to do the malignant and benign cases is important.

I mean if you've been to the ahpba in the last 5 years you know that this battle over livers etc is coming as well. It's just currently the number of crs fellowship trained surgeons massively dwarfs the hpb fellowship people so there isn't really any teeth to the argument. Most surg onc fellows don't really do a huge volume in hpb and probably outside of msk and md Anderson can't really compare with hpb fellowships. But that's a recent change and hpb is only graduating a dozen fellows each year.

 

[SLUser11]

...ones that only do the occasional cancer sometimes forget about things like what the appropriate staging should be and how that would impact the overall survivability, etc. or are less willing to engage in all the aspects of a multimodality approach such as preoperative chemotherapy or radiation therapy in favor of just getting their "part" done and letting the other specialists handle the disease.

I would guess that this is more true for SOs doing the occasional CRC case more than the average CRS, but we are all impacted by our anecdotal experience. My experience has been that SOs tend to be less up to date on the CRC literature.

Planning, staging, and multidisciplinary care are essential to colorectal surgery, and I don't think we are missing the forest for the trees very often. If you look at the colorectal cancer literature, CRS is much more involved than SO in trials, practice parameters, and expert recommendations. I would welcome any links that suggest otherwise.

That being said, I agree with you that volume dictates proficiency, and there are plenty of SOs who are excellent CRC surgeons. As I've said before, my fear is that SO does not guarantee an adequate foundation for new graduates to be considered experts in colorectal cancer, as experience varies greatly based on location, and the minimum numbers are extremely low.

I agree with @thedrjojo that SOs will have turf battles in many areas, not just the pelvis. For a 2 year fellowship which is not even entirely clinical, it's difficult to become proficient in such a wide variety of cancer care, and people outside of the SO world may see a new graduate as a "jack of all trades, master of none."

I hope my comments aren't misinterpreted as denigration of SOs in general. I believe the level of competition within the fellowship match process results in SO having some of our best and brightest. However, in the modern surgical world where everything is super-specialized, they may have to pick a team soon.

 

[vhawk]

MSK, MDA, Pitt, Hopkins, Toronto all offer fantastic HPB exposure (That's 25 fellows per year right there just from those 5 programs)

Ohio State is also good and only going to get better with Pawlik on board. Ditto for Miami with their new head of surg onc. Chicago has solid HPB.

Ok but Pitt and Toronto also have hpb fellowships so I'm not sure how that volume gets divided up.

 

[thedrjojo]

Ok but Pitt and Toronto also have hpb fellowships so I'm not sure how that volume gets divided up.

Toronto has asts transplant fellows and hpb fellows... So I'm not sure if the surg onc fellows are doing much hpb time in comparison.

My transplant fellowship, I don't know the exact numbers, but will probably have >75 liver transplants, >75 Multivisceral procurements, and >150 hpb cases (I have 8 months dedicated hpb plus hpb cases the other 16 months).

 

[JayDoc06]

As an inherently biased colorectal surgeon who trained at a surg onc heavy residency, I think that generally, colorectal surgeons should do the bulk of colorectal cancer work, over surgical oncologists. I think our day to day dealings with colons/rectums/ani gives us additive experience that benefits patients more often than you might think. Whether it's the difficult stoma or functional considerations or very low extended resections, there are many other categories of diseases that we treat that come into play when treat CRCa patients. Both can probably do equally adequate margin negative resections with adequate lymph node harvest.

Issues regarding robotic resection for rectal cancer also come into play, specifically when talking about skills out of fellowship. Graduating CRS fellows are getting increasingly in depth exposure to robotic pelvic operations. I don't think (no data opinion) surg onc get the same exposure, generally. And yes, I believe that robotic proctectomy is superior.

I agree that HIPEC is more of a surg onc activity. Some surg onc fellows do an entire month (or more) on a HIPEC service (plus they are so acclimated to dealing with horrific complications and poor survival, why not pile on?)

In the end though, it is all about volume. My surg onc partner could do a fine LAR just like I can do a liver resection. But, we choose, rightfully so, to get patients to whoever has the most experience with the procedure/disease.

 

[surg]

I think we are all trying to say the same thing...
Long term, day to day volume is what keeps people's skills and knowledge up to date. What drives volume is interest. I think most CRS trained surgeons try to stay up to date with CRCa and do a pretty good job of it. Surg Oncs who do a reasonable volume of CRCa also do. Believe me, coming out of fellowship the surg onc fellows are steeped in the literature. Going to weekly tumor board (I attend 3 tumors/week at various hospitals) helps keep that level up. Whether they choose to keep up specific knowledge in different areas though directly relates to the volume of the cases they do.

As to minimally invasive GI surgery skills, I would say some years ago, Surg Onc fellowships as a group (with notable exceptions) had fallen somewhat behind in robotic and minimally invasive training to some of their counterparts, however, from what I can see, they have closed the gap again, and I would say that my estimation (from continuing to talk to and meet >30% of most any year's graduating class over the past 10 years at some point at a meeting as well as knowing faculty at virtually every single program) is that few if any programs are not giving people the foundational skills to succeed doing MIS oncologic surgery to anyone who wants to do that as part of their practice. As I said previously, they may not graduate with the same number of cases booked as someone doing an anatomically based fellowship, however, combining what they know with the applicability from doing cancer across the body resulting in more combo cases which get booked as one type of case or another in the case log, they graduate far enough on the learning curve that they can do those cases independently on graduation.

As to AHPBA fellowships, I haven't really kept up with what is going on there, but I feel confident in saying that I would be comfortable with the vast majority of the Surg Onc programs I know to be able to do any oncologic liver or pancreas case open, but not all of those same programs provide enough volume to each fellow to do enough robotic or lap Whipple or liver resection although some do, and the number is increasing yearly

 

[vhawk]

I don't think I'll finish 100% ready to go doing robot whipples but I'm hoping to finish being certified for the robot and with the skills to at least do some robotic cases and build my skills in practice. We basically do lap resection and robotic recon for most of our straightforward whipples and I like that style as a way to build skills in practice. For distals I'm not really sure the robot adds much though I may do some for volume reasons. Robot livers who knows

 

[thedrjojo]

Both have decreased their HPB fellow presence with rumors that Pitt may drop it entirely. They take 5 and 4 surg onc fellows at Pitt and Toronto respectively compared to only one HPB. While they do have both, the SSO presence dominates. And the SSO grads from those programs are consistently getting better jobs (though that may be a chicken v egg argument)...

Toronto also takes 2 asts approved transplant fellows and I believe 2 unapproved fellows per year. And they are operating on the liver and hpb all 24 months.