2022 SSO Presidential Address: What is a Surgical Oncologist? Evolution of Surgical Oncology and the Society of Surgical Oncology in an Era of Hyperspecialization

It is truly an honor to be able to stand before you as President of this Society. The Society of Surgical Oncology is the one organization that I have been a member of my entire career. Most of the professional success I have enjoyed has its roots in the people I have met through this organization and the opportunities that this society has provided for me. As such, I wanted to spend a few minutes thanking some of those who I am indebted to as without their support I would not be standing here today.

Before becoming a surgical oncologist, two people impacted my early career in medicine: my father, who was Head of Neurology at the Brigham from 1956 to 1988, shown in Fig. 1a, and Dr. David C. Sabiston Jr., the Department Chair at Duke from 1964 to 1994 where I trained, as shown in Fig. 1b. Both were strong academic leaders with a clear vision of the path for success. For both, I veered from their recommended paths. My father wanted me to be an internist as he always felt that medical doctors were much better clinicians than surgeons. Needless to say, he was not happy when I told him I would be applying to general surgery training programs. Dr. Sabiston was adamantly against fellowship training in surgical oncology as he felt it made a statement that his training program did not provide enough cancer experience. He too was surprised and not happy when I matched at MD Anderson’s Surgical Oncology Fellowship. I wish both were here today to see how the passion to prove to them that there were alternative paths to success fueled my career. The concept of alternative pathways to success will also be an underlying theme to my talk today.

Fig. 1

a Dr. H. Richard Tyler. b Dr. David C. Sabiston Jr. c Dr. Hilliard Seigler. d Donna Tyler, Britta and Colby Tyler

My time at MD Anderson broadened my horizons as to what multidisciplinary cancer care was all about. Through Charles Balch and Raph Pollock, I found two individuals deeply committed to the academic success of the individuals they trained. They always had sage advice and support about balancing clinical and academic priorities long after my fellowship. In Doug Evans and Merrick Ross, I found two master clinicians that I tried to emulate in both their clinical knowledge and their technical expertise. Their teachings were the foundation of my surgical practice over the years and why it has focused on pancreatic cancer and melanoma. Merrick deserves additional thanks as he would also take on the role of family physician during my fellowship, when my wife Donna developed melanoma. Finally, Charley Staley, who was a co-fellow with me at MD Anderson in our small office oncology group, lovingly called the SOOG, has been a constant as our careers have evolved together in nearby southern academic centers. It is fitting that he is head of the Advanced Cancer Therapeutics meeting, a meeting he and I always looked forward to attending, and special thanks for his role as program chair of that meeting this year when we needed to creatively think about how to integrate it into the broader SSO 2022 program.

During my time at Duke as both a resident and as a faculty, Dr. Hilliard Seigler, shown in Fig. 1c, stands out as the one individual who went out of his way to foster my career by providing resources and mentorship. He is the quintessential first-generation surgical oncologist who started me originally down the pathway of becoming a cancer surgeon and encouraged me to pursue the fellowship at MD Anderson. When he turned over the reigns of Surgical Oncology at Duke to me in 2000, Bryan Clary and John Olson were the first two individuals that I recruited, albeit from MSKCC, who became close friends and helped grow specialization within Surgical Oncology at Duke. Bryan deserves special thanks for the time and energy he has put into leading this year’s scientific program committee and crafting our 2022 Dallas symposium.

I have had the good fortune of mentors from afar. Ron Weigel and I were co-chiefs at Duke in 1992 and have traveled similar academic paths. Fabrizio Michelassi and I worked closely together on the ABS to evolve surgical oncology from a field into a specialty. Tim Eberlein has also been a long-time advisor and supporter who I first met at the Brigham when I was a student. More recently, Suzanne Klimberg and Courtney Townsend have become close friends and colleagues as we have partnered at UTMB to develop a cancer program in the shadow of MDACC.

Over the years, I have benefited tremendously by being surrounded by unbelievably talented trainees. While there are many who deserve thanks, six stand out for their energy, creativity, dedication, and productivity that did more for the success of my career than they could ever imagine: Tom Aloia, Rebekah White, Mark Onaitis, Matt Kalady, Elizabeth Grubbs, and Georgia Beasley. To see how successful each has become in their own rights in the field of cancer is far and away one of the most enjoyable aspects of my career.

Last and obviously not least is my family, as shown in Fig. 1d. Donna has been along for the entire ride from when we first met in college over 40 years ago, including the infamous Pizza Hut dinner when we strategized how best to break the news to my father that I was going to be a surgeon. Her constant reminder that, quote, “they won’t carve the title of that paper on your tombstone” has helped me keep focused on what’s really important in life. And to Britta and Colby…Britta was born when I was a surgical resident at Duke and Colby when I was a surgical oncology fellow at MADCC. Britta now works in Boston, which allows me to relive my Boston roots vicariously through her and Colby, who now works as a surgical PA at MDACC. It has been fun to share my passion of surgery with her.

As I started to pursue a career in medicine, I was frequently asked at medical school interviews what a history major was doing applying medical school? My interest in history and what we can learn from it has led me to use this talk to remind you of the history of the Society of Surgical Oncology and its evolution in an era of specialization of cancer care. I will use this as a stepping stone to highlight many of the recent changes we have implemented in the Society this year. In doing so, I point out some areas to focus on as we get ready to take on a new strategic planning process, to make sure we stay relevant, change with the field, and can deliver on our mission statement of “improving multidisciplinary patient care by advancing the science, education, and practice of cancer surgery worldwide.”

While there are certainly many famous surgeons who performed and developed major cancer operations, the true origins of cancer surgery as a specialty have their roots in the creation of the Memorial Hospital in New York, which was set up as the first dedicated cancer hospital in the United States in 1884.¹ In 1914, a head and neck service was formed, which was the first subspecialty service of its type.¹ Subsequently, expertise for surgical management of tumors in other areas would develop, which attracted general surgeons from around the United States to the Memorial Hospital to learn the radical approach to managing these malignancies in an era where there were few other treatments. In 1939, the new Memorial Hospital opened at its present location on York Ave next to the Rockefeller Institute.² It was at this time that Dr. James Ewing, a pathologist, was named the first general director of the hospital. Popularized after appearing on a Time Magazine cover in 1931, he had the vision to foster surgery as the mainstay of cancer treatment.²

The Society of Surgical Oncology has its true beginnings in 1939, when five surgeons met over lunch to discuss forming a new Memorial Hospital Alumni Association for staff, graduates, and trainees of the Memorial Hospital Surgery Department.² These individuals, led primarily by Dr. MacComb, laid out the constitution and bylaws and took the initiative to set up the first meeting the following year. The first meeting of this new group was held on 10 June 1940. At this meeting, 19 Alumni and 5 current fellows met at the Hotel Lexington in New York during the American Radium Society meeting. It was at this first meeting that Dr. John Spiers, who was the most senior alumni present and the Dean at the University of Texas Medical Branch at the time, proposed the organization be named the James Ewing Society in honor of the noted pathologist and Director of the hospital.¹ Dr. Spiers would go on in 1941 to also play a major role in drafting the Texas State Legislation that led to the creation of the MD Anderson Hospital for Cancer Research. Dr. MacComb was elected the group’s first president

The group met the following year and then had a 5-year hiatus during World War 2. After the war, the group got back together and decided to formalize the membership and hold an annual symposium, which was initiated in 1948. Highlighting the desire to focus on research and treatment advances, the organization’s leadership created the Annual James Ewing Lecture in 1950, which has become the keynote honorific lecture of the Society. The first lecturer was Dr. Edith Hinkley Quimby,² a pioneer in radiation physics who helped develop therapeutic applications of radiation therapy as a component of multimodality cancer care, and her inaugural lecture was entitled “the history of Cancer Research.”

As the Society grew, an annual Presidential address was added to the program in 1966 at the 19th annual meeting.³ The first presidential address was given by Dr. Glenn Leak, who highlighted in his talk that the group’s meeting was evolving from an alumni reunion into a venue for the exchange of scientific ideas. It was in 1975 that momentum had built to change the organization’s name from the James Ewing Society to the Society of Surgical Oncology (SSO). This change was led by Drs Scanlon, Copeland, Baker, and Lawrence, who felt that the society should expand from its roots as a Memorial Hospital Alumni organization to represent all surgical oncologists regardless of where they trained or practiced.³ The name change would also highlight the importance of the surgical oncologist in training programs to enable them to stay abreast of the changing multidisciplinary approach to cancer treatment. In 1978, Dr. Lawrence’s Presidential address defined a surgical oncologist as “a well qualified general surgeon who has obtained additional training and experience in the cancer field and then devotes his professional work almost entirely to this activity.”³ It would take a number of years for the gender part of the definition to change, and it wasn’t until 2004, some 26 years later, that Eva Singletary would become the organization’s first female president.

Starting in 1979, the SSO started to develop a list of criteria for credentialing training programs in surgical oncology. By 1983, the first three surgical oncology programs, MSKCC, OSU, and Roswell Park, were site visited and SSO approved. Increasing recognition of surgical oncology as a specialty was manifest by a survey in 1986, showing that 47 departments of surgery (38% of all surgery departments at the time) had a division of surgical oncology.³ By 1989, when I was starting to consider surgical oncology programs, there were a total of nine SSO-approved fellowship programs. The Society, recognizing the increasing complexity and multidisciplinary nature of cancer care, worked in conjunction with the American Society of Breast Surgeons to develop criteria for specialized breast surgical oncology programs. The first breast surgical oncology fellowship site visit team is shown here in 2003.⁴ For the next 20 years, the SSO oversaw the credentialing and matching process for both general surgical oncology as well as breast surgical oncology programs. Concurrent with the evolution of surgical oncology training programs, the SSO created and launched its own journal, Annals of Surgical Oncology, with Charles Balch as its first Editor in Chief in 1994.⁴ This journal would help the society have a forum for expanding its reach in scientific discovery and education beyond its membership.

By the turn of the century, increasing data were emerging as to the benefits of specialization as a way to optimize outcomes of patients with cancer. A classic New England Journal of Medicine paper by John Birkmeyer from 2002⁵ highlighted the clear association between low hospital volume and high operative mortality for major cancer operations, especially esophagectomy and pancreatectomy. In this paper, best outcomes were seen by high-volume surgeons operating in high-volume hospitals whose operative mortality, for example, in pancreatic surgery was 3.7% as compared with low-volume surgeons operating in low-volume hospitals whose operative mortality was 16.3%. Numerous studies have supported this finding as specialized surgeons and centers are more likely to develop and embrace perioperative processes to optimize patient outcomes.

Subspecialty training also plays a role. In a study by Karl Bilimoria,⁶ almost across the board, outcomes for patients with cancer undergoing surgery were better when performed by individuals with subspecialty training as compared with individuals who did not have specialized training. This increasing recognition of surgical oncology as a specialty led the SSO to petition the American Board of Surgery (ABS) to have a representative from the SSO on the ABS. In 1983, this motion was approved, and since 1986, six individuals have represented the Society of Surgical Oncology on the ABS, as shown in Table 1. While initial attempts at certification were not favorably received, owing to concerns from individuals like Dr. Sabiston that cancer care was a core part of general surgery, a Surgical Oncology Advisory Board was eventually created within the ABS in 1998 to help the ABS navigate specialization in this field.

Table 1 Society of Surgical Oncology representatives to the American Board of Surgery

The Surgical Oncology Advisory Board worked with the Society of Surgical Oncology to propose a new certificate in Complex General Surgical oncology that would be overseen by the Accreditation Council for Graduate Medical Education (ACGME) in terms of credentialing training programs, and the ABS in terms of evaluating the competence of individuals who complete them. Furthermore, there would be no grandfathering in of surgeons who had completed their surgical oncology training at SSO-approved programs. This proposal was more favorably received and in 2010 was approved by the ABS, the American Board of Medical Specialties (ABMS), and the ACGME. In 2011, the Surgical Oncology Advisory Board formally became the Complex General Surgical Oncology Board, and certification of training programs started to transition from the SSO to the ACGME. By 2014, the Complex General Surgical Oncology Board held its first qualifying examination for individuals who had completed training at ACGME-approved Complex General Surgical Oncology Fellowships, and the following year in 2015 the first certifying examination was delivered in Philadelphia.⁷

The ABS has recently changed its structure such that organizations like the SSO are no longer slotted a representative on the board. In the new structure, the ABS has created a council that strives to have individuals with a broad range of competencies that represent a wide range of practices. Organizations like the SSO can nominate individuals to the council on the basis of the competencies the council feels it is deficient in or lacking. The current configuration of the Council of the ABS has several individuals who are members of the Society of Surgical oncology and/or practicing cancer surgeons. As such, you will note that this year, even though Russ Berman is rotating off as our last official SSO representative to the ABS, surgical oncology was not one of the competencies highlighted by the ABS that it was looking for in applicants to the council. Rising to this challenge, the SSO still nominated three individuals for the ABS council building on their non-oncologic strengths, and two of them, Caprice Greenberg and Bridget Fahy, were successfully selected to be on the council of the ABS starting this summer.

Developing strong lines of communication with the ABS will be critical in the future as cancer surgery continues to hyperspecialize and there is evolution of certification in areas not necessarily covered by ACGME-approved training programs. Currently, the proposal for a focused practice certificate for thyroid and parathyroid surgery is well on its way to achieving approval. Breast surgery is another area where focused practice designation is rapidly gaining momentum.

As an organization, it will be critical in moving forward that we embrace the new definition of a surgical oncologist as “a surgeon who specializes in an area of cancer care and can speak the language of multidisciplinary cancer management.” We must increasingly recognize and accept, as does the ABS, that there are many pathways to being a surgical oncologist that do not necessarily travel through breast surgical oncology or Complex General Surgical Oncology Fellowship training and have given rise to the focused practice efforts.

The growth of the SSO and its current sphere of influence since the early 1990s when I joined the organization and started my fellowship training to now is quite impressive. As shown in Table 2, we have tripled membership, we have an annual budget of nearly 7 million dollars, we have engaged international partners, and there has been significant growth in both complex general surgical oncology and breast surgical oncology training programs. Some of the organization’s greatest strengths have been the consistent investment in developing academic surgeon scientist with its research grant programs to support scientific advancement driven by surgeons in the field of oncology. The list of recipients, as shown in Fig. 2, is a tribute to how this funding has helped develop some of the brightest academic minds in the field of surgery.

Table 2 Comparison of SSO-related activities 1992–2021

Fig. 2

SSO research support

The Annals of Surgical Oncology is another strength. Today, as overseen by Kelly McMasters, it is one of the Society’s strongest assets and a major forum for scientific and educational content. It receives over 3000 manuscripts to review and has an impact factor of 5.34. It is sixth among surgical journals in H Index and has an active presence on social media.

The SSO has also recently expanded its investments in developing educational content in all areas of cancer care focused on educating cancer surgeons worldwide. We have an active, easy-to-navigate website to help deliver content for whatever cancer area you might be focused on. We also have expanded access with more podcasts, a landmark article series highlighting major papers published in other journals in specific areas of cancer care, a variety of research and educational grants to foster innovation among our membership, and, most recently, an SSO mobile app to help facilitate engagement to all these platforms.

Developing content over these various mediums has been a focus of the organization especially over the last 2 years. In 2021 alone we had 26 virtual tumor boards, created 69 educational programs across nine disease sites on our expert education website, had 23 surgical oncology today podcasts, and expanded our social media presence to help connect cancer care providers and further spread educational content significantly. We will be coming out with an SSO question-of-the-week program next month.

But in these numbers there are some seeds of concern. Interest in surgical oncology fellowship training is slightly decreasing. If you look at the number of applicants to Complex General Surgical Oncology Fellowships as shown in Fig. 3a over the last several years, the trend is slightly downwards, from a peak of 96 applicants in 2018 with a drift from 1.5 applicants per position to 1.3 applicants per position. A similar trend is seen in the Breast Surgical Oncology Fellowships, which have had a slight decrease in applications since 2018 as well (Fig. 3b). If you look further into our membership, as shown in Fig. 4, excluding residents and students, one can see a breakdown of the primary practice focus of our members, which suggests we are better at engaging breast- and hepatobiliary-focused surgical oncologists as compared with colorectal- and endocrine-focused surgical oncologists. The potential engagement gap can be viewed as more concerning when these primary focus numbers are compared with the membership data of hyperspecialized groups like the American Society of Breast Surgeons (ASBRS), Americas Hepato-Pancreato-Biliary Association (AHPBA), American Society of Colorectal Surgeons (ASCRS), and American Association of Endocrine Surgeons (AAES), and we see that our primary focus members account for only a fraction of the specialty society membership numbers. While not all of these groups’ members have cancer-focused practices, it certainly suggests that we have an opportunity to better focus some of our efforts to touch a larger group of cancer care providers.

Fig. 3

Applicants to complex general surgical oncology fellowships (a) and breast surgical oncology fellowships (b)

Fig. 4

Primary focus of SSO members

To that end, one of our goals this year was to start building bridges with several of these organizations. For example, we have had several meetings with ASBRS leadership and have developed a joint task force that I have asked Susan McLaughlin to lead to help build a better partnership around breast surgical oncology training and education. We have also had initial meetings with the leadership of the AHPBA focused on similar goals. We also feel that there is an opportunity to better engage the community surgical oncologist. Over the last several years, our main foray into this group was through the hot topics session in the American College of Surgeons (ACS) meeting each year. While attendance was not bad, the session was always the last day and last time slot of the annual ACS meeting. To more aggressively expand these efforts, this year we started meeting regularly with Heidi Nelson, who is head of the ACS cancer programs. The ACS’s programs, as many of you will recognize, are much more effective at reaching the community surgeon. We have developed a dialogue that will be continued by Sandra Wong, Kelly Hunt, and Russ Berman to have the SSO disseminate educational material to help in fostering the importance of engagement in these programs.

The Society has aspired to have a strong international program that dates back to 2010 with our first best-of-SSO program held in conjunction with the Mexican Society of Surgical Oncology. We currently have ten international partner organizations to which we welcomed our latest partner the Israeli Society of Surgical Oncology in 2020. In addition to the best of SSO programs, we also have shared tumor boards, and virtual meetings to foster collaborations.

The level of engagement and networking has led to a modest increase in international surgeons as members of the Society over the last several years (Fig. 5a). There is still a lot of opportunity for the SSO to help expand the concept and importance of surgical oncology and surgical oncologists worldwide, as our mission statement highlights. Shown in Fig. 5b, provided to me by Isabel Rubio the President-elect of the European Society of Surgical Oncology, is that, surprisingly, there are still large parts of Europe that don’t recognize surgical oncology as a specialty.

Fig. 5

a International membership trends. b Recognition of surgical oncology as a specialty in Europe

To help better align our international programs and integrate with the international community, the SSO has worked closely with Chandra Are, one of our members, to foster and support the Global Forum of Cancer Surgeons. This group, sponsored through the SSO, has worked to highlight the impact of cancer worldwide over the next 20 years and the important role surgery will have on trying to treat it. Working together with our international partners, there have been several position papers highlighting the issues of cancer care internationally including a position statement to promote cancer care globally published in 2020 in Annals of Surgical Oncology,⁸ and a paper on the impact of COVID-19 on cancer surgery practices worldwide has been published this year in Annals of Surgical Oncology.⁹ Programs like this can help increase our visibility on the international front.

To help the SSO achieve some of the goals I have outlined, we needed to make the Society more relevant to a broader and more diverse array of cancer providers. To that end, this year we have made several structural changes to the organization. We have expanded the role of the Vice President to be a 3-year term focused on developing relationships with other cancer organizations as I discussed. This will also shorten the cycle that individuals are in executive leadership from 6 to 5 years by now having each of the three positions secretary, treasurer, and Vice president be 3 years in duration before ascending up to president elect and president.

We have also made the nominating committee more diverse by removing the immediate past president (which will be me next week) and replacing this individual with the Chair of the Diversity, Equity, and Inclusion, Advisory Board. We are making all terms on this committee 2 years instead of 1 so there will be some continuity of less senior members. We have charged the new nominating committee to develop objective and broader criteria that define the qualifications for the society’s leadership positions. We have made the election process for officers more transparent. We have opened up nominations for officers to be proposed from any member in the organization. A larger group of individuals, the nominating committee and executive council, will now vote on and elect the officers. Our goal with these changes is to broaden the view of what leadership of the SSO looks like in the future. In this effort we need to develop a leadership curriculum, as part of our next strategic plan, not just for our organization but for cancer surgeons in general. There are many unique opportunities to lead for these individuals, for example, as cancer center directors, as disease site leaders in cancer centers, on hospital tumor boards, and in ACS liaisons and programs of cancer excellence to name a few.

We are saying good bye and sincerest thank you to Eileen Widmer, who has administratively led this organization for the last 15 years. She has been instrumental in the growth of this society. Her receiving the Layman’s award is a fitting tribute to her contributions (Fig. 6). We are pleased about having Anna Polyak coming on board as our new CEO in April to help lead our next strategic plan. Anna will bring new eyes to the organization as we move forward in the rapidly changing landscape of surgical cancer care. The future of the organization is bright. We have a great leadership team of Sandra Wong, Kelly Hunt, Ron Dematteo, and Russ Berman, who I have enjoyed working with on many of the things I have presented today. They are a talented group who bring to the table diverse cancer interests and backgrounds allowing for unique perspectives to many of the issues the organization will be facing in the years to come.

Fig. 6

New administrative leadership: Eileen Widmer and Anna Polyak

I believe our success and scope of impact as an organization will lie in a future vision for surgical oncology that at its core accepts the broader definition of a surgical oncologist as a surgeon who specializes in an area of cancer care and has mastered the vocabulary of multidisciplinary cancer management. We should encourage specialized training in surgical cancer care but also recognize that there may be many pathways to develop as a surgical oncologist beyond the two that directly involve our society. In addition, the SSO will need to continue expanding its more global view of cancer care, which should include, as a challenge, having an international member and a community member in line to lead this organization within the next 5 years, to fully deliver on our organization’s mission statement. Once again I want to thank the Society of Surgical Oncology for the opportunity to be your President. It has truly been a great honor.