Surgical Oncology Training Research Articles

Self-Reported Management of Inflammatory Breast Cancer Among the American Society of Breast Surgeons Membership: Consensus and Opportunities.

Inflammatory breast cancer (IBC) is rare and biologically aggressive. We sought to assess diagnostic and management strategies among the American Society of Breast Surgeons (ASBrS) membership. An anonymous survey was distributed to ASBrS members from March to May 2023. The survey included questions about respondents' demographics and information related to stage III and IV IBC management. Agreement was defined as a shared response by >80% of respondents. In areas of disagreement, responses were stratified by years in practice, fellowship training, and annual IBC patient volume. The survey was administered to 2337 members with 399 (17.1%) completing all questions and defining the study cohort. Distribution of years in practice was 26.0% 0-10 years, 26.6% 11-20 years and 47.4% > 20 years. Overall, 51.2% reported surgical oncology or breast fellowship training, 69.2% maintain a breast-only practice, and 73.5% treat < 5 IBC cases/year. Agreement was identified in diagnostic imaging, trimodal therapy, and mastectomy with wide skin excision for stage III IBC. Lack of agreement was identified in surgical management of the axilla; respondents with < 10 years in practice or fellowship training were more likely to perform axillary dissection for cN0-N2 stage III IBC. Locoregional management of stage IV IBC was variable. Among ASBrS members, there is consensus in diagnostic evaluation, treatment sequencing and surgical approach to the breast in stage III IBC. Differences exist in surgical management of the cN0-2 axilla with uptake of de-escalation strategies. Clinical trials are needed to evaluate oncologic safety of de-escalation in this high-risk population.

Minimally invasive training in surgical oncology: Current status and needs assessment

Utilization of minimally invasive surgery (MIS) has grown significantly over the past three decades, changing the face of surgical oncology practice. Changes to educational programming have been more scattered. Surgical training has undergone a major transformation with duty hour restrictions, decreased autonomy, and increased technology in the workplace. Despite increasing exposure to laparoscopic and robotic approaches, there is a lack of standardized training in residency, fellowship and beyond. As a result, surgeons report feeling ill-equipped for independent MIS oncology practice. While long term data is limited, several models of MIS curriculum implementation exist in gastrointestinal, hepato-pancreatico-biliary, and colorectal surgery. The aim of this review is to describe the current state of robotic training in surgical oncology and offer directions for future research and practice.

Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy.

Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

Should Pediatric Surgical Oncologists Receive Training in Vascular Surgery ? A Practice Survey Report From the International Society of Paediatric Surgical Oncology (IPSO)

BackgroundIs vascular training in paediatric surgical oncology considered desirable ? MethodsA voluntary survey of work practice was undertaken with the surgeon membership of The International Society Of Paediatric Surgical Oncology (IPSO) using a structured designed questionnaire. ResultsA total of 149 IPSO surgeon members completed the survey. 57% (N = 84) of surgeons surveyed had no specific training in vascular surgery. 43% surgeons (N = 63) stated they had acquired some skills in residency training and/or with transplantation surgery. 65% (N = 96) of respondent surgeons stated that vascular surgical training must be incorporated into pediatric surgical oncology training and 27% (N = 40) agreed that it was considered desirable. 89% (N = 133) of surgeon respondents had encountered major vascular injury during work practice while operating on pediatric solid tumors. Vascular injury repairs were undertaken and attempted by pediatric surgeons though expert assistance of vascular surgeons proved crucially essential in many instances. Emergent operations included patch repairs, vessel ligation techniques and insertion of vascular graft prostheses. Interventional radiology services to arrest life-threatening hemorrhage were also reportedly utilized by respondents. ConclusionVascular injuries have significant potential for devastating patient outcomes including never event ‘mortality’. The IPSO surgeon survey highlights that there are visible ‘gaps’ in skills training. Training to be a pediatric oncology surgeon must incorporate acquisition of skill sets proficiency in vascular surgery.

The SICO surgical oncology fellowship: the first specialized surgical oncology training program in Europe

The SICO surgical oncology fellowship: the first specialized surgical oncology training program in Europe

ASO Author Reflections: Advancing Racial Diversity and Gender Equity in Surgical Oncology Training: Addressing Imbalances and Building Inclusion.

ASO Author Reflections: Advancing Racial Diversity and Gender Equity in Surgical Oncology Training: Addressing Imbalances and Building Inclusion.

Trends in Racial and Gender Diversity Among Complex General Surgical Oncology Fellowship Trainees.

This study examines trends in racial and gender diversity of trainees within Complex General Surgical Oncology Fellowships, and compares the racial and gender proportions of trainees across different fields to assess potential barriers to increasing diversity within surgical oncology training programs. Accredited Council for Graduate Medical Education (ACGME) data were queried to identify surgical trainees between 2013 and 2021. Trainees were identified based on self-reported race and gender and were stratified based on residency type and fellowship program type if applicable. Chi-square tests were used to assess differences between groups and trends. A significantly lower proportion of individuals who are underrepresented in medicine (URMs) trained in surgical oncology fellowships (8.9%) compared with both the overall trainee pool (12.8%) and general surgery residency programs (13.1%) [p<0.05]. There was no significant increase in URM representation in surgical oncology fellowships across the study period. Furthermore, there was a significantly lower proportion of females training in surgical oncology fellowships (38.6%) compared with the overall trainee pool (45.6%) [p<0.05]. Despite a significant increase in female representation in general surgery residency and other surgical fellowships, there was no significant increase in female representation in surgical oncology fellowships across the study period. This study identifies disparities in gender and racial minority representation within ACGME-accredited Complex General Surgical Oncology Fellowship training programs. While steps have been taken to expand diversity, more needs to be done to combat the systemic barriers that both racial minorities and women face during their training.

Learning Curves in Establishing a New Minimally Invasive Pancreas Program.

Robotic pancreaticoduodenectomy (rPD) is a complex operation with a reported learning curve of 80 cases. Two recent graduates of a formal robotic complex general surgical oncology training program have been performing rPD at our institution since 2016, which had no previous institutional experience with rPD. To evaluate the learning curve associated with developing a new robotic pancreaticoduodenectomy (rPD) program by fellowship trained surgeons with institutional support. Sixty patients undergoing rPD from 2016 to 2022 were reviewed for and compared with proficiency benchmarks set by the University of Pittsburg experience. By 30 cases, operative time met the proficiency benchmark of 391minutes. Additionally, the entire cohort had comparable rates of clinically relevant postoperative pancreatic fistula (6.7% vs 3%, P = .6), 30-day mortality (0% vs 3%, P = .18), major complications (Clavien >2; 23% vs 17%, P = .14), and length of stay (6 vs 7days, P = .49) when compared to the benchmark. Perioperative outcomes were comparable to proficiency benchmarks from initiation of the new rPD program, and operative time reached proficiency benchmark by 30 cases. This data suggests that graduates of formal rPD training programs can safely establish new minimally invasive pancreas programs at sites with no previous institutional rPD experience.

Influence of the centralizing gastric cancer surgery on the health-related quality of life in Brazil.

The assessment of health-related quality of life (QoL) has improved the treatment of gastric cancer. Aiming to compare the influence of skilled surgeons in general hospitals versus specialized hospitals in cancer in Brazil, this study evaluated the relationship between quality of life and types of hospitals (general or cancer) in treating patients with gastric adenocarcinoma operated by surgeons with specific training in Surgical Oncology. This was a cross-sectional study involving 104 patients. Inferential analyses were used to compare two Brazilian general hospitals and a cancer center, evaluating scores of the SF-36 and FACT-Ga QoL questionnaires (Kruskal-Wallis test, Mann-Whitney test); gender, smoking, and Helicobacter pylori tests status (Pearson's Chi-Square test); ethnicity, alcoholism, location of the tumor in the stomach, Lauren's histological types, and type of surgery (Fisher's exact test), number of lymph nodes resected by Surgical Oncologists [Analysis of Variance (ANOVA) with a Fixed Factor], and comparative survival analysis (Log-Rank test). Patients treated at a cancer hospital had higher scores of the FACT-Ga (FACT-G total score, P=0.023; physical well-being, PWB, P=0.006; and functional well-being, FWB, P=0.011). The mean scores of the SF-36 questionnaire showed similar behavior but without reaching a significant difference. Patients operated by Surgical Oncologists at the cancer hospital had better scores in emotional well-being FACT-Ga domain (EWB, P=0.034 and P=0.047) compared to those operated by Surgical Oncologists in general hospitals. There was no significant difference in survival among the three hospitals (P=0.214). In this study, it was possible to suggest the relationship between QoL assessment scores with the centralization of care at specialized cancer hospital in the treatment of patients with gastric adenocarcinoma undergoing surgery with curative intent in Brazil.

Assessing the Complex General Surgical Oncology Pipeline: Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees.

Cancer incidence is expected to increase in coming decades, disproportionately so among minoritized communities. Racially and ethnically concordant care is essential to addressing disparities in cancer outcomes within at-risk groups. Here, we assess trends in racial and ethnic representation of medical students (MS), general surgery (GS) residents, and complex general surgical oncology (CGSO) fellows. This is a retrospective review of data from the American Association of Medical Colleges and the Accreditation Council of Medical Education (ACGME) from 2015 to 2020. Self-reported race and ethnicity was obtained for MS, GS, and CGSO trainees. Race and ethnicity proportions were compared with respective representation in the 2020 US Census. Mann-Kendall, Wilcoxon rank sum, and linear regression were used to assess trends, as appropriate. A total of 316,448 MS applicants, 128,729 MS matriculants, 27,574 GS applicants, 46,927 active GS residents, 710 CGSO applicants, and 659 active CGSO fellows were included. With every progressive stage in training, there was a smaller proportion of URM active trainees than applicants. Further, URM, Hispanic/Latino, and Black/African American trainees were significantly underrepresented compared with 2020 Census data. While the proportion of White CGSO fellows increased over time (54.5-69.2%, p = 0.009), the proportion of Black/African American and Hispanic/Latino (URM) CGSO fellows did not significantly change over the study period, though URM representation was lower in 2020 as compared with 2015. From 2015 to 2020, minority representation decreased at every advancing stage in surgical oncology training. Efforts to address barriers for URM applicants to CGSO fellowships are needed.

Competency-Based Medical Education (CBME): an Overview and Relevance to the Education of Future Surgical Oncologists.

In the next two decades, the global cancer burden is expected to rise by 47%, and the demand for global cancer surgery will increase by 52%. At present, only 25% of the estimated 80% of patients needing surgical intervention have access to timely surgical care. The shortage of a trained workforce of surgical oncologists is one of the main barriers to providing the optimal surgical intervention needed for cancer patients. Some of the contributing factors to the shortage of trained surgical oncologists are variations in the current global educational platforms, long training programs, and physician burnout. Therefore, the availability of a credible training framework and a sustainable certification pipeline for future surgical oncologists is critical to meet the global demand for an adequate healthcare workforce. The current surgical oncology educational program is a time-based construct that trains surgeons to function seamlessly in the multidisciplinary care of cancer patients. However, there is a lack of flexibility in the training framework and timeline despite differences in trainees' abilities. Developing a globally acceptable standard curriculum for surgical oncology training based on the competency-based medical education (CBME) framework and tailoring it to local needs can increase the surgical oncology workforce ready to tackle the rising cancer burden. However, successful implementation of the global CBME-based surgical oncology training curriculum requires an innovative approach to ensure that this framework produces a competent surgical oncologist that meets the local needs.

Surgical Training for Cancer Care in Africa: A Needs Assessment Pilot Survey of African Surgical Residency Programs

INTRODUCTION: Worldwide, 5 billion people lack access to safe surgical care, directly impacting care of cancer patients. Because 75% of cancer cases occur in the developing world, we sought to assess availability and utilization of educational resources for surgical cancer care among African surgical residency programs (SRP). METHODS: A pilot survey was sent in a single email distribution in October 2021 to all Pan-African Academy of Christian Surgeons (PAACS) SRP faculty and trainees. RESULTS: Of 275 surveys distributed to 11 SRP, 46 (16.7%) surveys from 9 countries were completed. Respondents included 25 (54.3%) faculty and 20 (43.5%) trainees with a median of 3 years (interquartile range 3.84) working or training at the institution. Forty-four (96.7%) reported need for advanced cancer training, 24 (52.2%) noted interest in pursuing advanced training, and 11 (23.9%) had access to such training. At least monthly, 11 (23.9%) experienced specialized surgical oncology (SO) education from visiting or long-term faculty, 17 (37.0%) had cancer-specific operative training, 23 (50%) had cancer-specific didactics, 24 (52.1%) used National Comprehensive Cancer Network (NCCN), European Society of Medical Oncology, or other national guidelines, and 24 (52%) used NCCN basic, core, or enhanced resources guidelines. Free text responses showed 5 (10.9%) comments reporting need for a surgical oncologist or SO training program to improve cancer care at their institution. CONCLUSION: These preliminary data reveal opportunities to augment education for cancer care in our limited sample of African SRP. Future research aimed toward developing sustainable advanced surgical oncology training is warranted.

296. A BEGINNER’S THREE-YEAR LEARNING CURVE WITH ESOPHAGECTOMIES: A STUDY FROM A PERIPHERAL CANCER CENTRE IN NORTH-EAST INDIA

Abstract North-East India has a high incidence of esophageal cancer but lacks good infrastructure for cancer care delivery. I aim to present my experience with esophagectomies done in a cancer center of the region, as a beginner immediately after completion of broad specialty surgical oncology training. The objectives include estimation of 30-day morbidity and mortality rates and the short-term oncological outcomes including nodal yield and completeness of resection. Retrospective observational study of a prospectively maintained database, during the study period from 1st November 2018 to 31st March 2022 (29 months). All patients had confirmed diagnosis of esophageal cancer and underwent esophagectomy by the same surgeon. They received neoadjuvant treatment as per institutional protocol. The results were presented with median values, range and percentages. 46 patients underwent esophagectomy; one had inoperable disease. Clinicopathological factors are in Table 1. 74.5% had neoadjuvant chemoradiation (NACRT). Minimally invasive trans-thoracic esophagectomy (67.4%) was favoured approach (conversion rate of 6%). 41.3% had ‘extended 2-field’ lymphadenectomy. 30-day mortality was 4.2% and morbidity included hoarseness of voice (17.4%), anastomotic leak (10.9%) and pneumonia (8.7%). Median nodal yield was 12 (range 4 to 48). Pathological complete response was noted in 44.1% of post-NACRT patients. Margin-negative resection was achieved in 91.3% patients. After median follow up of 20 months, 5 locoregional and 3 distant recurrences were noted. 76.6% patients are alive without disease. Surgical audit is key at the beginning of a surgical career to gain insights into learning curve and areas of improvement include nodal yield and morbidity rates. The high margin negative resection rates are partly attributable to selection bias of a beginner.

SuperSpecialty-Level Training in Head and Neck Surgical Oncology.

This letter concerns the article in South Asian Journal of Cancer by Mohan et al.[1] Although the argument for oral and maxillofacial surgery (OMFS) as a possible forerunner for head and neck surgical oncology training is largely acceptable, there are several riders to it, which I wish to point out. The deficiencies of a master's degree (MDS) in OMFS for cancer care include the following practical issues. A medical degree, comprising 4.5 years of coursework and 1 year of internship, is required at a basic level, even to be naturally eligible to sign on a death certificate. Didactic training in oncology, even up to the molecular level of at least 2 years, is necessary. Curriculum and syllabus for head and neck surgical oncology training are available at all training institutes and universities recognized by the Medical Council of India (MCI)/National Medical Commission (NMC).

Needs assessment in head and neck surgical oncology training: A qualitative study of expert opinions.

Few studies have investigated the needs of head and neck surgery trainees and areas for improvement of fellowship programs. We conducted a qualitative study by interviewing a nationally representative sample of program directors and national leaders in head and neck surgery. We asked about the current state and strengths of training; and areas for further improvement. All interviews were independently coded and analyzed by two reviewers. All experts (100%) believed that the current training provides a strong foundation and furthermore, a standardized curriculum is beneficial. Multidisciplinary training (80%), participation in tumor boards (75%), and a syllabus (60%) were the most frequently mentioned components. Most believed that a formal certification process would be beneficial (73%), though there was no consensus on the format. Experts in head and neck surgery are generally in favor of a standardized curriculum. Further discussions of a formal certification process might be warranted.

A training and implementation model for head and neck oncology service delivery in Mozambique

There is an extreme shortage of head and neck surgeons in Africa. In Mozambique prior to 2000, there were no surgeons with specific training in head and neck surgical oncology. Here, we introduce a training model and report our experience with implementation following the training of the first two head and neck surgeons from Mozambique. This training program, undertaken in Brazil, facilitated the formation of the first two head and neck surgeons from Mozambique. These surgeons received comprehensive training in head and neck surgical oncology and multidisciplinary care, allowing them to then treat their patients under continuous online mentorship collaboration. This model is expected to help in the local formation of new specialists and in the establishment of this specialty in Mozambique. The program started with remote training and support provided by the MD Anderson Cancer Center, in Texas, USA, as part of the Extension for Community Healthcare Outcomes program. Further training was then undertaken at an established fellowship program in Brazil as a focal point for 2 years, and the knowledge gained was replicated and disseminated locally.

Breast Cancer in Indonesia in 2022: 30 Years of Marching in Place

Breast Cancer in Indonesia in 2022: 30 Years of Marching in Place

Training in Pediatric Surgical Oncology.

Pediatric Surgical Oncology is a challenging sub-speciality field requiring strong discipline, resilience and a “never quit” attitude. Pediatric cancer patients are frail, vulnerable and have life limiting illness were the skill(s) of the operating surgeon may determine “cure” and survival or untimely death from inadequate tumor resection with disease progression and / or “never event” misadventure. It could be stated therefore that a career in surgical oncology may not be for the “faint hearted” surgeon. Training in a high volume center(s) accredited in the delivery of high quality care and clinical excellence driven by inspirational leaders in surgical oncology with motivated multidisciplinary teams is key. International surgery oncology fellowship(s) add significant credits to a residents' clinical training crucially also yielding opportunities for gaining research skills. On the journey toward subspeciality accreditation the aspiring surgeon oncologist must first demonstrate skill set(s) proficiency in general pediatric surgery residency training to advance to the next phase(s). This article offers a “snap shot” overview synopsis of pediatric surgical oncology training in its broadest perspective(s) for those seeking further information and career guidance.

Defining the Learning Curve for Robotic Pancreaticoduodenectomy at a Single Center with an Established Laparoscopic Pancreaticoduodenectomy Program

Introduction: Robotic pancreaticoduodenectomy (RPD) has a learning curve (LC) of approximately 30-250 cases to reach proficiency. The LC for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study compares the LC for LPD and subsequently RPD at a single institution. Methods: LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and LCs were defined with respect to operative time using CUSUM analysis. Results: Thirty-nine LPD and 69 RPD were analyzed. Introduction of LPD was completed first as a hybrid technique (excluded), followed by total LPD. LPD had a bimodal or inverted LC possibly accounting for proficiency attained from hybrid LPD and introduction of additional surgeons later in the experience. The LC for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 406 minutes, p<0.03), improved LN harvest (15 vs 19, p<0.02), and similar estimated blood loss and R0 resection. RPD also had improved LOS (7 vs 9 days, p<0.002), and lower rates of surgical site infection (10% vs 38%, p<0.001), abscess (7% vs 23%, p<0.04), and readmission (13% vs 33%, p<0.03). Conclusion: Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

Evaluation of surgical oncology fellowship websites: Are we showing what applicants need to see?

BackgroundThe Internet is a major resource for surgery fellowship applicants, especially during the COVID-19 pandemic. Online information for surgical oncology and breast oncology training programs can be found on the Society of Surgical Oncology's webpage and fellowship institution websites. The goal of this study was to analyze the comprehensiveness of complex general surgical oncology and breast oncology fellowship websites. Materials and methodsA list of all accredited surgical oncology and breast oncology fellowships was recorded from the Society of Surgical Oncology website and stratified by region. Then, a Google search was performed on each fellowship program to determine each institution's webpage. Two of the authors then analyzed 2 web resources, institutional website and Society of Surgical Oncology webpage, for each fellowship program to determine if information valued by applicants was provided. ResultsOnline information of 29 surgical oncology fellowships and 59 breast oncology fellowships was analyzed. Statistical differences were found among criteria in major information categories between Society of Surgical Oncology and institutional webpages for both fellowship types. Detailed criteria were more present on institutional rather than Society of Surgical Oncology webpages. ConclusionFor applicants to surgical oncology fellowships, institutional webpages provided the most pertinent information and may be used as a primary resource to guide fellowship application. For applicants to breast oncology fellowships, Society of Surgical Oncology webpages may be used as a primary resource to guide fellowship application. Both Society of Surgical Oncology and institutional pages lacked pertinent information regarding interview dates, and these resources should be updated to reflect program highlights as well as pertinent information for applicants.