Nick Mulcahy

March 11, 2013

Washington, DC — General surgeons appear to perform the majority of cancer procedures in the United States, according to a study discussed at the Society of Surgical Oncology (SSO) 66th Annual Cancer Symposium.

As a result, surgical oncologists, who are highly qualified due to their training, perform less of the cancer surgery workload than general surgeons, said lead study author Karyn Stitzenberg, MD, MPH, assistant professor of surgery at the University of North Carolina at Chapel Hill.

The lesser workload for surgical oncology specialists is partly a consequence of their concentration in metropolitan areas, especially on the coasts, she said.

Only 303 counties in the US have a surgical oncologist; that means that less than 8% of all counties in the US have a surgical oncologist, Dr. Stitzenberg reported, citing data synthesized from the 2013 Society of Surgical Oncology membership directory and the 2010 US Census Bureau.

"Specialized surgical oncologists comprise only a small portion of the workforce of surgeons providing oncology care," Dr. Stitzenberg said.

However, there is a "general exception" to this rule about surgical oncologists. "Specialized surgical oncologists comprise a larger portion of the workforce for complex/rare tumors," she said.

Most of Dr. Stitzenberg's talk on who performs cancer surgeries was based on a forthcoming study from her and colleagues that uses Medicare claims data and provider databases from the state of North Carolina.

The goal of the study is to determine, on the basis of a single state, the proportion of procedures for different types of cancer that are performed by different types of surgeons. The study may not be representative of the US because North Carolina has a higher density of surgical oncologists than the national average, Dr. Stitzenberg said. In other words, the situation may be worse than the investigators report; general surgeons probably handle even more of the cancer surgery in the US overall.

The study is especially important because it is difficult to ascertain if the "supply" of cancer surgery will meet the growing "demand" resulting from an aging Baby Boomer population.

In the US, from 2002 to 2020, there will be a 43% increase in inpatient oncology surgeries and 25% increase in outpatient cancer procedures, Dr. Stitzenberg said, citing data from the only published study on the subject (Ann Surg Onc. 2003;10:1112-1117).

"What that study did not do is…look at the projected supply of surgical oncology care to meet those growing demands," she said.

It is "incredibly difficult" to measure surgical oncology capacity because of the role that other surgeons play, she added.

Who Performs What Surgery

To address the wild card of other surgeons in the surgical oncology marketplace, Dr. Stitzenberg and colleagues used patient and provider databases to assess the role that those surgeons play in the state of North Carolina.

For 4 types of oncology surgery (GI, lung, breast, and melanoma), general surgeons performed about 50% of all procedures for the study period, which was 1 year (but which year was not specified in the talk). On the other hand, surgical oncologists performed less than 20%, said Dr. Stitzenberg. The other kinds of surgeons who perform these 4 types of surgery include plastic, vascular, colorectal, gynecologic, and thoracic surgeons.

Even when looking at lung and esophageal procedures, which are considered a bit more complex than breast and GI procedures, the percentage of procedures performed by general surgeons was high (about 25%), she pointed out.

However, with regard to even more technical and less common procedures, surgical oncologists performed the majority of cases, including about one-third of all pancreatic cancer procedures and about 50% of liver cancer operations.

There were a couple of exceptions: general surgeons did about 50% of both stomach and gall bladder procedures, while surgical oncologists did about 25% of each. Also, each group performed about 25% of melanoma surgeries, with plastic surgeons and dermatologists collectively handling the majority of procedures.

Older patients and minority patients were most likely to be treated by general surgeons. Patients living in small towns were also likely to be treated by general surgeons than were rural or urban patients. "Travel distance likely plays a major role in determining the type of surgeon," Dr. Stitzenberg told the audience.

Dr. Stitzenberg's talk took place on a day in which convention center power outages repeatedly caused presenters to talk without microphones and in low light from back-up generators. Her talk had the added drama of having a fire drill in the middle of it.

The authors have disclosed no relevant financial relationships.

Society of Surgical Oncology (SSO) 66th Annual Cancer Symposium. Abstract 75. Presented March 8, 2013.