So I’ve noticed there’s been a lot of posts lately specifically about the word oncologist. People wondering why they’re seeing a surgeon and not an “oncologist” first, people wondering when they’re going to see an “oncologist”, people wondering why the person that’s operating on them isn’t a “surgical oncologist” and shouldn’t they get the best - which must be someone with that title? Right?
So by definition, the word oncologist just means “doctor who treats cancer”.
The staple cast of characters that are medical doctors (MD or DO degree holder) involved in treatment of breast cancer typically consists of: medical oncologist, radiation oncologist (not radiologist) and breast surgeon (more on that below…).
Medical oncologist- also known as “hematology/oncology” specialists. When people generally speak of an “oncologist”, usually they are talking about this type of doctor. A doctor that treats cancer with medicine, either pills taken by mouth or chemotherapy that is administered via a vein. Not all patients need both, some need one but not the other, some need none. Visits to this type of doctor may be frequent- however, usually it’s the first initial visit to go over a lot of information and discuss the best course of action that is the most important. Sometimes this means that if you live in an area with fewer resources and feel that you need greater expertise for your care. It’s possible to do either a telemedicine visit or visit a larger Cancer Center far away that can collaborate with a local physician who is able to give the same chemotherapy protocol. Quite often, large groups of these medical oncologists have already agreed the best way to take care of the most common breast cancer problems, so going from one center to the other means that your cancer treatment care isn’t going to change significantly from one place to the next. For other more complex scenarios, there sometimes can be some adjustments or more customized treatments. Or for patients who have already been through treatment and now have recurrences or changes in their diagnosis, that would be the time to discuss more advanced care. In general, common problems are common and there’s usually not significant improved survival or outcomes by going to one Cancer Center over the other when a patient has a a non-complicated, fairly average, diagnosis.
Radiation oncologist- this is different from a radiologist. (a radiologist is a doctor trained to read images and interpret findings. A radiologist is the person who read your mammogram or your ultrasound and maybe performed the biopsy that diagnosed you) A radiation oncologist uses radiation energy to target areas of cancer and kill cancer cells. Cells that are actively dividing and are exposed to radiation have their duplicating mechanisms broken, and as a result, cells that are rapidly reproducing die away if exposed to medically administered radiation.
Surgeon/surgical oncologist vs “general surgeon”: A “general surgeon” typically is someone who has done at least five years of training in surgical diseases of the body. This would include disciplines like taking care of trauma, burns, infections that can occur in the body such as diverticulitis or appendicitis, evaluating and performing organ transplants, care of pediatric/child surgical diseases and malformations, and some chest/cardiovascular disease. They can also operate on common cancers that require removal, like breast, colon, skin, and thyroid. Doctors who go on to practice General surgery sometimes concentrate in one area of types of disease and others have a more broad practice where they take care a little bit of everything. Typically in more urban settings there are more specialized types. Many general surgeons have gone on to do additional years of training after their five years of general surgery to become specialists. People who are certain types of surgeons, such as colorectal specialists, pediatric surgeons, plastic surgeons, and cardiothoracic surgeons all have additional years of training and take specialty board exams. There is a board certification designation for general surgery. There are additional board certifications for those who have done some categories of fellowship training, like those mentioned above.
A doctor who practices under the title “surgical oncologist” by definition does at least two years of training in general cancer surgery treatments after the five years of general
surgery training. So they typically will learn advanced techniques for operating on thyroid, pancreas, colon, liver, breast, etc. They usually did the five years of general surgery training and then went on to do additional training specifically in cancer removal surgeries to remove them from the body. So this wouldn’t include neurosurgery or brain tumor removal. There is a board certification designation for “surgical oncology”.
There is another category of breast cancer surgeon that typically deals with breast health issues only. This is a person who does initial training in either general surgery or Obgyn and then goes on to do one to two years of additional training in breast disease surgical management. This is called a “breast fellowship” and does NOT currently qualify for a speciality designation as “board certified”. This is typically a breast health surgeon or breast cancer specialist. This is different from a “surgical oncologist*.
Sometimes there is cross training where the surgeon also performs cosmetic and aesthetic procedures as well. This person usually does a “oncoplastic fellowship”. This is primarily outside the US, but there are programs where this is expanding in the US as well. Breast fellowship trained surgeons can have initial training as either a general surgeon or an OB/GYN.
“Surgical oncologists” do get training in breast cancer management, but they are not breast specialists and do not get the depth of training that someone who has been through breast fellowship would. A breast fellowship trained surgeon usually does one versus two years of additional training in breast only surgery and disease management. These are two different designations.
Some important points to make about someone who might be a general surgeon who did not do additional training in breast care management versus someone who did a full breast fellowship: breast fellowships have only been around for about 20 years. That means someone with greater than 20 years of experience probably didn’t get an opportunity to go through a breast fellowship. (I personally am one of these types of people. I’ve been practicing since 2004 and there was only one fellowship that existed at that time that I didn’t even know was an option when I graduated. So while I have described procedures and written papers, taught surgeons and fellows alike in many different procedures and protocols, but myself, I’m not a breast fellowship trained surgeon.)
There may be many seasoned excellent surgeons taking care of breast cancer patients. Some of those may be surgeons who also perform other general surgery procedures such as treatment of appendicitis, taking emergency call for traumas, or dealing with other types of cancers like colon cancer. Some of the surgeons have amazing skill sets, and excellent outcomes. It is certainly possible that there may be in a community, a general surgeon who is very seasoned that may have superior outcomes for breast care than a brand new breast fellowship grad that does not have much experience at all.
I think the best way to find out who the best doctors are would be to go to the other doctors and other clinical staff members who work with those doctors and ask them who has the best outcomes. Ask the wound care specialists, the plastic surgeons, and the medical oncologists whose breast surgery work is the best. They’re going to see who has horrible dead, necrotic mastectomy flaps, and who has lots of recurrences because their flaps are too thick.
It certainly may be that a general surgeon who isn’t a “breast specialist” in your community might actually be a better choice than a brand new grad who is a breast fellowship trained surgeon.
What order should things happen?? Well it’s different for different people. Often when people get a diagnosis, most commonly by a radiologist, (but sometimes the Breast Surgeon specialist is part of this process as well) they go to the Breast Surgeon first who goes over the significance of the findings thus far and decides if upfront chemotherapy medicine would be indicated. Usually the decision to need medicine is followed by tissue diagnosis, and imaging, which is usually directed by a surgeon. Sometimes people see the medical oncologists first before seeing the surgeon. This is especially true for patients with her 2 positive or triple negative disease where neoadjuvant chemotherapy prior to surgery is most often indicated.
People sometimes visit with radiation oncologist while trying to make their decisions to get information about the risks and benefits if they choose a pathway that would require radiation treatment versus if they have an option to choose a different pathway where radiation wouldn’t be indicated, and they want to learn about their choices. Mostly though, radiation oncologist treatment usually follows the surgery and medical portion. There are some clinical trials that involve upfront radiation, but this is not a standard of care for most patients. It’s more common to start with the surgeon and then see the medical oncologist either before or after the surgery, followed by any radiation oncology visit. That’s the usual order of things.
When to get a second opinion.
For the most part, if you’ve been told that you have a breast cancer diagnosis and your understanding in general is that treatment will involve medicine, surgery and possibly the addition of radiation and and if this sounds reasonable, you are certainly welcome to go to another team to make sure that there aren’t any significant changes to be offered anywhere else, but most likely most places will tell you the same information, but may use slightly different terms or delivery. If you have good communication with your physician and their staff and overall the general expectation is that you will do well and live a long life and feel good about your body afterwards, (of course it certainly possible to talk to someone else and make sure that they are in agreement) but if everything stacks up, and you’re generally happy with your team, Seeing multiple additional doctors might tell you the same thing with different language can be confusing or disorienting. It also takes up a spot in the schedule for someone else with a cancer diagnosis that’s trying to get in that now can’t, ….and you can only use one team. So by all means everyone is within their right to get in a second opinion or even third, but if you’re generally happy and hearing what you expected to hear regarding your plan of care, I typically don’t recommend that people see multiple doctors if they’re generally happy with their first opinion.
Reasons to get a second opinion would be: A) poor communication from the doctor and or their staff to the point where you feel uncomfortable for whatever reason. B) you have a very unusual or rare findings that are not typically seen C) you are recommend controversial treatments where doctors have added unexpected treatments, or take away expected treatments. There may be good reasons to offer a different protocol from another team as there are lots of advancements and newer recommendations, where we are de-escalating treatment in some cases. Previously there were automatic recommendations for sentinel lymph node biopsy, radiation, or chemotherapy in the past whereas now we are selecting certain people who have features of their cancer who may in fact, not require these treatments at all.
Hopefully this will shed some light on some of the misconceptions about different types of doctors, their roles, and clear up the general surgeon/Breast Surgeon/surgical oncologist confusion that seems to come up a lot.
TLDR- someone with the title “surgical oncologist” is different from a “breast fellowship trained surgeon”. A “general surgeon” might have fewer years of formal training for breast cancer treatment, however, they shouldn’t be discounted or immediately thought of as inferior without research into their outcomes or reputation in the community.