Development of the Breast Surgical Oncology Fellowship in the United States

The surgical treatment of breast cancer has rapidly evolved over the past 50 years, progressing from Halsted’s radical mastectomy to a public campaign of surgical options, aesthetic reconstruction, and patient empowerment. Sparked by the research of Dr. Bernard Fisher and the first National Surgical Adjuvant Breast and Bowel Project trial in 1971, the field of breast surgery underwent significant growth over the next several decades, enabling general surgeons to limit their practices to the breast. High surgical volumes eventually led to the development of the first formal breast surgical oncology fellowship in a large community-based hospital at Baylor University Medical Center in 1982. The establishment of the American Society of Breast Surgeons, as well as several landmark clinical trials and public campaign efforts, further contributed to the advancement of breast surgery. In 2003, the Society of Surgical Oncology (SSO), in partnership with the American Society of Breast Surgeons and the American Society of Breast Disease, approved its first fellowship training program in breast surgical oncology. Since that time, the number of American fellowship programs has increased to approximately 60 programs, focusing not only on training in breast surgery, but also in medical oncology, radiation oncology, pathology, breast imaging, and plastic and reconstructive surgery. This article focuses on the happenings in the United States that led to the transition of breast surgery from a subset of general surgery to its own specialized field.

1. Introduction: The Breast Surgery Movement
Breast cancer awareness has become a social and cultural movement. Individuals worldwide understand the meaning of the “pink ribbon” as a symbol of support for breast cancer and its patients, survivors, and research. This international recognition is appropriate, as breast cancer is the world’s most prevalent cancer. At the end of 2020, there were 7.8 million women alive who were diagnosed with breast cancer in the last five years. [1] The treatment of breast cancer has radically changed over the past several decades, leading to the development of breast surgery as a surgical specialty. As only 50 years have passed since the first National Surgical Adjuvant Breast and Bowel Project (NSABP) clinical trial in 1971, it is fruitful to analyze the contributions and historical happenings that have led to the development of breast surgery as a specialty.

2. 1970-1971: Dr. Bernard Fisher’s Surgical Dilemma and Landmark Trial
Prior to 1970, the “Halstedian Hypothesis” governed the way that physicians thought about cancer and metastasis. This paradigm proposed an orderly spread from local to distant sites [2]. However, even after a “radical” resection of skin, breast, muscle, and lymphatics, patients succumbed to widespread breast cancer. It was at this time that Dr. Bernard Fisher from the University of Pittsburgh published a critique entitled “The Surgical Dilemma in the Primary Therapy of Invasive Breast Cancer: A Critical Appraisal” (Figure 1).