Author:

Anna Lisa Bonfranceschi

Abstract

For more than forty years, the European Society has been working to ensure multidisciplinarity and quality standards in cancer care

The European Society of Surgical Oncology (ESSO) was founded in 1981, alongside the emergence of more conservative strategies in cancer surgery and increasingly positive results from the integration of radiotherapy and chemotherapy in cancer treatment. Its American counterpart, the Society of Surgical Oncology, was founded 40 years earlier. Even today, Europe falls behind in recognising the central role of the surgical oncologist in managing cancer patients. Specialists' experience and data confirm that Europe is lagging behind in terms of centralising operations in facilities specialising in specific pathologies, which can ensure experience and high-quality standards, as well as in terms of the use of certified surgical oncologists. Since its foundation, ESSO has been committed to recognising and accrediting surgical oncologists throughout Europe, ensuring the best possible treatment for cancer patients — in part through ad hoc training programmes. The best treatment outcomes for patients, in terms of both therapy and quality of life, are achieved when treatments are provided by a multidisciplinary team in high-volume facilities. In this setting, the surgical oncologist integrates surgical knowledge with all aspects of tumour biology. A similar model of care is used in Breast Units to treat breast cancer. However, experts argue that it is time for similar models to be used for diseases affecting other areas of the body.

Introduction

“The role of training and continuous education in surgical oncology is fundamental in the era of information technology and super-specialization. The surgical oncologist should be exposed to a large number of operations and should become familiar with advanced technology instruments and techniques. At the same time he/she should not only act as a technician, but as a real scientist, being able to understand the results of basic and clinical research beyond the surgical domain, and integrate them into his/her everyday practice”. In 2012, Umberto Veronesi recounted the challenges of cancer surgery, a field in which Veronesi was a leading figure (Veronesi & Stafyla, 2012). He argued that surgery had advanced significantly in recent years due to the increased use of laparoscopic procedures, robotic surgery, more precise imaging guidance, genetic understanding and the expansion of medical oncology treatments in the adjuvant and neoadjuvant fields. At the same time, radiotherapy techniques have also been refined, becoming more precise and manageable in terms of treatment time and space, and related toxicities. Veronesi wrote that the promise of changing the clinical practice of oncological surgery is there, but what is still missing is true integration of the oncological surgeons.

General surgeons and oncological surgeons

Fourteen years have passed since the launch of this appeal in Frontiers in Oncology for oncological surgeons to become true scientists, and more than half a century since the foundation of dedicated scientific societies such as BASO (the British Association of Surgical Oncologists, in 1971). The vision of Veronesi remains largely theoretical, with scientific societies and experts in the field complaining that there is a lack of formal training and professional recognition, which threatens the quality of cancer treatment.

This isn’t just a widespread perception among clinicians, which has been denounced for some time (Naredi et al., 2008). At the latest ESSO congress, the European Society of Surgical Oncology (ESSO), in Gothenburg 2025, an ESSO Survey was presented, measuring the extent to which oncology surgery is actually performed by oncology surgeons across Europe (ESSO had already been involved in monitoring the recognition of the profession in the past). As Giuseppe Catanuto, ESSO Board Member, noted, when asked ‘Who performs the majority of cancer surgery in your country?’, the answer was general surgeons in 67% of cases. Recognised surgical oncologists perform just under 8% of the cancer procedures, and the remaining being performed by organ specialists. This, despite the fact that approximately two-thirds of countries have dedicated scientific societies, Catanuto points out (in Italy, the Italian Society of Oncological Surgery, SICO). “Even now, most tumours are removed by general surgeons”, confirms Riccardo Audisio, past president of ESSO: “The problem isn’t the surgeons themselves, who are generally skilled, but it’s crucial to understand that in oncology it’s necessary to work alongside other therapeutic strategies. Cancer surgery is a complex discipline, crossing boundaries of organ specialisation”. In other words, surgery is rarely the only treatment option for a patient, and planning and delivering other treatments — like chemotherapy, radiotherapy, targeted therapy or immunotherapy — necessarily requires knowledge far beyond that of a general surgeon. And the oncologist surgeon is required to continuously update himself/herself and to embrace all the innovations that concern oncology, including those deriving from artificial intelligence (Kleef, Rebelo, 2025), beyond technical skills and mastering of a continuously upgrading armamentarium.

“If I am knowledgeable about the entire oncology plan, I can offer patients much more”, Audisio continues, estimating a therapeutic gain rate of 20% to 30% for all solid tumours, making good use of oncological knowledge compared to general surgical skills. “This is not because cancer surgeons are technically better, but because they have gathered all the necessary information to offer the best treatment to cancer patient”. This knowledge is not limited to medical oncology, the availability of adjuvant and neoadjuvant regimens capable of enhancing the effectiveness of the intervention, but also takes into account the patient’s genetics. For example, this refers to genetic predispositions that are known to increase the risk of certain cancers. One such predisposition is the BRCA 1 and BRCA 2 gene, which can significantly increase the risk of gynaecological cancers. Knowing that a woman carries these risks variants may prompt her to choose preventive mastectomy or salpingo-oophorectomy to remove her ovaries and fallopian tubes. “Operating on a woman for breast cancer, or when she is exposed to a genetic risk of the disease, requires an understanding of not only the anatomy and biology of the breast, but also the concept of multidisciplinary management - neoadjuvant treatment, hormonal manipulation, radiotherapy - and the top of advanced oncoplastic techniques, to ensure the best possible clinical outcomes for breast reconstruction and quality of life”, explains Audisio.

Breast cancer and Breast Units as a model

Breast cancer is a well-known example of an integrated treatment strategy and is often cited as a positive case study. Today, there are centres across Europe that specialise in breast cancer treatment. These are known as Breast Units and ensure a dedicated and multidisciplinary approach for each patient. Staff are specialised in the knowledge and treatment of the disease and include oncologists, radiologists, psychologists, nurses, pathologists and, of course, surgeons. “They are dedicated to the treatment of breast cancers, exposed to the management of a large number of patients, and constantly upgrading their knowledge by contributing to the scientific community and to research projects”, adds Audisio. Breast Units are required to treat at least 150 new cases of breast cancer per year and to have certified experience in each department, to maintain a high volume of cases or examinations, and to comply with the requirements of an international network (EUSOMA). However, the question remains: who certifies the specialisation of these experts? Specifically, how can one be reassured that surgery is delivered by certified breast surgeons?

ESSO deals with this, defining the training and accreditation pathways for specialists in oncoplastic breast surgery. In 2019, together with other scientific organisations, it organised the European Breast Surgical Oncology Certification (BRESO). This is a European-level accreditation process for dedicated breast surgeons to standardise the quality of care provided in different centres. “In order to obtain the BRESO certification, it is necessary to participate in conferences dedicated to breast cancer, demonstrate that you have performed a certain number of operations as an assistant and as a lead surgeon, have attended a specific department for the treatment of breast cancer, be familiar with the scientific literature and have produced publications on the subject, as well as having collaborated with radiologists, pathologists, radiotherapists and other professionals involved in the treatment of the disease, and pass the European Board of Surgery Qualification exam of the Union of European Medical Specialists (UEMS) for breast cancer”, Audisio continues.

The birth of ESSO in the era of multidisciplinarity in oncology

Breast cancer treatment is far ahead of other specialities in recognising the central role of the surgical oncologist and integrating them with other professionals involved in the various aspects of breast cancer treatment. This is largely thanks to ESSO’s role as a catalyst for research, training, recognition and accreditation programmes for surgical oncologists, which encourage a multidisciplinary approach. This spirit has characterised the scientific society since its foundation in 1981 under the presidency of Umberto Veronesi, as recalled by Domenico D’Ugo, who also headed ESSO between 2020 and 2022 (D’Ugo, 2024).

The society was founded at a pivotal time for oncological surgery, with the establishment of multidisciplinary cancer treatment, when new and less invasive surgical techniques were being implemented. It was in fact the early 1980s when Veronesi demonstrated the effectiveness of a more conservative approach to the removal of small breast tumors - quadrantectomy combined with radiotherapy- compared to radical mastectomy (Veronesi et al., 1981). Shortly before this, the European Society of Medical Oncology (ESMO) was founded, and Gianni Bonadonna’s team, known as the ‘father of Italian medical oncology’, began using cyclophosphamide, methotrexate and fluorouracil following radical mastectomy. They observed the benefits of adjuvant treatment against breast cancer (Bonadonna et al., 1995).

“A multidisciplinary approach, in which surgeons collaborate with other specialists, enables us to offer patients less aggressive therapies while ensuring that the intervention is curative”, adds D'Ugo: “This paradigm shift, which began with Umberto Veronesi, has transformed our approach to cancer treatment. If we can do this today, it is because we have a better understanding of tumour biology and can integrate surgery with other disciplines”. Rather than anatomy, the biology of the tumour and a thorough knowledge of treatments other than surgery and their optimal timing are and must be the guiding principles of a surgical oncologist’s work, as Pankaj Kumar Garg and S. P. Somashekhar recently summarised (Garg PK, Somashekhar SP, 2025). “The philosophy behind the role of the surgical oncologist is not so much to have expertise in removing any affected organ, but to have an open mind, which allows for the optimisation of surgical performance”, adds Audisio.

ESSO’s commitment to training cancer surgeons

Tumour boards and molecular tumour boards are the direct result of the multidisciplinary approach to cancer treatment. However, the mere existence of tumour boards does not guarantee adequate treatment for all patients. Alongside this focus on multidisciplinarity, patients need to be referred to centres of excellence for specific types of cancer. Beyond Breast Units, Italy still lags behind the rest of Europe in this field, explains D’Ugo. This is particularly evident when compared to the United States, where the Society of Surgical Oncology (formerly the James Ewing Society) has existed since 1940 and the first certified surgical oncologists were recognised in 2015, despite the first surgical oncology fellowships dating back to the early 1980s (Blazer DG, 2022).

The ESSO above mentioned survey confirms this. To date, the vast majority of cancer surgeries take place in university facilities, with only a quarter taking place in cancer centres: there is a lack of centralisation of treatment. “Without an adequate case volume demonstrating knowledge of that specific tumour, we cannot offer patients any guarantees, either in terms of protocol or in reducing the risk of complications,” continues D’Ugo. “This is also part of ESSO’s mission: to advocate for patients to be operated on at competent centres, and to educate patients themselves to push for the adoption of models at a European level that guarantee appropriateness and better therapeutic results”.

Scientific evidence shows that survival rates for women with breast cancer are significantly better in the case of dedicated multidisciplinary centres such as Breast Units, which have extensive experience (Eileen M. Kesson et al., 2012). In some cases, patients treated by low-volume, non-certified centres are 30–40% more likely to die of the disease (Leroy et al., 2024). Similar evidence also exists in other areas, such as pancreatic surgery, providing support for the creation of dedicated multidisciplinary care units, such as Pancreas Units. Similar figures, adds Audisio, are available for colorectal cancer, sarcomas, melanomas, upper GI tumours and lung cancers.

In recognition of the discrepancy between the ideal model of care in specialised centres with a high volume of cases and certified quality, in Italy, the Italian Society of Oncological Surgery Foundation (the SICO Foundation) has been offering training fellowships for young surgeons with an interest in surgical oncology since 2023. This two-year programme is designed to train surgical oncology specialists and prepare them for EBSQ (European Board of Surgical Oncology Qualification) certification from the European Board of Surgery of the Union of European Medical Specialists (UEMS). “The division of Surgical Oncology a UEMS was established in 2003 to promote excellence in cancer surgery across Europe - Audisio explains - The range of subjects areas covered in the exam are set out in the ESSO Core Curriculum and more recently aligned with the global curriculum for cancer surgery developed jointly between ESSO and the US Society for Surgical Oncology (SSO)” (van der Hage et al 2021).

The SICO Foundation fellowship includes targeted activities in various surgical areas, including not only breast cancer, but also oesophageal, gastric, colorectal, sarcoma, pancreatic, liver, melanoma and peritoneal cancers. This is because the revolution that has taken place in breast cancer, in terms of knowledge about the disease and then treatment in clinical practice, has affected all cancers.

Giacomo Argento et al. in Cancers have recently highlighted how precision medicine has profoundly changed thoracic oncological surgery (Argento et al., 2025). In lung cancer, determining the genetic characteristics of the disease helps clinicians to identify targeted treatments and to predict tumour aggressiveness. This allows for the optimisation of the preoperative management of lung cancer by shrinking the disease prior to surgery, therefore enabling a better surgical management. Argento et al. suggest that a better knowledge of tumour biology, as provided by epigenetics and proteomics, will become part of surgical practice. In this context, surgery is becoming less invasive and increasingly targeted at preserving the affected organ; this is made possible by of the use of targeted chemotherapy, immunotherapy and radiotherapy - before, during or after the operation - transforming the methods and objectives of the procedure (Horváth ÖP et al., 2023).

The core mission of the European Society of Surgical Oncology is to promote the profession of surgical oncology, train specialists in the field, engage in dialogue with organisations involved in cancer care at various levels, and strengthen ties with national societies. ESSO also carries out its advocacy activities through participation in the Global Forum of Cancer Surgeons initiative (Are et al, 2020). With over 4000 members, the society’s ambition is to promote high standards in the surgical treatment of cancer and ensure they are widely adopted and harmonised. To this end, ESSO publishes its own scientific journal, the European Journal of Surgical Oncology (EJSO), with a respectably high impact factor in this field (D’Ugo, 2024).

Conclusions

Even today, most cancer surgery in Europe is performed by general surgeons, despite scientific evidence showing the added value, in terms of treatment and quality of life, of treatment carried out at centres with specialised staff. Since its foundation, ESSO has been committed to promoting the training and recognition of cancer surgeons, who have in-depth knowledge of tumour biology and coordinate with multidisciplinary teams, rather than acting as isolated specialists in the operating theatre. This ensures the best possible outcomes for patients.

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Other keyplayers: Riccardo Audisio