1. Working in Surgical Oncology
What is Surgical Oncology?
As the name implies, surgical oncology focuses on surgical management of cancerous tumors. The full spectrum of management of patients with cancer include detection and screening, diagnosis and staging, surveillance and palliation. Gynecologic oncology is the only subspecilaty of oncology where the surgeon performs the surgery and also administers the chemotherapy.
Why I picked Surgical Oncology
This may resonate with many people – I never envisioned that I would be where I am now back when I first started my training. I always thought I would be working in Family Medicine or Emergency Medicine. However, during my clerkship rotation, what sparked joy for me was my surgical rotations. One of my electives was in Gynecologic Oncology. I saw a variety of patients with gynecologic malignancies in clinic. I saw patients undergoing chemotherapy and patients on surveillance. I observed how the oncologist break bad news and how the patient responded. I participated in the OR and especially enjoyed the laparotomy cases (open abdomen versus minimal invasive surgery with the laparoscope). I had a very positive experience during my rotation and when the service was looking to hire a PA, I applied. Surgical oncology serves a vulnerable population and it’s been humbling to be part of their care.
How I was trained for my position
There was definitely a steep learning curve when I first started in Gynecologic Oncology. Since Physician Assistants are trained as generalists, our program probably only had 2 week’s worth of dedicated oncology cases and one half day observership with a medical oncologist. I completed a two week rotation in gynecologic oncology during clerkship which was what initially exposed me to this field.
There was a lot of self-learning and me taking initiative to advance my skills. I used Toronto Notes for a general overview and also acquired teaching slides from my supervising physician. Then, I went into the specifics/details with the textbook the residents are using for their gynecologic oncology rotation. If I started with the textbook instead, I would have felt super overwhelmed. For the patients I saw in clinic, I take a minute to understand their diagnosis and treatment. For example, what does“Stage 3C high grade serous ovarian cancer” mean, why is she on this type of chemotherapy, and why is she having these symptoms. Everyone is different in terms of their learning trajectory – to be honest, it took me at least 6 months to start feeling comfortable. It helps a lot when my staff nurtures my knowledge by asking me questions around patient cases. I shadowed a radiation oncologist for two days observing how vaginal brachytherapy and cervical brachytherapy is administered.
There are small procedures I can do as a Physician Assistant and I get this training through the physicians themselves. Like everything else when starting, my physician supervises me and once we both feel comfortable with my skills, I do them unsupervised. Procedures I am doing include paracentesis, endometrial biopsies, vulvar biopsies, etc.
I second assist in the OR, mostly in laparotomy cases. My main job is to create the optimal view of the surgical site and the key is knowing what your surgeon likes. This comes with time and experience. Eventually I was able to anticipate what my surgeon will be doing next and have the tools in the my hand already for that next step. Slowly I also started tying knots, suturing, and closing. I also like being there as a second assist and learning all the tips and tricks the surgeon is teaching the residents 😉 .
Common Conditions in a Surgical Oncology Service
Cancer Research UK / Wikimedia Commons
- Pelvic mass suspicious for malignancy (MOST COMMON REASON FOR REFERRAL TO OUR SERVICE)
- Endometrial cancer
- Peritoneal carcinomatosis/Ovarian cancer
- Cervical Cancer
- Vulvar Cancer
Rare Conditions I’ve seen
Gestational Trophoblastic Disease – Cancer arising from abnormal proliferation of the placental trophoblast. It often arises after a molar pregnancy but can theoretically arise from any pregnancy (miscarriage, term pregnancy). Age group usually runs < 16 years old or > 40 years old. Incidence of molar pregnancy is 1 in 1000 pregnancies, doubled if previous molar pregnancy (1 in 100). Risk of progression to malignant gestational trophoblastic disease can be up to 40% with certain risk factors. These cancers are very sensitive to chemotherapy which allows curative treatment while preserving the patient’s fertility.
My Current Practice Setting
I worked in two cancer centres now and it’s nice to see how different the PA is used based on what the service needs.
My first job was at the Juravinski Cancer Centre in Hamilton, Ontario, which is an academic hospital. I worked alongside five gynecologic oncologists, residents, oncology nurses and one to two medical students who rotated with us. There is less help available for a busy service, so the PA was able to fill in different roles (clinic, OR, inpatient).
At Princess Margaret Hospital in Toronto, Ontario, this is a bigger academic hospital. I work with six gynecologic oncologists, clinical fellows, residents, clinical associates and oncology nurses. I do notice a larger volume of patients being seen in clinic (upwards of 40 patients a day). The busiest part of the service is clinic and this is where the PA’s help is needed most. Many are actually younger than the demographic range I was use to in Hamilton. Therefore I have seen more cases where we have to consider fertility sparing treatment.
What patients can expect when seen by a PA
When patients visit the gynecologic oncology clinic for a scheduled appointment, I will meet with the patient and obtain a history and review of systems. Depending on the reason for visit, I may do the physical exam including a pelvic exam. I review imaging and pathology with the patient. I will also address any other concerns the patient may have (questions about their symptoms, counselling, prescriptions and referrals). I always review the patient with my staff but depending on the reason for visit, my staff may or may not come in the finish off the encounter.
Working with Medical Directives
I work under direct supervision and my staff is always available in clinic. However, having medical directives would be nice to allow me to write orders if patient is getting admitted or going to urgent care for management. As I was the first Physician Assistant at the Juravinski Cancer Centre, I started my medical directives from scratch, using templates from PAs in other specialties. I did not know how much work it took to work on it! It took me about 8 months to complete it and have all the right persons to review it (supervising physicians, nurse managers, pharmacists, directors, etc).
Currently, there are actually quite a few physician assistants practicing at University Health Network (UHN). There is a general medical directive for all physician assistants however, a specific one for gynecologic oncology physician assistant is still in the works.