Why I became a breast surgeon

My name is Malin Sund. I work as professor of surgery and consultant of surgery at the University of Helsinki and Helsinki University Hospital in Finland, and as guest professor of surgery at Umeå University in Sweden. I was invited to write this piece about why I became a breast surgeon. The question is interesting since I came to realize that perhaps this was more serendipity than an active pursuit. During surgical training, I found most clinical subspecialities interesting. I am also quite sure that if I had chosen another field of surgery, I would have been equally content.

Breast surgery as a subspeciality is in many ways location dependent. By this I mean that depending on the country, region and hospital you practice in, breast surgery can be performed by the general surgeon, plastic surgeon or gynaecologist. I trained and practiced for many years in Sweden, where most breast surgeons are general surgeons that subspecialize into breast surgery. My training was at the most northern university hospital in Sweden i.e. Umeå University Hospital. In Umeå, breast surgery is performed within a division of Breast, Melanoma and Endocrine surgery (dubbed the BRENDO division). This is quite a common combination in the Swedish setting outside of the biggest cities/hospitals. Since there are no paediatric surgery clinics in Sweden north of Uppsala, also elective paediatric surgery was the task of BRENDO surgeons. Therefore, when deciding upon the field of surgery to choose, I felt that BRENDO surgeons dealt with many fascinating diseases and interesting surgical procedures. Naturally, having a group of great colleagues also significantly influenced the choice!

I have since transferred to Helsinki in Finland. In this setting my BRENDO diagnoses were suddenly spread out at three different hospitals and performed by three separate specialities. Thus, for practical reasons it was not possible to continue with the broader surgical repertoire, and currently my clinical work is mostly breast surgery i.e. due to being location-dependent.

So, what is fantastic about breast surgery? Breast surgery and especially breast cancer surgery has for decades been deeply rooted and affected by the increasing knowledge of cancer biology. During my career, understanding the effect of molecular subtypes and mechanisms underlying breast cancer progression have become essential for how we tailor the surgical interventions, with a focus both on performing curative surgery but also to do this based on the biology of the cancer. Breast surgeons have historically championed the development of many adjuvant treatments, and our patients typically receive systemic or locoregional adjuvant therapy that best suits their cancer subtype. Decisions on treatments are done in close collaboration with colleagues from other disciplines, such as those representing different diagnostic specialities, medical oncologists and radiation oncologists. This exchange of expertise, insights, and perspectives fosters an intellectually stimulating environment that supports both innovation and continuous improvement. According to me this strong interdisciplinary and multidisciplinary teamwork enriches breast surgery practice.

The integration of the above scientific knowledge with surgical expertise enables breast surgeons to deliver personalised care that optimizes outcomes but simultaneously with a focus on quality of life. Most of our patients are cured after their cancer treatment. As advancements in surgical techniques and adjuvant therapies continue to evolve, the focus shifts towards achieving both optimal oncological outcomes while minimizing physical and psychological morbidity. From nipple-sparing mastectomies to innovative reconstructive options, the emphasis on preserving body image and maintaining function enhances quality of life and promotes long-term survivorship.

The field of breast surgery is characterized by rapid technical advancements, with innovations continually reshaping everyday surgical practice. We find ourselves in an era of rapid de-escalation of surgical procedures with high morbidity. This can be exemplified by the expanding indications for breast conservation through oncoplastic techniques, and the introduction of targeted lymph node dissection to harness the added value of effective systemic therapies. Even the need for surgical axillary staging by sentinel node biopsy might disappear within the coming years for the majority of our patients. Perhaps some systemic therapies will even eliminate the need for breast surgery in the early disease setting for specific cancer subtypes, but I believe that surgery will remain the base for curative treatment for the majority of patients for the forseeable time. Surgical treatment of metastatic disease by removal of residual disease is a likely development following the more effective systemic and targeted therapies. Embracing these advancements requires adaptability and a commitment to a career-long learning that characterizes many breast surgeons.

Breast surgery thrives on collaboration and collegiality among peers. I have often felt that the breast surgery community is defined by an openness to the exchange of expertise, insights, and perspectives. This generates a supportive environment and has for me personally been a good setting to practice in as a clinical professor in surgery and cancer researcher. There is an interest in teaching and research among most of my colleagues, and the strong professional relationships with colleagues enrich my practice of breast surgery.

Would I choose the same speciality again if I could – most likely yes! I still find, with the overly filled calendar that comes with my position, that the days spent in outpatient clinics and the operation theatre are the most fulfilling.