Cutting-edge organization: A consensus-informed framework in surgical oncology

Centralization of complex cancer surgery may improve outcomes but can also generate treatment delays, reduced access, inequalities, and fragmentation of care. Developed after the Surgical Oncology Meeting held on 7-8 May 2026 and refined through iterative discussion, this position paper proposes a network-based Hub-and-Spoke model designed to balance quality, equity, continuity, and sustainability. We argue that modern networks should move beyond case volume alone and incorporate procedure- and disease-specific referral criteria, minimum requirements for specialized centers, multidisciplinary decision-making, rescue capacity, outcome monitoring, equity safeguards, shared-care pathways, patient navigation, virtual tumour boards, workforce planning, digital support, and patient-centred performance indicators. However, the boundary between a coordinated network and pure centralization is fragile. Unidirectional referral may overwhelm hubs, deprive spokes of expertise, and worsen inequities; active governance is therefore essential. The multidisciplinary team represents the cognitive backbone of the network, but protocol-driven decisions, hierarchy, variable competence, and diffusion of accountability may limit personalized care. These shortcomings should be addressed through structured audit, transparent documentation, and tolerance of justified dissent. In the operating theatre, deviations from preoperative plans should not automatically be viewed as failures, but as expressions of clinical judgment under uncertainty, provided they are documented, explainable, and aligned with patient values. Ethical surgical practice also requires resisting technology-driven innovation that prioritizes institutional prestige over meaningful benefit. This paper is intended as a working map rather than a definitive code. The success of the Hub-and-Spoke model should be judged by the performance, equity, and accountability of the entire network for all patients.