Surgery – a pillar of modern oncology

Authors:

Details:

  1. The Royal Melbourne and Royal Women’s Hospital, Melbourne, Victoria.
  2. Peter MacCallum Cancer Centre, Melbourne, Victoria.
  3. Cancer Council Australia, Sydney, New South Wales.

Abstract

Surgery was the only recognised and available treatment for centuries; until radiotherapy entered the scene. Surgery was a single discipline approach to management underpinned by a sound knowledge of anatomy which has been established for centuries. Surgeons were among the early receptors of multidisciplinary care and were the leading groups in establishing the Clinical Oncological Society of Australia, 40 years ago. Multidisciplinary care frequently involves surgery and has led to cooperation between a range of disciplines of clinicians. This has led to better decision making, more rigorous strategies and improved safety. These factors have increased expectation of all the activities and have seen cancer screening and neoadjuvant therapies and better outcomes. Surgeons are now involved in cancer genetics and preventive surgery. Surgeons and their health care collaborators are helping patients through embracing the multidisciplinary approach espoused by the Clinical Oncological Society of Australia.


Since the earliest of times, surgery was regarded as the only hope for effective treatment for most cancers. The 18th century English surgeon, John Hunter, suggested that surgery might cure cancer if the tumour was contained. He remarked that “if the tumour is moveable… there is no impropriety in removing it”.1 Despite the giant strides made by the modalities of radiation oncology and medical oncology, surgery remains an essential aspect of potentially curative treatment for almost all solid tumours, plays an adjunctive role in other tumours and helps in the management of many patients with advanced cancer.2 Surgery as an effective cancer treatment was made possible by the developments in anaesthesia and in the engineering of precise surgical instruments that occurred in the 19th century. Improvements in anaesthesia, analgesia, intensive care, and the continued improvement of surgical and other technologies has expanded the scope of surgery, rendering previously inoperable tumours resectable, and improving patient safety and comfort during and after surgery.3

Multidisciplinary care

As surgery was the original single discipline used for treatment of many solid tumours, the development of multidisciplinary care and multidisciplinary teams has altered the way that surgery and surgeons are involved in cancer care. This was revolutionary for surgeons who were used to individual decision making and in some cases resisted the intervention of other practitioners. To their credit the flexibility of mind of surgeons shone through and they embraced this new approach.4

In almost all solid tumours, multidisciplinary care offers better outcomes, in terms of better survival and or reduced side-effects. It has allowed for the development of better selection criteria for patients having optimal surgery and made the spectre of incomplete excision a rarity in 2013. The bringing together of committed personnel expert in various modalities of cancer therapy has been the hallmark of the Clinical Oncological Society of Australia (COSA).

Breast cancer has been the model for this approach to care, with the early demonstration that patients treated in a multidisciplinary setting overall have better outcomes than those treated in the traditional model of singular or sequential care by various practitioners. As the benefits of adjuvant therapy became apparent in other diseases such as colorectal and oesophageal cancer, that were previously managed predominantly by surgeons, the view that multidisciplinary care is required for effective cancer management has become established across tumour types. This has been accompanied by a major change in the role of the surgeon in cancer care.5

Improved safety and increased expectations

Significant change has occurred in cancer surgery over the last 40 years. Surgical operations are far safer than they ever were, and patient comfort and pain control is now a major feature of care. The accepted operative mortality of major surgery such as pancreatectomy was once at least 10%, and many series with much higher rates of mortality were published by major academic institutions.  These institutions are now publishing large series with minimal or even no perioperative mortality.6 Factors behind this improvement include: the introduction of perioperative antibiotics, a much better understanding of perioperative pathophysiology; expert and multifaceted pain control; and the development and widespread availability of supplemental nutrition, either enteral or parenteral. 

A further, very important reason for these improved results is the subspecialisation of the team looking after the patient before, during and after surgery. It is clear that selected major procedures are much safer if they occur in institutions with a high case load and if the surgery is performed by surgical teams with specific expertise in that operation and its after care. Together, these have resulted in dramatically improved outcomes from surgical interventions.7 Ensuring that all patients have access to treatment by the appropriate team in the appropriate setting remains a challenge for the clinicians, the colleges and state and federal institutions.

Surgical intervention

Early diagnosis of cancer is the best way to improve cancer outcomes and it demands the best of clinicians’ diagnostic and observational skills. Screening programs for cervical cancer and breast cancer have been established to extend the benefits of early detection to as much of the population as possible.8 Screening for early colorectal cancer with faecal occult blood testing has also been proven to reduce mortality from the disease, and a national program is being introduced. Prostate-specific antigen testing identified early prostate cancer in many asymptomatic men, and testing for prostate-specific antigen has been shown to reduce the number of cases of advanced prostate cancer in a screened group of men.9

In all these cases, some form of surgical intervention to eradicate premalignant or early invasive cancer is the means by which the lesion identified on screening is treated.  While it is not really challenged that early treatment of a lesion that is destined to become a clinically significant and potentially metastatic disease is often beneficial, it is also true that screening programs do identify lesions that were not destined to become clinically significant during the person’s natural life. No doubt the balance between appropriate early diagnosis, and so-called ‘over-diagnosis’ will be debated for years to come.

Tailoring of the extent of cancer surgery

In the early days of cancer surgery, many decisions seem to have been relatively straight-forward.  The patient with a breast cancer underwent at least a total mastectomy, the patient with a kidney cancer underwent a total nephrectomy and the patient with an extremity soft tissue sarcoma underwent an amputation. Massive amputations of cancer were deemed the best treatment during the decade before COSA was established, with extended radical mastectomies, massive head and neck cancer resections and other highly morbid and mutilating operations being performed.

A number of developments have seen this approach carefully re-evaluated, such that function-preserving surgery is increasingly an option.  Breast cancer surgery has seen a dramatic evolution, first with the demonstration that breast conserving therapy with local excision of the cancer and adjuvant radiotherapy was equally effective as total mastectomy,10 followed by demonstration that sentinel node biopsy was as effective as axillary clearance for those with negative nodes,11 and now the suggestion that many patients with limited disease in the sentinel node may not benefit from further axillary surgery.12 These changes inevitably caused anxiety, until rigorous trials demonstrated their safety, and future efforts to tailor the extent of cancer surgery by identifying aspects of treatment that can be safely reduced or eliminated will continue to require scientific rigour.

Neoadjuvant therapy

The standard multidisciplinary treatment typically involved surgery as the initial modality, with recommendations for adjuvant therapies dependent on the surgical and pathological findings. Over recent decades, a number of situations have been found where altering the sequencing of treatment has resulted in better outcomes, either more effective cancer treatment and/or fewer side-effects. Examples include the approach to T3 or node positive rectal cancer, where pre-operative radiotherapy gives better local control than surgery followed by postoperative radiotherapy, T3 or node positive oesophageal cancer,13 preoperative systemic therapy for inflammatory and other locally advanced breast cancer, and preoperative radiotherapy for some cases of soft tissue sarcoma.14 In most of these cases the benefits of altered sequencing of treatment has been demonstrated through randomised trials, with better outcomes or fewer side-effects.

More recently, there has been a paradigm shift in the role of surgery for metastatic disease, with the demonstration that in many cases of metastatic colorectal cancer in the liver, a case that was previously considered incurable, may be rendered potentially curable with the use of systemic therapy prior to surgery. This has produced a new series of challenges to the surgeon, with side-effects specific to the preoperative therapy.15

In many diseases where preoperative systemic therapy is used, there is a group of patients who experience a complete pathological response to the systemic treatment alone.  In breast cancer, this varies from 5-50% depending on the subtype of cancer and the nature of therapy used.16 In oesophageal cancer, preoperative chemo- or chemoradiotherapy is associated with a significant chance of a pathologic complete response.17 These findings hold promise that some patients will be able to avoid the need for surgery altogether. While at present such a group is not able to be identified, mainly because the achievement of pathologic complete response is only established after surgery, it is one of the hopes for cancer treatment in the future that unnecessary surgery can be avoided to the patient’s ultimate comfort and benefit.

Cancer genetics and risk-reducing surgery

The traditional role of cancer surgery in the primary treatment of established malignancy has been extended into the area of cancer prevention. Better understanding of the natural history of cancer and in particular, developments in familial genetics, has allowed much better prediction of individual lifetime risk of cancer. Combined with safer resection surgery and improved options for reconstruction to limit the functional impact of surgery, risk-reducing surgery has become part of the therapeutic armamentarium for many diseases.

Carriers of mutations in the BRCA1 or 2 gene are at substantial lifetime risk of breast and ovarian cancer. Risk-reducing mastectomy will reduce the risk of developing breast cancer by around 95%, and risk-reducing salpingo-oophorectomy will have a similar impact on the risk of ovarian cancer.18 While these operations have minimal risk of operative mortality, the physical consequences of premature menopause, and the psychological impact of risk-reducing mastectomy are potentially serious, and the surgeon and other team members involved must address these issues.19

People with adenomatous polyposis coli mutations will inevitably develop colorectal cancer, and so risk-reducing colectomy prior to development of the cancer is logical and appropriate. The situation with herediatary non-polyposis colon cancer gene carriers is different, as the risk of cancer is lower. Carriers of a CDH1 mutation will almost certainly develop diffuse gastric cancer. Total gastrectomy is a large operation with a definite risk of mortality and potential long-term side-effects.20 The surgeon must be closely involved in decision making and must be able to perform the operation with minimal mortality and morbidity. The introduction of minimally invasive techniques for both colectomy and gastrectomy promise to further reduce the morbidity of the surgery, moving the balance of risks and benefits in favour of risk-reducing surgery.

Technological developments

Technology and surgery have developed hand in hand.  Developments in engineering allowed the production of precise instruments that enabled the pioneering operations of successful gastrectomy and safe thyroidectomy by Theodor Billroth and Theodor Kocher in the late 19th century.  Developments in electronics led to the introduction of the diathermy machine, which has contributed to minimisation of blood loss and precise instrumentation, leading to much safer anaesthesia, and developments in imaging have allowed precise pre-operative planning.

The last two decades have seen an explosion of technological developments in minimally invasive surgical technology. From the first laparoscopic cholecystectomy in the late 1980s,21 a vast range of procedures can now be performed using minimally invasive techniques.  Minimally invasive surgery in oncology was initially restricted to staging procedures such as staging laparoscopy in gastric and pancreatic surgery, which allowed incurable cases to be confirmed without the morbidity of open laparotomy. There was concern that minimally invasive procedures may result in port-site recurrences, or less effective oncological procedures, and so therapeutic minimally invasive procedures were introduced with caution. Randomised trials in colon cancer,22 and large series in gastric cancer,23 have demonstrated that these fears are unfounded.

The most recent surgical development is that of robotic surgery. This technology has included a ‘wrist’ that increases dexterity in a confined space, magnification, and removal of tremor to potentially improve surgical accuracy.  Many reports show that a variety of procedures are feasible using robotics,2426 and these have been enthusiastically publicised leading to rapid dissemination of the technology.  Reports to date have not shown clinical benefits to robotic surgery,27,28 and trials demonstrating superiority of this expensive technology are awaited.

Future developments

Predicting future developments is always hazardous. What is certain however, is that developments in our understanding of cancer and its various natural histories, development of new and targeted therapeutics and technical developments in surgical instrumentation will continue to modify the role of surgery in cancer care. It is likely that surgery will play a lesser role in many cancers, but also a greater role in others, where improved systemic therapies render a previously incurable situation potentially curable.

Whatever these developments, it is certain that optimal cancer outcomes will be achieved with appropriate teams of practitioners dedicated to the care of the cancer patient and that surgery will continue to play an important role in this.

COSA plays a unique role in bringing all the professionals involved in cancer care together under the one organisation.  It has a unique opportunity to continue to promote multidisciplinary care and educate the future generations of cancer practitioners in this manner of cancer care.

“We are what we repeatedly do. Excellence is not an act, it is a habit” – Aristotle

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