2 Essentials of Surgical Oncology
Surgery is an essential part of the treatment for patients with many types of cancer. 1 – 4 Achieving the best results, however, often requires the coordinated efforts of an interdisciplinary team (multidisciplinary concept). Surgical oncologists are uniquely trained not only in the techniques of cancer surgery, but also in how surgery fits in to the big picture of cancer care. 5 Rather than viewing surgical procedures in isolation, surgical oncologists consider operations within the context of treatment plans that may incorporate chemotherapy, radiation therapy, and/or alternative approaches before, during, and after surgery. A surgical oncologist establishes a strong collaborative disease management program with other cancer-related disciplines to offer patients with a wide array of cancer treatments at the right time for the best chance for long-term quality of life.
Education is an essential part of surgical oncology that commonly involves interdisciplinary cancer conferences on breast, liver, pancreatic, biliary, and gastrointestinal (GI) malignancies, which are usually held on a weekly basis. These conferences serve an important role in optimizing patients’ multidisciplinary care as well as educating students, residents, and fellows about approaches to cancer care. Even more importantly, from the patients’ perspective, these conferences are the forum for cancer teams to plan the management of complex cases, review the results from surgery, determine the need for additional postoperative treatment, and consider patients for whom effective standard therapy is not available for entry into clinical trials. 6
Surgery, while the best treatment available, does not yet offer a sure cure for many cancer patients; an active program of clinical and translational research, bringing the newest promising developments from laboratories, is integral to any surgical oncology program. Studies in early cancer detection, tumor markers, cancer genetics, environmental risk factors, minimally invasive surgical techniques, nonsurgical tumor ablation, downstaging of advanced cancer to allow for surgical resection, transplantation for tumors, anesthesia for cancer surgery, adjuvant treatment to prevent cancer recurrence, tumor vaccines, gene therapy, and nonchemotherapy treatment of advanced cancer are all components in surgical oncology.
For the first half of the 20th century, cancer was essentially a surgical disease. By the mid-20th century, with the development of radiation therapy subsequent to discovery of X-rays and chemotherapy, the treatment of cancer changed dramatically. The significant expansion of medical oncology and radiation oncology has made evident that cancer is not a surgical-only disease, but one best treated with a multimodality therapy. The concept of surgical oncology first arose in the 1960s to better differentiate between medical oncologists and surgeons who did not specialize in oncology.
The essential principles of surgical therapy are established on several key factors.
Identifying and diagnosing of suspicious masses.
Staging of established cancers.
Providing curative resection of primary and several metastatic cancers.
Prevention of surgery by risk-reducing surgery.
Evaluating the concept of debulking malignancies as part of a multimodality therapy.
Providing surgical palliation of incurable patients.
The role of surgery in the treatment of cancer was initiated with John Hunter (1728–1793), the father of scientific surgery. 7 He first described the concept that cancer could be a localized process and amenable to surgical therapy with the discussion of the removal of regional lymph node disease. As surgery became safer and more feasible and as extensive understanding of anatomy and pathology finalized with the introduction of general anesthesia in 1842, surgery became the cornerstone of cancer treatment. It allowed the field to move beyond the superficial tumors and foray into intra-abdominal malignancies. The initial description of major intra-abdominal procedures began in the next few decades with the description of partial gastrectomy (Bill Roth in 1881), colectomy (Weir in 1885), radical mastectomy (Halstead in 1891), and abdominal perineal resection (Myles in 1908). For the next several decades, surgery was the mainstay of cancer therapy with the mortality and morbidity of surgery limited by the potential of long-term palliation and disease-free survival. This was accompanied by significant growth in cytotoxic systemic chemotherapy 8 as well as radiation oncology, 9 and with this the field of oncology began to transform rapidly.
With these developments, the role of the surgical oncologist evolved as well and it continues to do so in the management of cancer as we gain additional knowledge in tumor immunology, genetics, and molecular biology (tumor immunology). Whereas historically and even up to 10 years ago surgery was almost always the first step in therapy, now with the escalating use of neoadjuvant therapies, both systemic and localized, surgical therapy or consolidative surgery is now the second-or third-line treatment after the biology of the disease and the physiology of the patient have been established. This has required surgeons to become extensively knowledgeable in systemic chemotherapy, local regional therapies, as well as radiation oncology.