Lara Bonner Millar, MD
The Abramson Cancer Center of the University of Pennsylvania?
Last Modified: January 13, 2011
Surgery as a medical field has been changing rapidly since the late 1800s, in large part thanks to the development of safe and effective anesthesia. Surgical oncology is a specialty that focuses on the surgical treatment of a variety of tumors. Ephraim McDowell did the first reported resection of an ovarian tumor in 1809, but as early as the 7th century, ancient Egyptians described techniques for removing breast tumors. Today, general surgeons can pursue additional training after their residency in the form of a surgical oncology fellowship. However, a surgeon does not have to do a surgical oncology fellowship in order to be a surgical oncologist. What is more common is that a surgeon who is trained in a particular body site may develop expertise in cancers of that site, and thus have experience in the multidisciplinary approach to the prevention, diagnosis, and treatment of those cancers. For example, a thoracic surgeon who is a surgical oncologist may devote most of his practice to lung cancer, while a head and neck surgical oncologist would be involved in treatment of cancers specific to her training, such as cancer of the larynx.
Surgery is the oldest form of cancer treatment, and for most patients, part of the curative plan includes surgery. The most important part of the consultation with the surgeon is a complete history and physical exam. Before surgical resection, diagnostic and staging studies should be performed. This helps the surgeon determine if the cancer is resectable (removable with surgery), and allows him or her to plan the surgical approach. Due to improved screening techniques, many patients have disease that is curable with surgery alone at diagnosis. In such cases, after surgery, the patient's follow-up care includes close observation and/or radiology and lab tests.
The goals of the surgical oncologist are to remove the cancer and an area of healthy tissue surrounding it, also known as a clear margin or clear excision, in order to prevent the cancer from recurring in that area (which is called a local recurrence). Sometimes it is not possible to remove the whole tumor, and a surgery known as "debulking" may be done to remove as much of the tumor as possible and to relieve symptoms such as pain, airway obstruction, or bleeding. However, the contribution of the surgical oncologist goes beyond what is done on the day of surgery itself. As part of the multidisciplinary care team, he or she provides expert opinion about biopsy techniques, optimal image guidance, the likelihood of achieving clear margins (especially in borderline resectable cases), and what role there is, if any, for surgical management of more advanced disease.
Although chemotherapy and radiation therapy are commonly used either pre- or post-operatively, a quality surgery is critical because it is not clear that chemotherapy or radiation can correct or compensate for an inadequate surgery. Excision of lymph nodes in the area of the tumor may be done at the time of surgery, depending on the type of cancer. The information regarding lymph node status (i.e. do they contain cancer cells or not?) can help determine prognosis as well as further treatment options. For example, if a patient has a small rectal cancer that is thought to be node-negative pre-operatively, but there is nodal involvement discovered after surgery, this finding portends a less favorable prognosis than if all the nodes had been negative. Additionally, chemotherapy and/or radiation would be recommended for node-positive disease, but with node-negative disease and an absence of other risk factors, observation alone after surgery would be recommended.
The types of surgeries that are done for cancers depend on the stage and location of the tumor and the fitness of the patient for surgery, and will continue to evolve. A classic example of the evolution of surgical technique is in the management of breast cancer. In 1890, Dr. William S. Halsted pioneered the radical mastectomy, a surgery which removed the whole breast, all draining nodes and the pectoral muscles (the muscle in the chest just below the breast). This was an extreme procedure that resulted in poor cosmetic outcomes and other long-term issues. While this was effective against the cancer, other surgeons wondered if they could achieve good oncologic results with a less extensive and disfiguring surgery. Breast conserving surgery was pioneered by Dr. Veronesi in Italy, who performed quadrantectomy (removing one quadrant of breast tissue) starting in the 1970s, although it took decades of follow-up to demonstrate that this less extensive surgery was acceptable. Nowadays, breast surgeons tend to do even smaller and more cosmetically pleasing surgeries called lumpectomies (which should be followed with breast radiation), while still maintaining excellent cancer control. Additionally, all women used to have surgery to remove the lymph nodes in the underarm, called an axillary dissection. The dissection left some women with arm swelling, pain, and/or limited range of motion. Now, for diagnostic staging of the axilla, sentinel lymph node dissection (removing only the first draining node) is done. Axillary dissection is reserved for situations where the sentinel node is positive for tumor, or if a sentinel node cannot be found.
Sometimes, after removal of the tumor, there is a defect left behind that could be physically devastating or impact on function. To remedy this, reconstructive techniques are increasingly being used for certain cancers and are important because of the impact on the patient's quality of life. Reconstruction can take place at the same time that the cancer is removed, ("immediate reconstruction"), or weeks to months later, "delayed reconstruction." When a surgical oncologist operates in conjunction with a plastic surgeon - for example, a breast surgeon performing a mastectomy with immediate reconstruction done by the plastic surgeon - the combined surgical approach is described as "oncoplastic surgery."
Like radiation therapy, the precise details of surgical technique are dictated by patient anatomy, tumor location, and cancer cell biology. Therefore, there is not always one exact way of doing things. Experience and evidence continue to shape the field of surgical oncology.
Pollock, Raphael E. Advanced Therapy in Surgical Oncology. 2008, BC Decker, Hamilton, Ontario, Canada.
Bland, Kirby I., Daly, John M, and Karakousis, Constantine P. Surgical Oncology: Contemporary Principles & Practice. 2001, McGraw-Hill, New York.
Feig, Barry W., Berger, David H., and Fuhrman, The M.D. Anderson Surgical Oncology Handbook, Fourth Edition. 2006, Lippincott, Williams, and Wilkins.