Oncosurgery:

Surgical oncology is a specialized area of oncology that engages surgeons in the cure and management of cancer.

Purpose

Cancer has become a medical specialty warranting its own surgical area because of advances in the biology, pathophysiology, diagnostics, and staging of malignant tumors. Surgeons have traditionally treated cancer patients with resection and radical surgeries of tumors, and left the management of the cancer and the patient to other specialists. Advances in the early diagnosis of cancer, the staging of tumors, microscopic analyses of cells, and increased understanding of cancer biology have broadened the range of nonsurgical cancer treatments. These treatments include systematic chemotherapy, hormonal therapy, and radiotherapy as alternatives or adjunctive therapy for patients with cancer.

Not all cancer tumors are manageable by surgery, nor does the removal of some tumors or metastases necessarily lead to a cure or longer life. The oncological surgeon looks for the relationship between tumor excision and the risk presented by the primary tumor. He or she is knowledgeable about patient management with more conservative procedures than the traditional excision or resection.

Demographics

According to the American Association of Cancer Registries, the most commonly diagnosed cancers for males in the United States during 1995–1999, with total of over 1.7 million cases for all races, were:

• prostate–28.6%
• lung–16.3%
• colon and rectum–11.7%
• bladder–6.6%
• non-Hodgkin's lymphoma 4.2%

White males make up more than 1.4 million of the total prostate cancer cases, with African Americans and Hispanic Americans accounting for 160,356 and 75,237 cases respectively. Each of the latter groups had higher stomach cancer incidence in the top five list, replacing non-Hodgkin's lymphoma. For women, the total cases for all races was over 1.6 million, and white women made up more than 1.4 million of this number. There were 140,888 female African American cases and 76,810 Hispanic American female cases.

Leading cancers for all groups were:

• breast–30.7%
• lung–12.5%
• colon & rectum–12.2%
• corpus & uterus–5.9%
• ovary–3.9%

African American women had higher rates of cervical cancer, replacing ovarian cancer in the top five list.

Description

Surgical oncology is guided by principles that govern the routine procedures related to the cancer patient's cure, palliative care, and quality of life. Surgical oncology performs its most efficacious work by local tumor excision, regional lymph node removal, the handling of cancer recurrence (local or widespread), and in rare cases, with surgical resection of metastases from the primary tumor. Each of these areas plays a different role in cancer management.

Excision

Local excision has been the hallmark of surgical oncology. Excision refers to the removal of the cancer and its effects. Resection of a tumor in the colon can end the effects of obstruction, for instance, or removal of a breast carcinoma can stop the cancer. Resection of a primary tumor also stops the tumor from spreading throughout the body. The cancer's spread into other body systems, however, usually occurs before a local removal, giving resection little bearing upon cells that have already escaped the primary tumor. Advances in oncology through pathophysiology, staging, and biopsy offer a new diagnostic role to the surgeon using excision. These advances provide simple diagnostic information about size, grade, and extent of the tumor, as well as more sophisticated evaluations of the cancer's biochemical and hormonal features.

Regional lymph node removal

Lymph node involvement provides surgical oncologists with major diagnostic information. The sentinel node biopsy is superior to any biological test in terms of prediction of cancer mortality rates. Nodal biopsy offers very precise information about the extent and type of invasive effects of the primary tumor. The removal of nodes, however, may present pain and other morbid conditions for the patient.

Local and regional recurrence

Radical procedures in surgical oncology for local and regional occurrences of a primary tumor provide crucial information on the spread of cancer and prognostic outcomes. However, they do not contribute substantially to the outcome of the cancer. According to most surgical oncology literature, the ability to remove a local recurrence must be balanced by the patient's goals related to aesthetic and pain control concerns. Historically, more radical procedures have not improved the chances for survival.

Surgery for distant metastases

In general, a cancer tumor that spreads further from its primary site is less likely to be controlled by surgery. According to research, except for a few instances where a metastasis is confined, surgical removal of a distant metastasis is not warranted. Since the rapidity of discovering a distant metastasis has little bearing upon cancer survival, the usefulness of surgery is not time-dependent. In the case of liver metastasis, for example, a cure is related to the pathophysiology of the original cancer and level of cancer antigen in the liver rather than the size or time of discovery. While surgery of metastatic cancer may not increase life, there may be indications for it such as pain relief, obstruction removal, control of bleeding, and resolution of infection.

Diagnosis/Preparation

Surgery removes cancer cells and surrounding tissues. It is often combined with radiation therapy and chemotherapy. It is important for the patient to meet with the surgical oncologist to talk about the procedure and begin preparations for surgery. Oncological surgery may be performed to biopsy a suspicious site for malignant cells or tumor. It is also used for tumor removal from such organs as the tongue, throat, lung, stomach, intestines, colon, bladder, ovary, and prostate. Tumors of limbs, ligaments, and tendons may also be treated with surgery. In many cases, the biopsy and surgery to remove the cancer cells or tissues are done at the same time as the biopsy.

The impact of a surgical procedure depends upon the diagnosis and the area of the body that is to be treated by surgery. Many cancer surgeries involve major organs and require open abdominal surgery, which is the most extensive type of surgical procedure. This surgery requires medical tests and work-ups to judge the health of the patient prior to surgery, and to make decisions about adjunctive procedures like radiation or chemotherapy. Preparation for cancer surgery requires psychological readiness for a hospital stay, postoperative pain, sometimes slow recovery, and anticipation of complications from tumor excision or resection. It also may require consultation with stomal therapists if a section of the urinary tract or bowel is to be removed and replaced with an outside reservoir or conduit called an ostomy.

Aftercare

After surgery, the type and duration of side effects and the elements of recovery depend on where in the body the surgery was performed and the patient's general health. Some surgeries may alter basic functions in the urinary or gastrointestinal systems. Recovering full use of function takes time and patience. Surgeries that remove such conduits as the colon, intestines, or urinary tract require appliances for urine and fecal waste and the help of a stomal therapist. Breast or prostate surgeries yield concerns about cosmetic appearance and intimate activities. For most cancer surgeries, basic functions like tasting, eating, drinking, breathing, moving, urinating, defecating, or neurological ability may be changed in the short-term. Resources to attend to deficits in daily activities need to be set up before surgery.

Risks

The type of risks that cancer surgery presents depends almost entirely upon the part of the body being biopsied or excised. Risks of surgery can be great when major organs are involved, such as the gastrointestinal system or the brain. These risks are usually discussed explicitly when surgerical decisions are made.

Normal results

Most cancers are staged; that is, they are described by their likelihood of being contained, spreading at the original site, or recurring or invading other bodily systems. The prognosis after surgery depends upon the stage of the disease, and the pathology results on the type of cancer cell involved. General results of cancer surgery depend in large part on norms of success based upon the study of groups of patients with the same diagnosis. The results are often stated in percentages of the chance of cancer recurrence or its spread after surgery. After five disease-free years, patients are usually considered cured. This is because the recurrence rates decline drastically after five years. The benchmark is based upon the percentage of people known to reach the fifth year after surgery with no recurrence or spread of the primary tumor.

Morbidity and mortality rates

Morbidity and mortality of oncological surgery are high if there is organ involvement or extensive excision of major parts of the body. Because there is an ongoing disease process and many patients may be very ill at the time of surgery, the complications of surgery may be quite complex. Each procedure is understood by the surgeon for its likely complications or risks, and these are discussed during the initial surgical consultations.

There are comprehensive surgical procedures for many cancers, and complications may be extensive due to the use of general anesthetic and the opening of body cavities. Open surgery has general risks associated with it that are not related to the type of procedure. These risks include possibility of blood clots and cardiac events.

There is an extensive body of literature about the complication and morbidity rates of surgery performed by high-volume treatment centers. Data show that in general, large volumes of surgery affect the quality outcomes of surgery, with smaller hospitals having lower rates of procedural success and higher operative and postoperative complications than larger facilities. It is not known whether the surgeon's experience or the advantages of institutional resources in operative or postoperative care contributes to these statistics.

Alternatives

Alternatives to cancer surgery exist for almost every cancer now treated in the United States. Research has been very successful for some—but not all—cancers. There are many alternatives to surgery, and chemotherapy and radiation after surgery. Most organizations dealing with cancer patients suggest alternative treatments. Physicians and surgeons expect to be asked about alternatives to surgery, and are usually quite knowledgeable about their use as cancer treatments or as adjuncts to surgery.

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