Introduction

Historically, surgery was the sole method used for treating cancer. However, with the introduction of ionizing radiation and the development of anticancer drugs and biologics, cancer therapy rapidly progressed to involve the careful integration of an extensive array of therapeutic options in the treatment of both primary and recurrent tumors. As a result, the cancer surgeon is an integral part of a multidisciplinary team involved in the treatment of most solid tumors and in the design and implementation of clinical trials to validate new therapies and technologies.

The surgeon involved in cancer patient care must have a clear understanding of the complex biology of cancer and its natural history and must be experienced in the technical procedures needed to accurately diagnose and appropriately resect primary cancers and, when indicated, locally recurrent and metastatic tumors. Because the cancer surgeon is often the member of the team who establishes the diagnosis, he or she must be prepared, in many cases, to function as the primary cancer care provider, or cancer-oriented “family physician,” for the patient and the patient’s family. Often, the surgeon provides for the patient a focus of treatment integration among the various cancer specialists. Cancer surgeons find that it is common for patients to call or visit them for advice about all aspects of their treatment, often leading to a lifelong relationship of continued supportive care and follow-up.

Historical Perspective

In medicine, professional and public acceptance of a subspecialty has historically depended largely on accomplishment. The development of the surgical oncology subspecialty is no exception and has been intimately tied to the history of surgery. In fact, surgical treatment of cancer has been significantly responsible for the role of surgery in modern medicine. The earliest discussion of surgical treatment of tumors appears in the E.S. Papyrus (circa 1600 BC), but it is believed to be based on earlier writings dating back to 3000 BC.¹

Before the introduction of anesthesia, surgery was primarily reserved for the treatment of abscesses and for managing trauma. The few operations performed for tumors were amputations. Not only did patients suffer excruciating pain in the absence of anesthesia, but also, before the advent of antisepsis, the death rate from infection was extraordinarily high. As a result, few patients were willing to undergo such intense pain electively, with so little chance of survival.

Advances made using anesthesia in the 1840s were led by John Crawford, a dentist who first discovered the loss of pain sensation with ether inhalation. John Collins Warren, who in 1838 published the earliest American work on tumors,² was the first person to use ether in the removal of a tongue cancer.³ Sepsis, however, remained a major barrier to successful surgery until Joseph Lister (subsequently Baron Lister), an accomplished surgeon, introduced the concept of bactericidal therapy with carbolic acid in 1867.⁴ This concept was an outgrowth of Pasteur’s theory that bacteria caused infection. By using carbolic acid as an antiseptic agent in conjunction with heat sterilization of instruments, absorbable ligatures, and a drainage tube, Lister dramatically decreased the rate of postoperative fatalities.

Although the value of Lister’s contributions was not recognized by his senior colleagues, they were quickly adopted by William Stewart Halsted,⁵ the first professor of surgery at the new Johns Hopkins Hospital in Baltimore, Maryland. Halsted introduced to the United States the meticulous techniques of tissue handling during surgery and the antiseptic methods proposed by Lister. Halsted, who had a major interest in cancer, was strongly supported in his work by his close friend and colleague at Johns Hopkins, Sir William Osler. Osler was a student of abdominal malignancies, and the collaboration of these two great American physicians represents one of the earliest occurrences of the multidisciplinary approach to cancer treatment.

As noted, much of the progress of surgery as a specialty in medicine was directly related to the attempt to eradicate cancer when it was initially diagnosed. Over the decades since the work of the early giants of American surgery—Halsted, Ernst Wertheim, and William James Mayo—operations for cancer became more and more aggressive in their design. The concept was that of removing as much tissue as possible to prevent the recurrence of the tumor. It was not until perhaps the 1970s that surgeons began to accept the systemic nature of the disease and began a series of clinical trials to demonstrate that often more conservative, less physically compromising resections had equal outcomes and less morbidity for the patient. Of course, the introduction of anticancer systemic therapies and the use of these as adjuvants to surgical resection also played an important role.

Today cancer surgery is involved in another period of transition as surgeons evaluate the pros and cons of minimally invasive surgical techniques in the diagnosis and resection of malignancies. Although minimally invasive surgery (MIS) can be traced to 1910 with the first endoscopic surgery in humans performed by Hans Christian Jacobaeus in Sweden,⁶ it was the advent of the computer chip television camera in the 1980s and the ability to view the operative field on a monitor that were foundational to rapidly advancing this new era of surgery during the next several decades.

In 1987, the first laparoscopic cholecystectomy was performed by Phillipe Mouret in France.⁷ Since then, technical advances and instrumentation have propelled the field into a highly competitive surgical technology and expanded its application to encompass a list of procedures involving the chest, heart, abdomen, and pelvis. Today, MIS, including robotic surgery, is being applied to the primary resection of tumors of the colon, rectum, and prostate, female pelvic malignancies, gastric cancer, lung cancer, and esophageal cancer. The benefits of MIS are smaller incisions, decreased postoperative pain, decreased risk of infection, better cosmesis, shorter hospital stays, and significantly reduced convalescence. In today’s health care market, these advantages are popular among surgeons, patients, hospital administrators, and insurance companies. The questions have been whether resection for cure is compromised using an MIS approach and whether there is a risk of cancer cells seeding the port sites or other areas of resection.

The Surgical Oncologist

Surgical oncology, as a subspecialty of general surgery, has emerged to play an increasingly important role in the multidisciplinary treatment of cancer (Box 25-1). There are many reasons for this evolution of subspecialization within general surgery, but the most significant are: (1) the increasing complexity of multidisciplinary cancer care; (2) the opportunities for clinical and laboratory investigation of cancer’s complex biology; (3) the rapid increase in the number of medical and radiation specialty boarded oncologists, which threatens to diminish significantly the traditional role of the surgeon in coordinating the management of cancer care for patients (even those with early disease); and (4) the expectation of patients that surgeons have the latest information and understand the newest treatment options.⁸

Today the surgical oncologist is really a “cancer physician” who interacts with all other members of the cancer therapy team in a knowledgeable and confident manner (Box 25-2). This role requires a sound knowledge of cancer biology (including cancer prevention and the biology of metastasis), imaging technologies, chemical and biological therapy, and radiation therapy.

In a 1996 address before the American College of Surgeons, Murray Brennan of Memorial Sloan-Kettering Cancer Center in New York stated, “In defining what might be considered the role of the surgeon in cancer care, there are at least seven important areas that I believe need to have renewed emphasis.”⁹ Brennan used his experience with soft-tissue sarcoma to illustrate the importance of the following performance objectives for the cancer surgeon: (1) understands etiology and genetic predisposition; (2) understands prognostic factors and natural history; (3) performs cost-effective treatment; (4) develops clinical trials; (5) guides advanced disease management; (6) guides compassionate support; and (7) evaluates outcome. Brennan’s analysis of the cancer surgeon’s role as a member of today’s therapy team is an excellent real-life description of the responsibilities involved and the opportunities to provide real leadership in cancer care. These principles remain just as true today as when Dr. Brennan first spoke of them in 1996.

The surgical oncologist often provides the leadership for cancer care, cancer research, and cancer teaching within the academic or hospital-based surgical community. This role is extremely important, and it has become increasingly clear that programs that emphasize strong cancer leadership from surgical oncologists have developed solid research and clinical programs for patients seeking cancer treatment.

The general surgeon and/or specialty trained surgical oncologist is most often the one involved in the early stages of cancer diagnosis, an ideal position for providing significant institutional leadership in developing community interest in cancer prevention, including screening and early diagnosis.

In addition to community responsibilities, much ongoing work in national clinical trials depends heavily on surgical oncology leadership directed at establishing quality control of the surgical aspects of multidisciplinary protocols. Cancer surgeons have historically provided significant leadership in the conduct of clinical research, in designing clinical trials, and in maintaining control of the quality of surgery when it was part of the study. Standardizing and maintaining the quality of surgical intervention has proved especially important in evaluating studies of adjuvant therapy.

When surgery is part of the therapy being evaluated in a clinical trial, it must be performed in a uniform way by surgeons specifically trained and competent to deliver the procedure in a quality and consistent manner.

The most effective weapons against cancer are prevention and early detection. Much of the debate about prevention has focused on the cost of delivering cancer prevention and screening services and the availability of enough adequately trained individuals to perform the appropriate screening test. Furthermore, the application of a screening test is a complex process (Box 25-3), and multiple layers of evaluation are needed to prove test efficacy. Clearly, a screening test must be applied at the right time and to the appropriate population to be effective. Moreover, the screening test itself is merely designed to identify a possible condition that needs further in-depth evaluation. For the surgeon, the effectiveness and cost of screening are directly related to the strategies used to address positive test results, including the rate of false positive results for a screening test. An example of the problem of false-positive results is seen in the use of computed tomography (CT) screening for lung cancer.