Surgical Interventions in Cancer

Published on 04/03/2015 by admin

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Surgical Interventions in Cancer

Soroush Rais-Bahrami, Peter A. Pinto and John E. Niederhuber

Summary of Key Points

• The cancer surgeon is a key member of a multidisciplinary cancer care team.

• The surgeon is frequently the “entry point” for patients who are suspected of having cancer or are newly diagnosed with cancer.

• The surgeon must be prepared to communicate the results of initial biopsy pathology and staging to the patient, interpret these results in a meaningful way, and prepare the patient for the next steps in care.

• To be an effective member of the “team,” the surgeon must have knowledge of the biology and natural history of the cancer to be treated.

• The surgeon must be technically experienced in diagnostic procedures and operative interventions used in cancer management.

• The cancer surgeon must be experienced in the preoperative and postoperative care of surgical patients with complex cases.

• The surgical oncologist must have an appropriate knowledge base in medical and radiation oncology.

• Patients treated in a multimodality setting and in high-volume centers have improved outcomes.

• Training of the surgical oncologist must encompass the following:

image Etiology and genetic predispositions of cancer

image Environmental risk factors and natural history of specific tumors

image Knowledge of genomic characterization, subclassification, and current options for highly targeted therapies

image Understanding of how to provide cost-effective treatment

image Skills to develop, conduct, and manage clinical trials

image Guidance in the management of advanced disease, including appropriate nutritional support

image Guidance in offering compassionate support

image Guidance in determining and evaluating outcomes

image Skills in managing complications of treatment and of disease progression

• The surgical oncologist should be a participant in clinical trials, providing guidance in design and monitoring of quality control aspects of the surgical intervention component, as well as providing overall leadership and guidance in the study design and implementation.

• The surgical oncologist should be an educational resource in the health care environment and the community.

• The surgical oncologist plays an important role in prevention and screening.

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.

Surgical Research and New Procedures

Surgeons have been somewhat notorious for the introduction of new surgical procedures and devices without evidence of a random assignment prospective evaluation. Perhaps it is the nature of what we do. We learn from the experience of repeated procedures, and from that experience comes new ideas and new technologies that we believe improve patient outcomes. Although not wishing in any way to hinder this category of innovation, the surgical oncologist often hastens the introduction of evidence-based results in dealing with such new technologies to eradicate tumors, with lesser operative procedures (e.g., sentinel lymph node biopsy, breast-conserving surgery, and limb preservation in managing sarcoma in an extremity), and now with the various approaches to MIS.

Training in Surgical Oncology

Historically, training in surgical oncology occurred at the small number of large stand-alone cancer hospitals in the United States, primarily with the goal of preparing a select group of general surgeons to work as cancer specialists in university hospitals or at large medical centers.

During the 1970s there was more interest in developing the subspecialty of surgical oncology within academic surgery training programs and in obtaining board certification, as had been done for other oncologic subspecialties. This effort, led by several prominent cancer surgeons, encountered considerable difficulties in the ensuing years for many reasons. First and foremost was the practice of surgical cancer care in the community traditionally falling to the general surgeon. Thus the surgical oncologist was viewed as somewhat redundant by general surgical colleagues.

To address some of these issues, a conference was held at the National Cancer Institute (NCI) in 1979. It was the consensus of this conference that training in surgical oncology should involve a 2-year period after completion of a general surgery residency.10 The committee charged a national organization, the Society of Surgical Oncology (SSO), with developing training guidelines, reviewing criteria, and developing the approval process for identifying qualified training programs. Clearly, the hope of those involved was that expertise in surgical oncology could be increased in significant numbers and disseminated more broadly in the community practice arena, not just in academic centers. Further, it was hoped that the development of a number of university training programs would eventually lead to board certification.

Guidelines established by the SSO in 2001 called for 12 months of training in the surgical management of cancer cases, with a minimum number of procedures established for specific anatomic categories. In addition to surgical cases, trainees were required to gain experience in the other aspects of the multidisciplinary management of cancer. Nonsurgical experience was required in radiation oncology, surgical pathology, medical oncology, and supportive and rehabilitative care. Clinical research on human subjects was also part of the training experience, and participation in laboratory research was encouraged.11 By 2012, 14 surgical oncology training fellowship programs had been approved; additionally, 32 SSO-approved fellowship programs had been developed specific to the clinical training of the breast surgeon.

The effort to enhance training in surgical oncology, broaden available training opportunities, and provide a measure of qualification or certification of competence has been supported and nurtured by the SSO, which was founded in 1940 as the James Ewing Society.12 This organization has become the leading academic oncologic society for surgeons around the world. In assuming this leadership role, the SSO developed and disseminated optimal guidelines for the multidisciplinary care of patients with cancer, provided an important resource for continuing education through its annual meeting, initiated and supported a monthly journal (The Annals of Surgical Oncology, founded in 1994), and actively stimulated cancer research.13 The Society has willingly taken on the responsibility of evaluating and approving fellowship training programs. It embraced the recommended guidelines proposed by the 1979 NCI Committee and, in 1982, approved the first three training sites.14 In 1992, the World Federation of Surgical Oncology Societies was inaugurated and immediately worked to develop “standards of education, training, and practice” in surgical oncology.15,16 It is through the efforts of the SSO and the World Federation of Surgical Oncology Societies that excellent training opportunities now exist for a significant number of general surgery graduates. The work of the SSO and its leaders, beginning in 1982 with the approval of three fellowship training sites, recently achieved one of its most important goals when, in March 2011, the American Board of Surgery approved the new certificate in “Complex General Surgical Oncology” and on April 28, 2011, announced the formation of the Surgical Oncology Board.17

Concurrently, the Accreditation Council for Graduate Medical Education and its Residency Review Committee–Surgery began work on the requirements for the surgical oncology training programs. The Accreditation Council for Graduate Medical Education has assumed from the SSO the responsibility for evaluating and accrediting existing and future fellowship programs. This step is truly a milestone in the evolution of surgical training in oncology to ensure the best care for patients with cancer and the best-trained surgical colleagues to work with and complement those certified in medical and radiation oncology. Standardization of the process of review and accreditation ensures that more well-qualified cancer surgeons will be available to serve as experts in cancer care within multidisciplinary teams. The SSO deserves much praise and credit for its untiring and expert leadership in fostering the training of future surgical oncologists.

Although the SSO and other international organizations have taken on a leadership role in surgical oncology education, all surgical oncologists have an educational responsibility and a role in teaching that should extend to their hospital staff, health care students, residents, fellows, colleagues, and the community. The surgical oncologist should have the capacity to develop effective training programs, laboratory research programs, treatment guidelines, clinical trials, and protocols. In addition, surgical oncologists must teach other surgeons and surgical residents how to incorporate oncology principles into their daily practice.

The Surgeon’s Role in Cancer Management

Prevention and Screening

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.