Surgery for cancer dates back to at least Ancient Egypt. Despite all the advances in drugs for cancer, radiotherapy and other treatments since then, surgery often remains the best chance for a cure. A surgeon can remove a localized malignancy that has not spread. This depends, of course, on detecting the cancer when the malignant cells remain in one place.
Of course, small cancers are easier to remove than larger tumours. Removing a small cancer is less likely to damage the surrounding area and often produces a better cosmetic outcome than an operation for a larger tumour. Surgery can also:
•prevent some cancers, such as when a surgeon removes premalignant tissue;
•repair damage caused by previous operations (such as reconstructive or cosmetic surgery);
•alleviate certain symptoms that might emerge in advanced cancer;
•help treat some recurrences and metastases2 – indeed, occasionally surgery might cure very limited, localized metastases.3
Aims of surgery
Most people with cancer need more than one treatment. Your initial management plan – first-line treatment – might include surgery, chemotherapy and radiotherapy. If the cancer recurs or does not respond adequately, you will move to second-line treatment. If second-line treatment fails, you will move to the third line and so on. The large number of drugs for some cancers means that you could have multiple lines: some women with breast cancer receive 10 or more lines of treatment, for example. In other words, surgery is often one stage in a longer journey.
In many cases, the cancer team will suggest treatment before surgery to shrink the tumour and increase the chance of a good outcome. This could include chemotherapy – for example, for breast or oesophageal cancer – or radiotherapy, such as for rectal cancer.3
Thinking about your treatment
Before starting any cancer treatment you should fully discuss the expected risks and benefits with the cancer team. Learning about the treatment can help you understand the importance of sticking to their recommendations and how to deal with and prevent side effects.
You and anyone who might need to help you should think about how the treatment will fit into your lifestyle. You might need to plan childcare, lifts to hospital and work around your chemotherapy sessions, for example. So learn as much as you can about your treatment. The cancer charities are a great place to start to do this, but you should also ask the cancer team some questions, such as the ones listed below.
•Why is this the best treatment for me at this time in my cancer journey?
•What is the goal of treatment? For example, are we trying to cure the cancer or tackle a particular symptom? Is it an attempt to augment the effectiveness of another treatment?
•How and when will I know that the treatment is working?
•How and when will I know that the treatment is not working?
•What are my goals? What do I want to do after the treatment ends?
•How will the treatment help me to reach my goals?
•What are the risks, complications and side effects? How do these compare to other treatments? (You should think about the type and severity of side effects that you are prepared to accept and which would impose an unacceptable burden.)
•Will the treatment affect my quality of life for better or worse?
•What can I do to reduce the risk of side effects?
•Will I need to change my lifestyle or activities?
•What should I do if I miss a dose?
•Whom should I contact if I have any concerns or questions?
You and your family will inevitably have questions, but remembering everything you want to ask in the short time you have in the clinic can be difficult, so keep a notebook or use your mobile phone to jot down any questions. Feel free to make notes and ask questions during the clinic visits. Taking a friend or relative with you might help you understand what you discussed during the visit and can help refresh your memory.
The cancer team may also use radiotherapy or drugs to mop up any cancer cells that evade the scalpel. For example, using radiotherapy after the operation might allow breast-conserving surgery rather than a mastectomy for a breast cancer.3 After lumpectomy alone, about half (40–60 per cent) of breast cancers recur. A course of radiotherapy after the surgery reduces the risk of recurrence tenfold (4–6 per cent of breast cancers recur). That is about the same risk as if the surgeon had performed more extensive mastectomy,2 but the cosmetic outcome is much better. The cancer team works together to plan the best sequence of treatments for you.
Individualizing treatment
Each cancer in each person is unique, so the cancer team individualizes the treatment plan depending on several factors, including those listed below.
•Your general health, well-being and ability to perform the tasks of daily life The cancer team calls this your performance status. If you are fit and strong, you might be able to tolerate more ‘aggressive’ treatment that may produce more severe side effects and complications, but offers a better chance of a good outcome, than someone who is more frail.
•Your goals, plans and attitudes Some people with metastatic cancer trade a few weeks or months of expected survival for what they see as a better quality of life if that means, for example, they do not experience some side effects. For instance, some men with metastatic prostate cancer are very concerned about losing sexual function, a common side effect of some treatments for this malignancy. As a result, they may refuse surgery or certain drugs that could increase their survival but might compromise sexual function.
•The site of the secondary tumours and your symptoms Certain cancers, such as certain primary tumours and metastases in the brain, might be unsuitable for surgery.
•The treatments – especially drugs – you have received before Cancers can become resistant to a particular treatment, so a drug used to treat the primary cancer might not work as well if it or a similar medicine is used to treat metastases.
Ensuring that you receive the right treatment at the right time is one reason why it is so important to have a full and frank discussion with your cancer team before you embark on a course of therapy. You should explore the uncertainties. So if a doctor says you will gain an expected year of life, you might benefit more or less than this. You might not develop the expected side effects or they might be unexpectedly severe. A surgeon cannot guarantee to cure a cancer and will speak instead about ‘curative intent’.
The intention of treatment
The intention of treatment might differ depending on the stage of the cancer and your performance status. The cancer team might refer to:3
•radical treatments, which aim to cure the cancer;
•palliative treatments, which aim to control symptoms, extend life or both when a cure is unlikely;
•neoadjuvant therapies, which use drugs to reduce the size of the tumour before radiotherapy or surgery;
•adjuvant therapies, which use drugs after radiotherapy or surgery to try to mop up any remaining small tumours and circulating cancer cells and radiotherapy can also be used as adjuvant therapy following an operation, as we saw with breast cancer;
•debulking, which is when the surgeon removes as much of the cancer as possible, but knows that some malignant cells remain (hence ‘debulking’), and the person receives chemotherapy or radiotherapy to remove the rest of the cancer; as such, debulking:
–increases the chance that the chemotherapy or radiotherapy will kill all the cancer cells;
–can alleviate symptoms of advanced cancer and increase survival.
Preventative surgery
Some people undergo surgery to remove ‘precancerous’ lesions, such as small masses of cells called polyps in the stomach or intestine (lesions are areas of cells damaged by disease or injury). Some polyps can develop into gastrointestinal cancer. Similarly, surgeons remove abnormal, precancerous areas of the cervix to prevent cervical cancer.
In addition, some people with a strong family history of thyroid, breast or ovarian cancer might decide to have the potentially affected organ removed.2 Increasingly, the cancer team can screen to see if you carry the genes responsible for some cancers. For instance, four relatively common genes – BRCA1, BRCA2, CHEK2 and FGFR2 – increase the risk of breast cancer as well as some other malignancies. Four-fifths (80 per cent) of women with one of these genes develop breast cancer, while up to three-fifths (60 per cent) develop ovarian cancer.2 Some women at high risk decide to have their ovaries or breasts removed to avoid any risk of cancer. Some of these would have never developed the cancer, however, so the operation and the resulting cosmetic and clinical issues were unnecessary. It is a very difficult, very personal decision.
Reconstructive surgery
Often a surgeon aiming to cure a cancer will remove the tumour along with a surrounding ‘margin’ of healthy tissue and any nearby lymph nodes.2 This helps ensure that the procedure removes any cancerous cells that have moved into the surrounding area, but surgeons need to strike a careful balance. The more healthy tissue they remove, the greater the potential effect on normal function and, in some cases, the worse the cosmetic appearance.3
Reconstructive surgery repairs damage from an operation to remove the cancer or because the malignancy affected a visible part of the body. Advances in cosmetic surgery mean that most people can achieve a good appearance, often despite extensive operations. People with cancer might undergo cosmetic procedures to improve appearance, reduce the psychological burden and enhance quality of life. The best-known example is probably breast reconstruction using, for example, implants, tissue taken from elsewhere in the body or both.3
In other cases, reconstructive surgeons might take a flap of skin from, for example, the forearm to repair damage to the face following surgery for head and neck cancer or after an operation to remove a skin cancer in a visible area. The surgeon can replace a lost area of the tongue with a flap of skin, for example. This helps restore speech and swallowing as well as improving the cosmetic appearance. Surgeons can also make tubes from tissue taken from elsewhere in the body, to replace a removed oesophagus (food pipe), for instance.3
Helping people with advanced cancer
Surgery can also help alleviate symptoms in advanced cancer. For example, a tumour might block the intestine and, in many cases surgery can relieve the blockage. Surgeons might insert a feeding tube, if you are having difficulty eating, or implant a plastic or metal stent. A stent is a mesh-like tube that can hold open a blocked bowel, food pipe, airway or ureter (carries urine from the kidneys to the bladder).2
Surgery can treat some metastases that develop in the skeleton. These secondary bone cancers can cause pain, increase the risk of fractures and hinder normal living.3 About half of people with metastatic cancer develop a pleural effusion, in which excess fluid accumulates around the lungs. Surgeons can drain the excess fluid.3
Before the operation
The operation, associated risks and possible consequences depend on, for example, the cancer, the operation, your particular symptoms and your performance status. So speak to your cancer team and check out the information provided by patient support groups. For example, during surgery for bowel (colorectal) cancer, the surgeon removes the section of the gut containing the tumour, then joins the ends together. In some cases the surgeon passes one end of the gut through the wall of the abdomen to allow the bowel time to heal (a colostomy). The person passes bowel motions into a colostomy bag. Occasionally, the colostomy is permanent.
In breast cancer, the team will discuss the various procedures – such as breast-conserving surgery, mastectomy and reconstruction – to decide which is right for you. In head and neck cancer, a speech and language therapist should discuss the possible effect on speech and swallowing.3 You might also receive supportive treatments, such as antibiotics to prevent infection or drugs to reduce the risk of venous thromboembolism.3 If you need major gastrointestinal surgery, you might receive carbohydrate-rich drinks and nutrients that boost the immune system.3
You might also take nutritional supplements after the operation, especially if you find you are off your food or have difficulty swallowing. These help your body repair the damage from the operation. Some antioxidants – such as vitamins C and E, zinc, selenium and copper – can improve wound healing, for example.53
Venous thromboembolism
In a venous thromboembolism, a blood clot can form in a vein (a blood vessel that carries blood back to the heart). Fragments of this clot can break off, forming an embolism – the word derives from the Greek for throw – that can travel to and block arteries supplying the brain, causing a stroke. Similarly, emboli in an artery supplying the kidney can cause part of this essential organ to die. Emboli in a major vessel supplying the legs can cause gangrene.54 A fragment that travels to the lungs can cause a blockage called a pulmonary embolism. A large pulmonary embolism can stop the supply of blood to the lung, which can prove fatal.55
Reducing the risks of surgery
Advances in surgery have markedly improved the prospects for people with cancer. For example, laparoscopic (keyhole) surgery limits collateral damage to the body. This reduces the need for strong painkillers after the operation, hastens recovery and lowers the risk of complications. Laparoscopic approaches might be appropriate for some breast, colorectal, gynaecological and lung cancers, depending on the size and location of the tumour. Unfortunately, laparoscopic surgery cannot always be used.3
Increasingly, surgeons use computer and robotic assistance to further limit collateral damage. For example, during brain surgery, a computer can use imaging data to display the location of the tumour and the instruments as a three-dimensional map on a screen. During robotic surgery, the system can translate the surgeon’s movements into smaller, more precise actions at the end of the surgical implement. This allows incredibly delicate procedures, such as removing all or parts of the prostate gland, which is surrounded by a large number of important nerves.3
In the early days of breast cancer treatment, surgeons removed all the breast and the underlying tissue, often along with the chest muscle and sometimes even some ribs.17 Today, surgeons, working as part of the multidisciplinary team, can limit damage to the surrounding tissue while maximizing the outcome. New medicines for cancer often capture the headlines, but advances in surgery have also helped to markedly improve the prospects for people with cancer and helped save countless lives.