The Kindest Cut
Before undergoing surgery, cancer patients should look for experienced surgeons, get second opinions and ask about the risks and benefits.
By Stephen Ornes
Jessica Martin, a full-time college professor, was midway through a busy year as president of the parent-teacher organization at her children’s elementary school when she began experiencing persistent stomach pain, constipation and diarrhea. A visit to a gastroenterologist in March 2013 led to a diagnosis of irritable bowel syndrome, brought on, the doctor said, by a stomach virus and an overtaxed immune system. He recommended a gluten-free diet for the then 38-year-old mother of two.
When Martin’s symptoms worsened despite changes to her diet, she returned to her doctor and insisted that they keep looking for answers. The doctor suggested a colonoscopy, which revealed a mass in her sigmoid colon. Additional scans showed metastatic lesions on her liver, and she was diagnosed with stage IV colorectal cancer in April 2013.
In early May, the Denver resident underwent emergency surgery to remove the tumor, which was obstructing her bowel, and part of her colon. After the operation, Martin met with an oncologist, who told her she wasn’t a candidate for surgery to remove the liver metastases. Instead, he recommended chemotherapy, starting immediately, to try to shrink the liver tumors.
Before Martin agreed to the treatment plan, her husband did some research on her condition. The couple learned that only about 10 percent of patients with stage IV colorectal cancer live five years or longer. They concluded that additional surgery to remove the liver metastases, combined with chemotherapy, offered the best chance for Martin to be declared NED, meaning no evidence of disease. Martin decided to seek a second opinion about whether more surgery was a good option.
“I wasn’t ready to settle my affairs,” she says.
Surgery, alone or with other treatments, has long played a central role in treating cancer. For many patients with localized solid tumors, such as early-stage cervical, skin or lung cancer, surgery may mean they can live the rest of their lives cancer-free. But once cancer has spread to other parts of the body, the decision to operate becomes more complicated. Some oncologists take a dim view of surgery at this point because they believe the risk and negative impact outweigh the survival benefit.
“The most important thing is recognizing when we should and shouldn’t be operating on patients,” says surgical oncologist Jeffrey Drebin, chair of the department of surgery at Memorial Sloan Kettering Cancer Center in New York City.
An Effective Cancer Therapy
More than 2,000 years ago, Hippocrates wrote that surgical treatment of cancer usually leads to a speedier death and that avoiding surgery was the best way to prolong life for people with cancer. Today, experts agree that surgery can mean long-term survival for many patients, especially in the early stages of their disease.
“Surgery is the most effective cancer therapy in history,” says Kelly McMasters, a surgical oncologist at the University of Louisville in Kentucky and president of the Society of Surgical Oncology. “The majority of patients with solid tumors who are cured of their cancer are cured because a surgeon cuts the cancer out.”
For early-stage cancer, surgery entails removing as much of the tumor as possible and often all or part of the organ where the tumor originated. The surgeon may also remove surrounding healthy tissue and nearby lymph nodes to check whether the cancer has spread through the lymphatic system.
“The goal is to get every last bit of cancer while doing as little harm to normal tissue as possible,” says Drebin.
Although traditional open surgery is still widely used, less invasive techniques are also available for some cancer patients. For example, laparoscopic surgery, which uses narrow tube-like instruments, tiny cameras and other tools inserted through small incisions, may be an option to find out the stage of cancer or sometimes to remove masses, such as gynecologic and gastrointestinal tumors. Some hospitals and cancer centers offer surgery performed by a minimally invasive, human-guided robot that can remove tumors from a variety of sites, including the pancreas, gallbladder, liver and ovaries. Cryosurgery, which may be an option for patients with some precancerous conditions and cancers of the eyes, skin or prostate, destroys abnormal cells by freezing them. Laser surgery uses focused beams of light that burn off localized gynecologic and colorectal tumor tissue. Some researchers are exploring surgeries that don’t require an incision at all, with entry to the body through the mouth or rectum.
Yet new techniques have important limitations. For example, laparoscopic surgery may not be an option for large tumors. In addition, patients who have had surgeries in the past may have scar tissue that can make laparoscopic or laser surgery difficult, if not impossible. Clinical trials using robotic surgery have not shown increased patient survival over open surgery.
The goal of new techniques is to safely minimize pain, speed up recovery times and reduce the risk of postoperative side effects associated with more invasive procedures, McMasters says. “There are a lot of people trying to push the envelope to figure out how to best use the technology, and where it has the most impact,” he says. At the same time, “we have to show that we’re adding value when we do these approaches, and not just cost.”
McMasters would like to see more clinical-trial evidence that demonstrates an improvement using newer methods over conventional surgery or other treatments: “There are plenty of times, in my estimation, that the best way by far to take care of the cancer is a good old-fashioned, open operation.”
Patients should look for a surgeon with experience doing the type of procedure recommended to treat their cancer. “There’s very good data that high-volume surgeons in high-volume settings tend to have the best outcomes in surgery,” Drebin says. He recommends seeking out surgeons who work at cancer centers and specialize in treating specific cancer types.