Cancer Management: A Surgical Perspective
From time memorial surgeons have played a significant role in the management of cancers. Drugs generally have been only able to prolong lives of patients with advanced refractory cancers an average of 2.7 months (1). Interestingly the advance of cancer immunotherapy resulted in a group of patients effectively cured of advanced cancers with the flattening of survival curves (2,3).
Surgery and surgical oncologists however remain relevant in cancer treatment. In Singapore cancer registry, the main cancers here for the males are lung, colorectal and prostate cancers. For females, they are breasts, colorectal, cervical and ovarian cancers. In all of these, surgeons play an important role in either the diagnosis and/or the definitive treatment for these tumors. At the leading cancer centre in the world, Memorial Sloan Kettering Cancer Center, 20,000 surgical operations are performed a year for cancers (4). In 50% of these, surgery is the only treatment for the cancers and in 70% surgery formed part of the overall treatment.
Thus surgical oncologists are critical in the management of cancers. It however begs the question – is there such a creature in the era of subspecialisation. Is he a complete surgeon? Is he/she someone with advanced degrees in oncology or worse viewed as a technician on behalf of medical and radiation oncologists.
Who is a surgical oncologist?
A surgical oncologist is best defined by his behavior and management philosophy. He is concerned with the diagnosis and treatment of primarily solid tumors. He participates in a multidisciplinary setting in the management of his patients with cancers. Perhaps his is best identified as a clinician with a deep understanding of cancer biology.
Understanding of cancer biology helps to define principles that guide the surgical oncologist. Principles includes :
- Tissue diagnosis before treatment. A suspected cancer may turn out to be a benign tumor or inflammatory mass. Also pathologist often grade tumors to suggest biological aggressiveness. Tumor types also vary in chemo and radiation sensitivities. Thus the first step in cancer management is a good histopathologist characterizing the tumor.
- Single modality treatment especially for early stage cancers. This is especially so for cancers of the larynx and oral cavity. We expect a very high cure rate and therefore additional treatment with other modalities will only increase the complication rates without improving the survival rates. This is best exemplified in well differentiated thyroid cancers where the 20 year survival rate can be up to 99%.
- The quest for radicality. One of the most important determinants of local recurrence and overall survival is the adequacy of surgical margins. Cancer resections should ensure the surgical margins are all clear. The surgical clearance should at least be 5 mm. There is hardly any situation where radiation in the postop setting can adequately compensate for insufficient surgical clearance. In many situations, tumors transgress traditional anatomical boundaries and surgical oncologists should be comfortable in enbloc resections (Fig 1,2,3)
- Multimodality treatment has become very important for the treatment of many solid tumors especially those in advance stage. clinical trials have demonstrated that adjuvant and neoadjuvant treatments for cancers of the head and neck, breast, stomach, rectum etc confer survival advantage. Tumors that keep recurring locally are also consideration for multimodality treatment (Fig 4,5,6)
- Surgical practice based on the understanding of anatomy and physiology. Patients with extensive nodal bilateral metastases from thyroid or mucosal head and neck cancers will often require bilateral radical neck dissections. Clearly such patients cannot have at the same sitting removal of both internal jugular veins because of inevitable brain and laryngeal oedema. Hence conservation of at least one internal jugular vein is important likewise doing the neck dissection the 2 phrenic nerves been damaged because patients become respiratory cripples otherwise (Fig 7,8,9)
- Conservation surgery but not conservative surgery. Understanding anatomy and physiology and also pathology will allow us to do organ and functional conservation. Voice conservation is especially important in patients suffering from laryngeal cancers. In most instances we would use radiation therapy upfront in order to preserve function. However patients do recur after radiation. In some of such patients especially if the recurrence is detected early there is still an opportunity for partial laryngectomies preserving voice albeit of lower quality (5,6), (Fig 10,11,12,13).
- Quality of life is an important part of assessment for a surgical oncologist. Limb conservation where a patient would otherwise have required amputation is important in maintaining good quality and addresses the very strong cultures of certain communities of keeping the bodies intact even at demise (Fig 14,15,16, 17, 18). In other situations, recurrent cancers in the abdomen give rise to intestinal obstruction and ascites, both of these conditions are often palliated with appropriate surgery of intestinal bypass or peritoneal venous shunts respectively.
- Innovative techniques. Surgical oncologists embark on technical excercises in the attempt to eradicate the disease eg enbloc resection of tumours including removing major vessels (7). In other instances, we do peritectomies and cytoreductive surgeries for otherwise incurable peritoneal disease without extraabdominal spread (Fig19,20,21,22). Such operations have allowed patients to have significant 3 year survival especially for peritoneal mesotheliomas and pseudomyxoma peritonei (8)
- Practice of evidence based medicine and in some cases to generate the evidence for the scientific basis of practice (9).
- Lastly surgical oncologist should work in an environment supportive of academic pursuits including support or conducting basic translational or clinical research.
A Specialist’s Point of View – Written by Prof. Soo Kee Chee
Prof. Soo Kee Chee started his own surgical practice in Farrer Park Hospital and Farrer Park Medical Centre with an interest in surgical oncology and head and neck surgery.
After his medical and surgical training, Prof Soo returned to Singapore General Hospital in 1988 and has been there since. In 1993, Prof Soo became Head of the Department of Surgery in Singapore General Hospital and held that position for 11 years. He was for a period Chair of the NUS Department of Surgery.
In 1997, Prof Soo became the Founding Director of the National Cancer Centre Singapore and recently retired from that position after 20 years. He was also the Senior Vice Dean of Duke NUS Medical School and now continues to hold the Benjamin Sheares Professorship in Academic Medicine.
Prof Soo Khee Chee studied medicine in the university of Singapore graduating in 1975. He did his surgical training in Sydney and then had his fellowship training in surgical oncology and head and neck surgery in London and New York.
Soo Khee Chee Surgery
(Surgical Oncology/ Head & Neck Surgery)
1 Farrer Park Station Road ,
10-09 Connexion, Farrer Park Medical Centre
Tel: 6443 3238