3.1 Surgical Treatment of Cancer

Slide 1
Hello, I’m Ana Shaw and I’m going to give an introduction in the surgical treatment of cancer.

Slide 2
Surgeons are involved in a variety of places in the cancer care of patients. Surgeons are involved in diagnostic techniques, staging and severity of cancer patients, the treatment of cancer patients, and in multidisciplinary care/coordination of care among different physicians and the care of the patient.

Slide 3
Surgeons are often seen as the gatekeepers for patients who have cancer. Patients who find a mass might often present to the surgeon’s office and the surgeon then must ask, what’s the risk for malignancy? What is the most appropriate diagnostic technique? Can I use a different type of biopsy and will that biopsy change my management in that patient?

Slide 4
For example, thyroid fine needle aspiration [acronym used on slide: FNA] biopsies are often now routinely performed. Many years ago, thyroid patients, when a nodule was found, had to have the nodule resected and if the nodule was removed, only about 14% of those nodules were actually cancer, meaning that 86% of nodules, and patients who had those nodules, had a surgery that they didn’t need. Fine needle aspiration biopsy uses a small needle to remove some parts of the cells of the thyroid nodule leading to a better understanding of the risk for malignancy and a better understanding of how to treat that patient. And in 2007, where there’s widespread use of final aspiration, greater than 50% of thyroid nodules that were resected were cancer.

Slide 5
[table showing thyroid FNA outcomes with associated malignancy risk for each and how they guide treatment decisions, such as observation or surgery]
The reason is, is that the fine needle aspiration biopsy is able to give the surgeon a risk for malignancy, meaning that thyroid nodules can have a low risk or a high risk for malignancy based off of that aspiration biopsy leading to be able to guide the surgeon as to what the management of that patient should be: A repeat biopsy, typical follow-up, all the way up to complete removal of the thyroid gland for cancer.

Slide 6
[two images showing an open surgical biopsy in an operating room and a needle biopsy with an ultrasound]
Similarly, patients who have breast cancer or breast nodules should undergo biopsy. Core needle biopsy of breast cancer allows evaluation of the breast architecture while being less invasive. It can be performed with an ultrasound or mammogram whereas an open surgical biopsy requires an operation and really only five to ten percent of biopsies require surgery.

Slide 7
Breast biopsies, when done by needle or surgical, are drastically different. Core needle biopsies lead to fewer operations and re-operations, less scarring, and less morbidity for the patient. It really facilitates pre-operative multidisciplinary treatment, allows the surgeon to recognize if this is cancer and if other things need to be performed at the time of the cancer surgery, and is really the gold standard for breast biopsy. [core needle biopsy is considered the gold standard] Some areas, however, remain slow to adopt this type of technique including a study recently done in Florida that show up to 30% of patients are still getting open surgical biopsies. Surgical oncologists often think differently about this however and are- often employ the needle biopsy over the surgical biopsy.

Slide 8
Surgical oncologists are also involved in staging of cancer patients. This can be done with scans or with techniques such as sentinel lymph node biopsy.

Slide 9
[three-image panel showing dye injected near a tumor to map spread to lymph nodes and aid removal]
Sentinel lymph node biopsy is a technique where dye is injected near the tumor. The dye then is picked up into the lymphatic system and drains to the most likely lymph node for cancer to spread. Then that lymph node can be targeted during a surgery using special techniques and special machines in the operating room. This can target that specific lymph node and allow that lymph node to be removed at the time of surgery.

Slide 10
[image showing arm swelling due to lymphedema following lymph node removal]
Removing just one lymph node or a couple of lymph nodes as opposed to all of the lymph nodes in an area allows for that important staging information- has the cancer spread to the lymph nodes with, with- decreased morbidity? Such as seen in this woman who has lymphedema.

Slide 11
Evaluation of the lymph nodes allows the surgeon to answer that really important question: “Hey doc what are my chances?” When tumors spread, we have some information about tumors and their behavior and whether or not they’ve spread to the lymph nodes or if they spread to distant metastases allows surgeons to help predict survival in patients. When patients don’t have spread to the lymph nodes, they have a much higher survival over time whereas lymph node involvement presents a lower survival and an even lower survival in patients who have cancer that has spread. So sentinel lymph node biopsy helps answer that really important question of whether or not the cancer has spread and then what is the prognosis.

Slide 12
En bloc resection is really the most important traditional concept in surgical oncology and it’s how surgical oncologists traditionally practice. What it means is to take out the cancer with an edge of normal tissue around the cancer so not just the cancer is removed but lymph nodes associated with it, blood vessels that are associated with it, tissue that surrounds that area. And there’s a well-established benefit for most cancers in performing an en bloc resection the goal is truly an r0 resection which means no cancer under the microscope anywhere at the edges.

Slide 13
[diagram showing that during an en bloc resection for rectal cancer, the rectum and surrounding tissues, and blood and lymph vessels are removed]
That’s demonstrated really nicely in rectal cancer surgery where a total mesorectal excision is performed for rectal cancer. Not just the cancer is removed- the entire rectum and surrounding tissues, including the lymph nodes that drain that area and the blood vessels that supply it. This ensures adequate staging so that lymph nodes are removed as well as the rectum and surrounding tissues.

Slide 14
Now although surgeons perform en bloc resection, the trend is really from initial treatment to less radical surgery.

Slide 15
So, consider a 66-year-old woman with an abnormal mammogram. Her core biopsy shows a breast cancer. What are her options for treatment? What do you want to do?

Slide 16
Cooperative groups help us answer these questions as to how best to treat patients. Perhaps medications should go first or surgery should be performed. Radiation treatments are often employed first in the treatment of cancer patients and really, in order to understand these facets, we need a lot of patients to be able to determine what is best. So many physicians across the country pool their patients and run clinical trials together to answer these questions on what’s the best treatment.

Slide 17
One of the best examples of this is the NSABP B-06 trial. This is the gold standard trial on the treatment of breast cancer and it was a randomized clinical trial for surgical patients. Patients were randomly assigned to mastectomy, lumpectomy with radiation, lumpectomy without radiation and then followed over time. And what the trial found is that the treatment of patients who had a mastectomy was exactly the same as patients who had lumpectomy and radiation: their outcomes were identical. And this trial has stood the test of time and repeated time and time again finding, again, that mastectomy is equivalent to lumpectomy with radiation. The trial also found that lumpectomy with radiation is better than patients who did not have radiation.

Slide 18
[graph showing breast cancer diagnosis rates remaining stable or increasing while death rates decline over time; side-by-side illustration of mastectomy vs breast incision]
What that shows is that patients can have a radical mastectomy with removal of the entire breast and the chest wall muscles and that the outcomes in the correct patients are exactly the same as women who just have a small incision on their breast. All the while that’s seen with patients in the light green line denoting the diagnosis of patients. So the diagnosis of breast cancer patients is largely either the same or slightly increased over time because of the good use of mammograms, while the dark line shows a slow decrease in the death rate for surgery for breast cancer patients. So although we’re performing less radical surgery, we’re actually improving patient survival.

Slide 19
This is largely due to multidisciplinary treatment. We understand the timing of surgery, radiation, and chemotherapy. We ask questions like: What do we do when the cancer comes back? What’s the first treatment? What’s the best treatment for this patient? It allows us to choose the correct therapy and personalize therapy. And really, multidisciplinary treatment reminds us to address those other patient-related issues.

Slide 20
The timing of surgery radiation and chemo is very important in the different types of cancers. So, for small cancers, do you need all these different therapies? Are you able to eliminate radiation in this patient? For marginal cancers, things that are approaching important structures- Can something be done to shrink this cancer? Or in metastatic cancers, is there something that can be given for palliation? This all involves careful planning among members of the treatment team.

Slide 21
Treatment teams often meet in what are called tumor boards. Tumor boards allow for all physicians and other people who take care of the patient to all give support to the patient. Seeing the patient at the center facilitates communication among the team members and often includes people such as physical therapists or geneticists, social workers, psychologists, nurses, and other physicians who are treating the patient.

Slide 22
[images comparing a small tumor in the breast and a large tumor in the pelvis to illustrate cancer variability]
Cancer can be really variable. Cancer can be as small as the small clip seen in the breast cancer patient or the large tumor seen in the pelvis of the patient with a retroperitoneal sarcoma. And what’s different about both of these patients can be combined into a single person who’s able to treat those types of patients and that’s a surgical oncologist. Because surgical oncologists think about cancer and think about the cancer patient and therefore they are able to treat patients with tiny cancers and big cancers.

Slide 23
Putting the cancer patient really at the center of the discussion. And the difference between a surgical oncologist and a general surgeon?

Slide 24
Well, surgical oncologists think about cancer. They have experience that’s more specific to the cancer patient, they get the diagnosis right more often and ask more in-depth pathologic questions. They address diet, exercise, mental health, they test for molecular markers that can guide therapy, they order gene testing more frequently, they have better cancer-related outcomes. And that’s really because they’re thinking about the cancer patient and multi-disciplinary treatment.

Slide 25
So, in summary, surgical oncologists are involved in every aspect of care of the cancer patient. They use several types of biopsies that can help diagnose cancer, they perform cancer staging which can be done through scans or additional types of biopsies like sentinel nodes, and depending on the type and stage of cancer, surgical treatment is often less radical with equivalent or better results. And this is really because of the multidisciplinary care, seeing the patient at the center.