Treating cancer: when is surgery the best option

Surgery, in the context of oncology, primarily aims to remove the cancerous tumor and a surrounding margin of healthy tissue (known as a “clear margin” or “negative margin”) to ensure all malignant cells are excised. This approach is rooted in the understanding that for many cancers, the disease begins as a localized lesion before potentially spreading to distant sites (metastasis).

Primary Treatment (Curative Intent)

For many early-stage solid tumors, surgical excision offers the best chance for a cure. This is particularly true for cancers detected before they have invaded surrounding structures or metastasized to regional lymph nodes or distant organs. Examples include:

• Early-stage Breast Cancer: Lumpectomy (removal of the tumor and a small amount of surrounding tissue) or mastectomy (removal of the entire breast) are often curative for localized disease.
• Colorectal Cancer: Resection of the affected segment of the colon or rectum for stage I-III disease can lead to long-term survival.
• Non-Small Cell Lung Cancer (NSCLC): For resectable stage I or II NSCLC, lobectomy (removal of a lung lobe) or pneumonectomy (removal of an entire lung) can be curative.
• Skin Cancer (Melanoma and Squamous Cell Carcinoma): Excisional biopsy with wide local excision is the primary treatment for localized melanoma and often curative for squamous cell carcinoma.
• Prostate Cancer: Radical prostatectomy (removal of the prostate gland) can be curative for localized prostate cancer.

The success of curative surgery is largely dependent on achieving a complete (R0) resection, meaning no cancer cells are detected at the margins of the removed tissue under microscopic examination.

Debulking Surgery

In cases where a complete removal of a large or widespread tumor isn’t feasible without causing significant harm to vital organs, surgery may be performed to remove the majority of the tumor (debulking). The goal here is not necessarily a cure but to reduce the tumor burden, alleviating symptoms, improving the efficacy of subsequent therapies (like chemotherapy or radiation), or prolonging life. A prime example is advanced Ovarian Cancer, where optimal debulking surgery significantly impacts survival.

Palliative Surgery

When cancer is advanced and incurable, surgery can be used to alleviate symptoms and improve a patient’s quality of life. This is known as palliative surgery. Examples include:

• Bowel Obstruction in Colorectal Cancer: To relieve blockages and enable eating.
• Spinal Cord Compression: To decompress the spinal cord and preserve neurological function in patients with metastatic spinal disease.
• Pain Relief: Removing a tumor that is pressing on nerves or causing significant discomfort.
• Bleeding Control: To stop intractable bleeding caused by a tumor.

Reconstructive Surgery

Following definitive cancer surgery, reconstructive procedures may be necessary to restore function or appearance. This is common after head and neck cancer resections, breast cancer mastectomies, and certain bone or soft tissue tumor removals.

The decision to proceed with surgery is highly individualized and involves a multidisciplinary team of specialists (oncologists, surgeons, radiologists, pathologists). Key considerations include:

1. Cancer Type and Histology

Not all cancers are suitable for surgery. Hematological malignancies (leukemias, lymphomas, myelomas) originate in the blood or bone marrow and are systemic diseases from the outset, making surgery generally ineffective as a primary treatment. Similarly, diffuse cancers, such as certain types of stomach cancer that spread through the stomach wall rather than forming a solid mass, are often not amenable to surgical cure. Surgery is most effective for solid tumors with well-defined boundaries.

2. Stage of Cancer

This is perhaps the most critical factor. * Early Stages (I and II): For localized disease, surgery is often the primary and potentially curative treatment. The absence of nodal involvement or distant metastasis makes complete resection more achievable. * Locally Advanced Stages (III): Surgery might be combined with other treatments (neoadjuvant therapy before surgery to shrink the tumor, or adjuvant therapy after surgery to kill residual cells). For instance, in locally advanced rectal cancer, neoadjuvant chemoradiation is often given before surgery to improve surgical outcomes and reduce recurrence. * Metastatic Stages (IV): Generally, surgery is not curative at this stage as the cancer has spread. However, it may be used for debulking, palliation, or in highly selected cases of oligometastatic disease (a limited number of metastases) where surgical removal of both the primary tumor and metastases may be considered (e.g., liver metastases from colorectal cancer).

3. Tumor Location and Size

The location and size of the tumor profoundly impact surgical feasibility and safety. Tumors located near vital structures (major blood vessels, nerves, organs like the brainstem or spinal cord) may be deemed “unresectable” if their removal would cause unacceptable damage or functional loss. For instance, a small lung tumor on the periphery is easier to remove than a large tumor encasing the aorta.

4. Patient’s Overall Health and Comorbidities

A patient’s fitness for surgery is paramount. Oncologic surgery can be extensive and demanding. Factors such as cardiovascular health, lung function, kidney and liver function, nutritional status, and presence of other chronic diseases influence the ability to withstand anesthesia, the stress of the operation, and the recovery period. Frail or severely ill patients may have higher surgical risks, leading the team to consider less invasive or non-surgical options.

5. Potential for Complete Resection (R0)

The primary goal of curative cancer surgery is to remove all visible and microscopic cancer cells. If imaging (CT, MRI, PET scans) suggests that a complete (R0) resection is unlikely without causing severe morbidity, surgery might be deferred in favor of systemic therapies or local radiation. Pathological examination of the resected tissue confirms whether clear margins were achieved.

6. Availability of Alternative Effective Treatments

When equally effective non-surgical options exist, or when surgery carries significant risk, a less invasive approach might be favored. For example, some early-stage prostate cancers can be managed with active surveillance or radiation therapy, offering similar outcomes to surgery but with different potential side effects.

Modern oncology surgery has evolved significantly, incorporating advanced techniques to improve precision, reduce invasiveness, and enhance patient recovery.

• Minimally Invasive Surgery (MIS): Techniques like laparoscopy and robotic-assisted surgery involve smaller incisions, leading to less pain, shorter hospital stays, and faster recovery. These are now common for colorectal, gynecological, prostate, and some lung cancers.
• Image-Guided Surgery: Real-time imaging helps surgeons precisely locate tumors and critical structures, improving resection accuracy.
• Sentinel Lymph Node Biopsy: For cancers like breast cancer and melanoma, this procedure identifies the first lymph node(s) to which cancer cells are most likely to spread, avoiding the need for a full lymph node dissection in many cases, thereby reducing complications like lymphedema.
• Intraoperative Radiation Therapy (IORT): A single, high dose of radiation delivered directly to the tumor bed during surgery, often used for breast cancer or sarcomas, to target any microscopic residual disease.
• Hyperthermic Intraperitoneal Chemotherapy (HIPEC): For select abdominal cancers (e.g., ovarian, appendix, mesothelioma), heated chemotherapy is circulated within the abdominal cavity immediately after surgical tumor removal to kill remaining cancer cells.

Surgery stands as an indispensable pillar in the multifaceted treatment of cancer. Its role is most dominant and potentially curative for early-stage solid tumors, where complete tumor removal can lead to long-term remission or cure. Beyond primary treatment, surgery also plays vital roles in debulking advanced disease, providing palliative symptom relief, and aiding in diagnosis and staging. The decision to recommend surgery is never made in isolation but is the result of careful consideration by a multidisciplinary team, weighing the cancer’s characteristics against the patient’s individual health profile and the potential benefits versus risks. As surgical techniques continue to advance, offering more precise and less invasive options, surgery will remain at the forefront of effective cancer management.