Re-Examining Cancer Surgery in the Modern Era: The Way Forward.

Since the origin of cancer surgery there have been only two reasons to take a patient to the O.R.

Curative Intent: The first was curative intent. Surgeons would only engage if they could remove all the disease, leaving nothing behind known as En-bloc resection. If this couldn’t be accomplished, the surgeon would decline reasoning that the patient would undergo anesthesia and the associated risks but still have cancer.  

Alleviate Complications: The second indication was to alleviate life threatening complications like bowel obstruction, spinal cord impingements or brain metastases. In these instances, surgery addressed an urgent need, and curative intent was no longer the indication.

What is Cytoreductive Surgery

Over recent years, there has been a re-awakening of non-curative surgeries. This was pioneered by gynecologic oncologists who conducted upfront chemotherapy, known as neoadjuvant, and then after 3 cycles removed the remaining tumor.

Upon entering the abdomen and pelvis, they knew that there would be residual disease. They were conducting “cytoreductive surgery” to achieve optimal volume reduction before completing the job with chemotherapy. This is particularly attractive in the gynecological malignancies which tend to be very responsive to available chemotherapies.

Other diseases are now being explored for this approach including partial hepatectomy for metastatic colon cancer and re-resections in sarcoma, breast and lung cancers. Although the cancers have spread and there is residual disease, reducing tumor volume can still provide benefit. Again, these surgeries are not curative or palliative but instead offer the opportunity to reduce tumor burden and allow systemic therapy a better chance.

It is now time to advance a new and potentially life-saving indication for surgery; to obtain tissue for Functional Profiling / Ex Vivo Analysis (EVA/PCD) allowing the study of drugs, combinations and targeted agents to achieve maximal response.

Despite the compelling arguments to use tissue for therapy selection, this seems to go against the grain of many physicians, who cannot conceive of surgical procedures in this context. They are simply so accustomed to patients failing treatment that they have largely given up.

Nagourney Cancer Institute is Disrupting How Cancer Treatment is Provided

To address this, we have published that patients who receive the right chemotherapy chosen by the laboratory have a significantly higher chance of response (P <0.001) and survival (P=0.02). This remains true even at the time of relapse.

Unfortunately, randomly selected therapies based on NCCN guidelines cannot provide these benefits leading many physicians to “throw in the towel”. This is not unexpected as a recent update showed that less than 50% of patients who receive NCCN guideline-based treatment respond and that is in the first-line setting. Taken together, modern day oncologists are literally being forced to fail. 

Patients must rethink modern surgical oncology dogma. Cancer patients realize that their best chance of durable remission is the receipt of the right combinations of treatments and targeted agents. Patients must insist that portions of tissue be submitted so that their laboratory analysis can identify the best, most active treatments with the least toxicity.

It is time to introduce an entirely new indication for surgery; procurement of tissue to define the best treatment for each patient. Patient’s lives depend on it.