The past twenty-five years have seen a drop in deaths from cancer, particularly in the last half of that period. The changes in surgical oncology have been primarily fostered by two thrusts: prospective integration of irradiation and medical therapies for treatment of the primary cancer, and less morbidity from the surgical procedure itself. Breast cancer, soft-tissue sarcoma, and rectal cancers each illustrate the remarkable diminution in morbidity that can be accomplished when surgery to eliminate the apparent gross tumor is combined with irradiation with or without chemotherapy to sterilize microscopic regional tumor. This approach has been combined with more refined surgical techniques (eg, total mesorectal excision), and the goal—no residual deficit from the cancer or from its treatment—is moving steadily from ideal to reality.
The progress in hepatobiliary surgery techniques has been complemented by advances in anesthesiology and critical care; the threat of mortality from operations that, 25 years ago, were often avoided for all but the healthy young has been drastically reduced. Today the resections of hepatic tumors or metastases, biliary cancers, and pancreatic malignancies are safely undertaken in centers of excellence for all but the most frail. The increasing use of minimally invasive techniques, sometimes with robotic instrumentation but often without, has diminished the early cosmetic effects of the surgery. For thoracic neoplasms as well as intra-abdominal procedures, there appears to be a more rapid recovery, although the overall extent of benefit is still being quantified. The rapid introduction of ever-more minimal incisions continues to modify surgical approaches to cancer.
Morton’s introduction of sentinel lymph node biopsy has had a drastic effect on the approach to both melanoma and breast cancer: the ability to limit nodal dissections to those with involvement of the lymph nodes was dramatic by itself. Further refinements allow maximal staging information for planning chemotherapy and radiation and may increasingly identify node-positive patients who need not have nodal dissections with their attendant morbidity. For those who still require node dissections, refined techniques of anatomic limitation of dissection and sparing of traversing sensory nerves can greatly reduce morbidity.
In the past 25 years, neo-adjuvant therapy has been utilized increasingly in oncologic surgery. It has the two-fold advantage of shrinking many tumors to allow more conservative resections in conjunction with irradiation, and identifying those patients whose tumors fail to respond to chemotherapeutic combinations that have proven superior in adjuvant population trials. New trials of approaches to these resistant tumors will be a key area of ongoing investigation. Wonderful as the halving of recurrence by adjuvant therapy may be, we must now turn to look at “the other half.” As genomic and proteomic dissection of individual neoplasms redefine the classification of malignant and pre-malignant conditions, new biologically based agents are being produced. Neo-adjuvant trials such as “I SPY” and “I SPY2” allow the rapid screening of new agents that may contribute to such advances, although they are tools for discovering rapid response, not protracted improvement.
Much of the progress in the last quarter-century has resulted from a combined assault on the primary tumor with contributions from each discipline working together. This has been exciting. However, the “abandoned child” has been the problem of metastatic disease. This has been left to our colleagues in medical oncology to cope with, and they call for help from the other disciplines as needed. It may be time to bring the effectiveness of cooperative, prospective treatment planning to this population. Another area that is now opening up is the use of surgical or radiation interdiction of cancer before it becomes invasive, and this poses new challenges in the balance between over- and under-treatment that will require a new generation of clinical trials to address.