A Century of Surgical Oncology

In the 100 years since the founding of the Commission on Cancer (CoC), surgical oncology has evolved significantly and has been largely driven by research and the advancement of technology. The sheer breadth of oncologic surgeries—including both basic and complex procedures involving a large number of organ sites from brain to bone—make even a cursory review impossible within the scope of a single article.

Because of multiple factors—including, but not limited to, anatomic site, impact on function and collateral organ systems, availability of adjuvant therapies, and disease incidence—the evolution of surgical care has varied across different malignancies. Incidence has been a factor in that it impacts the pace of research particularly for the gold standard of randomized prospective trials. While there are multiple worthy discussions one could have regarding surgical oncology, I have focused on four broad trends during these 100 years

• Anatomic extent of surgical resections
• Adjuvant/neoadjuvant multimodality therapy
• Minimally invasive surgical access
• De-escalation of surgery

Anatomic Extent of Surgical Resections

During the first 60 years of the CoC century, there was a general trend towards more extensive surgical resections predicated upon observations of anatomic extent of cancer spread, particularly to regional lymph node basins. The theory behind the development of increasingly radical locoregional resections was the “Halstedian” concept of cancer spread. These more extensive and elaborate resections would not have been possible without the capabilities to support patients through longer operative procedures and maintain or temporarily supplant insufficient organ system function. Vital to this trend, therefore, were advances in anesthesia, antibiotics, use of blood products, perioperative management, and critical care.

Adjuvant/Neoadjuvant Multimodality Therapy

To the credit of surgeons, we recognized that only small incremental benefits in terms of disease-specific and overall survival were realized by an increase in the extent of surgery and often these were felt unjustified given the increased risks of morbidity and mortality. The sixth and seventh decades of the CoC century saw increased interest and research in the concept of systemic micrometastases and the exploration for effective adjuvant systemic therapies, in some cases initially by surgeons and subsequently in combination with our medical oncology colleagues. Many early research trials had insufficient numbers to demonstrate small but significant benefits of this approach, but over time the accumulation of high-quality research and the use of meta-analysis clearly showed that a large number of solid organ tumors respond systemically to chemotherapy and locally to regional radiation therapy. With the development of effective systemic therapies, enhanced disease-specific and overall survivals and improvements in local control were observed with increased use of multimodality therapy, reducing the need for radical and extended radical surgeries. Landmark studies such as NSABP B-18 explored neoadjuvant systemic therapy and the potential for reduction in volume of local disease, allowing for more defined and limited subsequent surgical resections, was recognized. Examples included breast-conserving surgery, sphincter-preserving low anterior resection after preoperative chemo/radiation therapy for rectal carcinoma, and, in the extreme case, the replacement of most surgical resections for squamous cell carcinoma of the anus by chemotherapy and radiation therapy.

Minimally Invasive Surgical Access

This trend towards “appropriateness” of the extent of surgical resection accelerated with the development of minimally invasive surgical access, initially laparoscopic and subsequently robotic. In the late 1980s, first generation cameras and equipment were insufficient for complex intracavitary surgical resections. However, technological advances and the perseverance of highly skilled and dedicated surgeons had within a decade expanded the boundaries of laparoscopic surgery to include appropriate oncologic resections. There was also a focus on better defining the minimal extent of an oncologically appropriate surgical resection.

De-Escalation of Surgery

The fourth major trend, and the most recent, is de-escalation of surgery, which clearly dovetails with much of what was previously presented. Perhaps the best example of this is the re-introduction, largely in the seventh decade of the CoC century, of lymphatic mapping and sentinel lymph node biopsy in lieu of regional lymphadenectomy. Popularized initially by Morton for melanoma and subsequently by Guiliano, Krag, and others for breast cancer, the hypothesis that the status of a lymph node basin could be predicted by the absence of metastases in the sentinel nodes has been proven for multiple solid organ tumors. Opportunities for de-escalation have been identified by many major medical societies, including the CoC in the Choosing Wisely guidelines published almost a decade ago. These guidelines stipulate the low value of some standard interventions, including surgeries, in specific clinical situations and for certain patient populations. Furthermore, some current research focuses on whether neoadjuvant systemic therapies for specific subtypes of malignancies can replace surgical resection, as with anal carcinoma, and whether in vivo ablation can prove curative.

While this article was initially intended to focus on trends in surgical oncology during the CoC century, it quickly became apparent that one cannot review modern surgical oncology in a vacuum. The Commission is a multispecialty cancer organization that throughout its standards emphasizes and mandates multidisciplinary care. In aggregate these multidisciplinary advances have resulted in improved survival and quality of life for many patients.

Looking Forward

As we enter the second CoC century, what would Halsted think of these trends, including those in which his radical anatomic surgical resections are replaced by surgeries based upon the concept that there is no benefit to the removal of normal tissues? I suspect he would respond as he did when he stated “The Art of Surgery is not yet perfect and advancements now unimaginable are still to come. May we have the wisdom to live with this with grace and humility.”