Surgery under-appreciated in cancer care?

11 Mar 2009

It is common knowledge that the three most important approaches to cancer treatment are surgery, radiotherapy and chemotherapy. Of these, surgery is responsible for the largest number of complete cures; if a tumour is small enough, and in an appropriate position, to be removed surgically, and if there are no distant metastases, the prospects for the patient are excellent. Yet in recent years almost all the ‘buzz’ about new advances in cancer treatment has revolved around the pharmacy.

The introduction of a novel anti-cancer drug usually receives extensive media coverage, but the advantages in and the innovative nature of cancer surgery is often ignored. More importantly, surgery has often – relatively speaking – been neglected by the planners and funders of cancer research.

Peter Johnson, the chief clinician at Cancer Research UK, the country’s leading cancer research charity, admits that “research into surgery has declined significantly in recent years”. Cancer Research UK recently published a strategy for 2009-14 that identifies steps necessary to redress the balance of research funding between treatment modalities, particularly in areas of unmet medical need.

Surgery may be something of a victim of its own success. “Cancer surgery has got about as far as it can go in terms of curing people, as it can only cure local disease”, says Justin Vale, a consultant urologist at Imperial College Hospital, London. “Most novel surgical developments in oncology now aim to improve the quality of life for the patient’. Improving patients’ experience, however valuable for them, may be seen as less ‘heroic’ and less fashionable than improving cure rates. Johnson even suggests that this may be one of the reasons behind the relative lack of research funding: “Existing techniques are so successful that surgeons have been reluctant to take the risks necessary to experiment with new approaches.”

Yet even in tumours where the cure rate for surgery has not changed significantly for decades, innovative surgery techniques can make a huge difference to patient outcome. Twenty years ago, for example, most women with breast cancer treated with surgery would be given a full mastectomy: now, lumpectomy, where the cancerous lump and a margin of normal tissue are removed, is far more common. This is a simple example of the trend towards conservative surgery, which aims to remove as little tissue as possible and which is often combined with chemo- or radiotherapy to maximize the chance of removing all cancer cells.

Another, complementary trend is towards minimally invasive “keyhole” or laparoscopic surgery, in which the body is entered, either through a natural orifice, or through a number of small incisions. It involves the use of specialist instruments including fibre-optic probes and tiny cameras that allow the surgeon to see inside the body cavity without a large incision. Laparoscopy can achieve the same results as conventional open surgery, with faster recovery times and improved quality of life. This is still causing some controversy, however; it is not completely clear whether this improved patient experience will always justify what can be significant extra expense, particularly with the newest techniques.

Men under 70 diagnosed with early stage prostate cancer will usually be offered a choice of surgical removal of the prostate gland (radical prostatectomy), radiotherapy or monitoring. Radical prostatectomy is now often carried out laparoscopically, and can now be assisted by robots. Vincent Gnanapragasam is a surgeon at Addenbrookes hospital in Cambridge, a centre of excellence in the UK for this type of operation. “We use the da Vinci robot, which was originally developed within the US defence industry, for minimally invasive radical prostatectomy. The surgeon can sit at a distance from the patient, view a TV monitor and guide the robot to work very precisely deep within the patient’s pelvis”, he says. “The main advantage for us is that the learning curve is less steep than for more conventional laparoscopy and affords excellent close up visualization of the prostate and associated anatomy.”

Both robot-assisted and conventional laparoscopy cause much less blood loss than open surgery and the patients recover more quickly. Some people have said that incontinence and erectile dysfunction are less common after robotic surgery, but this has not been proven in randomized controlled trials. “Clinical trials in this field are complex to design, challenging to recruit to and may need long follow up times to show significant differences”, says Gnanapragasam.

Nevertheless, the first randomized controlled clinical trial of different surgical techniques for treating early-stage prostate cancer has just got off the ground, led by Sir Ara Darzi, Vale and colleagues at Imperial College. This study aims to recruit 200 men who have chosen surgery for their prostate cancer, randomize them between robotic surgery, conventional laparoscopy and open surgery, and follow them post-operatively for two years. “Our first aim is to determine what proportion of eligible men are prepared to enter the trial, rather than choosing the type of surgery they prefer”, says Vale. “Other end points we will consider are duration of hospital stay, general quality of life issues, and continence and potency.”

If this study is successful the group will move on to a full scale Phase III trial which will follow patients for long enough to test for differences in cancer recurrence rates. “Most men given surgery for prostate cancer will be still alive 10-15 years later, so mortality is unrealistic as an end point. Instead, we aim to monitor cancer recurrence using PSA (prostate specific antigen) levels. Any measurable PSA level after a radical prostatectomy indicates recurrent disease.”

Laparoscopy is now also commonly used in colorectal cancer, where it is considered appropriate for about 95% of planned operations. This operation was quite slow to catch on in the UK, where for a long time it was considered that, as cancer outcomes were similar, the undoubted advantages in quality of life did not justify the complexity and additional expense of the operation. Robin Kennedy of St. Mark’s Hospital in London has been doing laparoscopy for colorectal cancer since the mid-90s. “The main benefit to the patient is reduction in hospital stay; keyhole surgery alone can reduce the median stay for from 10 days to seven”, he says.

He has also been investigating an enhanced recovery programme developed by Henrick Kehlit in the Netherlands. “This has challenged traditional post-operative care in a number of ways, using different methods of pain control and encouraging patients to resume normal activities much earlier with support. Laparoscopy and the enhanced recovery programme together can reduce hospital stay for colon cancer surgery to 3-4 days”, he adds. He is now involved in the EnROL clinical trial, funded by Cancer Research UK, which is comparing length of hospital stay and other quality of life related outcomes for laparoscopic and open surgery when both are followed by the enhanced recovery programme.

These innovations are typical of current research, which aims to improve patients’ quality of life while recognizing that improvements to cure rates are very unlikely. Surgery has, indeed, reached the point when it can cure almost all “suitable” patients: those with accessible, non-metastatic solid tumours. But there is one way in which surgery can help raise the percentage of cancers that are cured, and that has nothing to do with innovations in technique.

Many cancers are only suitable for surgery – and only curable – if they are detected before they have spread. Improving early detection rates will increase surgery’s contribution to beating cancer; by increasing the numbers of patients with tumours that are appropriate for surgery.