Surgery
If your doctor has reason to suspect that you may have cancer, you are likely to be referred initially to a surgeon. This is partly because, as explained on pages 20–3, some kind of surgical procedure is very often required to make a definitive diagnosis, and partly because surgery is the best treatment or the best initial treatment for many types of cancer. Where cancer is discovered, its extent may also be established in the course of an operation; sometimes this is an important aim of the procedure. Examples include armpit lymph node removal (‘axillary dissection’ or ‘clearance’) for women undergoing surgery for breast cancer, and a thorough inspection of the abdominal cavity (during a ‘staging laparotomy’) for women undergoing removal of ovarian cancer.
It is only understandable that most people will feel nervous about having to have an operation. However, the overwhelming majority of cancer operations proceed very satisfactorily. It is of course inevitable that the results are not always perfect, but it is not feasible to discuss in detail here the possible short- or long-term adverse effects of particular operations, which may vary from relatively minor procedures lasting a few minutes to major undertakings over many hours.
Some operations do of course leave substantial long-term effects on appearance, function or both. Other operations carry risks of certain side effects for some patients, for example arm swelling (‘lymphoedema’) after axillary clearance and impotence after surgery for rectal or prostate cancer. Any such risks will normally be discussed in detail with you beforehand, but if you feel you need more information don’t be afraid to ask for it.
Some patients only need to spend a very short time in hospital afterwards, others two or three weeks or even longer. Some are able to return to a normal lifestyle almost straightaway, whereas others may take some months to recover fully after major operations. Although most patients will feel some discomfort in the period immediately after the operation, they can nevertheless expect nowadays to receive a high standard of postoperative care including very good pain control.
The following are some commonly used surgical terms.
• Resection
The removal of a tumour or organ; words ending in ‘-ectomy’ mean the same thing. For example, removal of a lung lobe containing a cancer may be called a ‘pulmonary lobectomy’ and removal of a cancer-containing prostate gland a ‘prostatectomy’.
• Radical
In addition to cutting out the obvious tumour, this involves the removal of tissue near or connected to the tumour or organ involved, with the aim of doing everything possible to get rid of every last cancer cell.
• Words ending in ‘ostomy’
When one of the body’s internal tubes is blocked by a tumour or when part of it has to be removed, the surgeon may need to bypass the obstruction and create an inlet or outlet by joining the tube to an artificial opening made in the skin (a ‘stoma’ – see below). For example, joining the wind-pipe or ‘trachea’ to the overlying skin is called a ‘tracheostomy’ and may be temporary or permanent, depending on the circumstances. Joining the large bowel or colon to a stoma in the abdominal skin is called a ‘colostomy’. This too may be temporary or permanent.
• Stoma
An artificial opening in the skin to allow the contents of the underlying tube to exit the body. After a colostomy, for example, a bag will be fitted over the stoma to collect the bowel contents, and modern designs enable the great majority of people who undergo this procedure to lead virtually normal lives.
SURGERY FOR CURE
In most cases, the surest way of eradicating a localised cancer is, where possible, to excise it (cut it out) with an adequate margin of surrounding normal tissue. Surgery cannot cure a cancer that has spread to distant parts of the body or when it is not technically possible to remove the cancer completely.
Most cancer surgery is conducted as a carefully planned or ‘cold’ procedure, the diagnosis having already been made with near or absolute certainty. However, a small minority of people are first discovered to have cancer during an emergency operation made necessary by complications of the cancer, such as perforation or obstruction of the bowel. In this situation, the results of surgery unfortunately tend to be rather less good. This is because these tumours are quite often at an advanced stage and also because the person concerned may not be in good general health.
There has been a trend in recent decades towards less radical surgery for some tumours. For example, providing the size and position of the growth are favourable, it may be possible to remove a cancer from a woman’s breast, together with sufficient surrounding tissue (‘wide local excision’), while avoiding the need to remove the whole breast (mastectomy). This operation is then followed up with radiotherapy to the breast to get rid of any remaining microscopic traces of cancer, and the prospects for cure are just as good as with mastectomy. A similar combination of less aggressive surgery and radiotherapy can also be used to treat the much rarer soft tissue sarcomas.
In other situations, however, surgery is more extensive than it used to be. For example, most women with breast cancer now have lymph nodes removed from under their arms, in addition to surgery to the breast itself. This is quite often a thorough removal of all the nodes that can be identified, known as an ‘axillary clearance’ (but see ‘sentinel node biopsy’). Not only can such procedures eradicate any metastases that might be present in the nodes, they can also give useful information about whether or not the cancer is likely to have spread microscopically to other parts of the body. The risk of this increases if there has been spread to the lymph nodes. This knowledge may be used to advise patients about what further treatment they should have.
Some women who have lymph node metastases from breast cancer will have their chance of cure increased significantly by chemotherapy or hormonal treatment.
Surgery has long been known as a potential cure for many people whose cancer has spread to nearby lymph nodes, but there is now growing enthusiasm for surgery for carefully selected patients whose cancer has spread via the bloodstream to a fairly small and removable part of the lung or liver. The chance of success tends to be greater when there is a long interval between treatment of the primary growth and the development of a metastasis. Some liver metastases can be destroyed by heat, ‘radiofrequency ablation’, which involves inserting a probe through the liver tissue into the growth.
SURGERY TO IMPROVE QUALITY OF LIFE
Reconstructive surgery
Considerable progress has also been made in restoring appearance or function after operations to remove cancer. For example, many women who have had a breast removed are now offered surgery to create a ‘new’ breast, either by inserting some form of artificial ‘implant’ beneath the muscle underlying the skin, or by building up a new ‘breast’ using muscle and fatty tissue (a ‘flap’) from the back or lower abdominal wall. The results, although not perfect, are frequently highly satisfactory. They can make a huge psychological difference for those women who understandably find it very difficult to live with the loss of a breast.
Such reconstructive procedures often involve highly specialised surgical expertise. This is sometimes provided by plastic surgeons. As well as contributing to the care of some patients with breast cancer, they perform a very important role in helping to restore appearance and function after major surgery for cancers involving the mouth and throat and other nearby structures. Some reconstructive procedures are done at the time of tumour removal, with the plastic surgeon operating together with the surgeon who removes the tumour. Others may be done some time later.
The artificial material used in any form of reconstructive surgery is known as a ‘prosthesis’. Some people with bone sarcomas of the limbs can now benefit from bone replacement prosthetic surgery after removal of the growth, avoiding the need to amputate the limb.
Palliative surgery
Surgical procedures are also performed to relieve symptoms. Sometimes this is in conjunction with other treatments aimed at destroying the cancer.
Prosthetic tubes or ‘stents’ may be inserted to relieve obstruction caused by a growth. This is often done for people with cancer of the oesophagus. Obstructions within the abdomen are sometimes relieved by ‘by-pass’ operations. Metal prostheses may be inserted into a bone that has been fractured or substantially weakened by a metastatic tumour. This restores strength to the bone and allows a rapid return of normal or near-normal use to the limb. Lasers are sometimes used to bore a hole through tumours obstructing the oesophagus or one of the major air tubes or ‘bronchi’ within the lung. A tracheostomy may be necessary when a tumour is obstructing the voice box or larynx and causing difficulty in breathing.
A tumour that is pressing on the spinal cord can cause leg weakness by interfering with the nerve supply to the muscles. This can sometimes be relieved by partial removal of the tumour by a neurosurgeon or orthopaedic surgeon. Some people with breast and prostate cancers benefit from surgical removal of their ovaries or testes, operations known respectively as ‘oophorectomy’ and ‘orchidectomy’. These cancers are often susceptible to hormonal influences, so removing the sources of these hormones can bring about marked tumour shrinkage which may last for a long time. Finally, surgical procedures are also undertaken occasionally to control bleeding from a growth.
