The First Step for Cancer Patients – Cancer Survival Toolbox
When Surgery Is Not the First Step
In many cases of cancer, surgery is not the best initial treatment. And sometimes surgery is best avoided altogether. Although most patients diagnosed with cancer naturally “want the cancer out,” this may not always be possible or in their best interests.
The three main situations when this is the case are:
1. The cancer is in a critical location, and removing it would lead to an important loss of function
2. The cancer is too extensive to be removed easily
3. The cancer has already metastasized
Each situation is discussed in next papers.
The Cancer is in a Critical Location
A cancer can sometimes grow in such a vital part of the body that an operation to remove it would result in permanent disability, disfigurement, or even death. For example, surgical treatment of advanced cancers of the larynx (voice box) requires removal of the larynx (laryngectomy), which results in loss of the ability to speak. Surgical removal of a bone tumor may require amputation, resulting in loss of a limb; resection of a cancer of the rectum may require the rerouting of feces to an external bag (colostomy).
In all of these situations and others, oncologists have developed “organ preservation” treatments that seek to avoid surgery in order to treat the cancer. These treatments usually involve both chemotherapy and radiation, often given at the same time. If organ preservation fails to eradicate the cancer, surgery can then be performed in an attempt to do so. The recommendation to administer chemotherapy and radiation rather than surgery as the primary way to treat a cancer is arrived at jointly by the medical, surgical, and radiation oncologists involved in a case.
The Cancer is too Locally Advanced to be Removed Easily
Sometimes a cancer is large by the time it is diagnosed; at other times the primary cancer may not be big but nearby lymph nodes containing cancer are large. Both situations refer to cancers that are “locally advanced,” meaning that they have not formed detectable distant metastases but have grown rather extensively in the region where they arose. Such cancers usually fall within stage III (stages I and II are localized, whereas stage IV is disseminated cancer). In these situations, were surgery to be performed first, it would have to be either very extensive, removing large areas of normal tissue, or less than complete in entirely removing the cancer.
Increasingly, surgeons and medical oncologists are first recommending chemotherapy (and often radiation) in order to shrink locally advanced cancers and make them easier to remove. A cancer treatment that is given before surgery is called neoadjuvant or induction therapy.
The modern-day treatment of rectal cancer is an excellent example of how neoadjuvant therapy can greatly diminish the extent of surgery required. In the past, many patients with rectal cancer first underwent extensive surgery, which required a permanent colostomy. Today, patients with large rectal tumors (T3 or T4) or lymph node involvement (detected by rectal ultrasound) will typically first be prescribed a course of radiation to the pelvis given along with chemotherapy in order to shrink the cancer. A good result enables the surgeon to remove a limited area of the rectum, leaving the patient with intact bowel and no colostomy.
But the treatment is still not done! Adjuvant chemotherapy will then be given after surgery in an attempt to eradicate micro metastases throughout the body and cure the patient.
Other examples of cancers that may be treated with induction chemotherapy include certain locally advanced cancers of the lung, esophagus, prostate, bladder, breast, and head and neck regions. In contrast to cancer treated in the adjuvant setting, locally advanced cancers can often be seen or felt and cause symptoms: a large breast mass may cause pain and psychological distress, a lung cancer may cause shortness of breath and cough, and an esophagus cancer may cause difficulty eating and weight loss. It is very gratifying for the physician and a hopeful sign for the patient to witness a large breast mass shrink, breathing become easier, and the ability to eat restored as the treatments do their job.
Sometimes neoadjuvant treatments work so well that they drive the cancer into a complete remission: pathology analysis of the surgical specimen obtained after treatment reveals no evidence of living cancer cells. This does not guarantee that the cancer is cured and will not return; local recurrences or distant metastases may still arise at a later date. Yet patients who do experience a pathologic complete remission have a greater chance of being cured than those who do not because chemotherapy that wipes out all the cancer cells in a primary tumor may have the same effect on micro metastases throughout the body.
One prominent exception to the neoadjuvant therapy approach to locally advanced cancers is ovarian cancer. Most women with ovarian cancer are diagnosed when the disease has spread to many areas of the abdominal cavity. Despite this, surgery is usually performed first because removal of as much disease as possible (called “optimal debulking”) improves both how a patient feels and the response to subsequent chemotherapy. Exceptions exist here, too; some women with ovarian cancer may need chemotherapy before surgery in order to decrease the bulk of the cancer and improve their overall health. To quote my own mantra, “there’s nothing simple about cancer!’”
