Shanel B. Bhagwandin, DO, MPH
As a surgical oncology fellow, I have had the privilege and the opportunity to treat patients afflicted with malignancies of different etiologies, mostly within the abdominal cavity. Variety is one of the primary reasons I was attracted to my specialty: On any given day, we perform a liver or pancreatic resection or an extremity sarcoma excision or deliver heated chemotherapy into the abdomen for advanced peritoneal malignancies.
My interests and training are solidified by the collaborative relationships we have with multiple specialties, such as medical oncology, radiation oncology, and therapeutic interventional radiologists. Through this complex approach to oncology care, I am challenged by the patients referred to us following a devastatingly new diagnosis of cancer with hopes of a cure.
The breadth of surgical oncology introduces us to the wide spectrum of gastrointestinal malignancies, melanoma, sarcoma, etc. Within each specific cancer stage, I have learned that the biology of each cancer can be highly variable, and patients can recur having already received neoadjuvant or adjuvant chemoradiation as treatment for locoregional or distant metastasis. The personalization of cancer care is more elaborately expressed in multidisciplinary tumor conferences and clinical trials.
The truth is, we don’t have the answer yet. There isn’t a magic pill, vaccination, or preventive treatment to get ahead of every type of cancer. The approach we most commonly advocate is behavior modification and screening modalities that detect cancer earlier, such as regular mammography or colonoscopy screenings. Often there are some tumors that present at such an advanced stage that surgery is no longer an option. It is difficult to present that reality to a patient who may very well still feel healthy, and knowing that disease progression is inevitable can quickly transition that conversation to focus on quality of life.
Starting the Process: I’m Sorry We’re Meeting Under These Circumstances
When patients are referred to a surgical oncologist, there has been very little opportunity for them to accept a recent cancer diagnosis. The denial, the rationalization of blame, compounded by any attempt to explain to their loved ones what may be going on, is only about to become even more complicated. I firmly believe it’s important to take a step back, recognize there is a person in front of you, and address any obvious misconceptions before proceeding.
A reassuring interview tone versus one of judgment is a formidable foundation for trust in patient–physician communication. Being able to professionally address barriers to health literacy or delays in care is an important quality of any patient advocate. During my first few months of fellowship, I was dumbfounded by how long patient symptoms persisted without intervention, how physicianled work-ups spiraled, and how patients were inappropriately treated. It didn’t take long for me to reflect on my training in public health to quickly recognize that the disparities among my patients were also a reflection of the inadequate referral patterns and poor follow-up in our healthcare system.
You Can’t See It All: Decisions for Surgery Are Complicated in Oncology
Following any cancer diagnosis, patients understandably seek consultation and sometimes second or third opinions to see if they can undergo surgery to remove their cancer. A subtle distinction between surgical oncologists and other surgical specialties is our underlying training in oncology that marries the technical feasibility with an understanding of the biology of the disease.
There’s nothing more disappointing than operating on a patient who recurs or presents with metastases on their 3-month surveillance imaging. It’s unjustifiable, and surgery is not without considerable risks in these complicated cases. The psychological impetus for any patient is to “get the cancer out, now!” We commonly explain that certain aggressive cancers, albeit resectable, may benefit from treatment with chemotherapy or radiation up front instead of surgery. A treated cancer, which is now smaller with regression from nearby vessels or lymph nodes, makes for a greater likelihood that the surgical oncologist will remove all visible disease. More important, it allows for earlier treatment of cancer cells that may have already escaped the operative field to distant organs, such as the liver and lungs. Without our being able to guarantee a treatment response with upfront chemotherapy, patients can also progress despite treatment, and the reality is that they probably would have suffered all the risks of surgery without any real benefit.