In general, where surgery is a medically appropriate option, it is the surgeon who takes the leading clinical role in discussions with the patient and her or his family regarding the development of an optimal strategy for that individual.
Maurie Markman, MD
The primary role of surgery in solid tumor cancer management requires no explanation. From the time the presence of a malignant condition is revealed and subsequently confirmed, the question to be addressed is whether the cancer can be surgically removed and if a cure is possible. In general, where surgery is a medically appropriate option, it is the surgeon who takes the leading clinical role in discussions with the patient and her or his family regarding the development of an optimal strategy for that individual.
During the past several decades, initial solid tumor management has evolved in many, if not most, settings from a sequential approach in which initial surgery as the primary modality is followed, if necessary, by radiation therapy and then antineoplastic drug therapy to a consideration of a multimodality strategy at diagnosis. Additionally, efforts to minimize the extent of surgery (eg, neoadjuvant chemotherapy) and attempts to maximize functional outcomes (eg, limb-sparing surgery) have become an increasingly relevant component of oncologic care.
The history of oncology includes a period of time where many surgeons appeared to reject the idea that their firmly held beliefs regarding the natural history or biology of cancer could possibly be incorrect, with probably the most poignant example of this unfortunate phenomenon being the insistence by some that extensive surgery was required in the initial treatment of breast cancer. The rejection of the concept that in most situations a more modest surgical effort could result in equivalent long-term survival and locoregional disease control with a more satisfactory quality of life and cosmetic outcome for a woman diagnosed with this malignancy characterized an era that is now fortunately past.Today, the surgical community has certainly embraced evidence-based medicine. However, the utility and interpretation of so-called “gold standard” randomized phase III trials have sometimes been considered problematic in the surgical arena. Perhaps the major reason for this concern is that outcomes of short- and long-term surgery can be strongly influenced by the skills and experience of an individual surgeon as well as the overall surgical team and institution where the procedure and postoperative care are undertaken.
Even with the successful conduct of outstanding randomized studies in the surgical domain where there is little or no debate regarding the quality of the effort, the implications of an individual trial may not necessarily be clear. A provocative commentary discussing the results of several highly clinically relevant noncancer-related randomized surgical trials highlights this point. The studies in question addressed the issue of primary surgical versus medical treatment of 3 common conditions: colectomy in the management of diverticulitis, appendectomy for appendicitis, and knee replacement for osteoarthritis.1
As the commentary notes, unequivocal superiority for either the surgical versus nonsurgical strategies was not demonstrated. Rather, there was solid evidence for clinically relevant trade-offs associated with the use of one approach versus the other. For example, in the appendectomy study, a meaningful percentage of patients (approximately two-thirds of the population) were able to avoid surgery and its potential complications with medical management, but primary treatment with antibiotics did nothing more for the remaining patients than delay the necessary surgery. Surgery, however, may relieve symptoms more quickly but was associated with intraoperative and postoperative risks. The clear message of the commentary was that patients need to be notified about these trade-offs, hopefully with information that is helpful in the decision-making process.An excellent example of the relevance of this topic in oncology is the current ongoing and rather intense debate regarding the clinical utility of neoadjuvant chemotherapy for patients with advanced epithelial ovarian cancer.2-4 Phase III trial data have revealed an equivalent survival outcome associated with an attempt at primary surgical cytoreduction followed by platinum-based chemotherapy versus initial management (after confirming the diagnosis) with several cycles of this chemotherapy followed by surgery. These studies have also demonstrated the superiority of the neoadjuvant approach related to serious post- operative morbidity, including mortality.
However, several individual reports of institutional surgical experiences have challenged the conclusions of these phase III trial results; these reports claim superior survival outcomes and less serious morbidity associated with primary surgical cytoreduction compared with the trial results.2-4
What is the most appropriate response to the rather substantial differences in the interpretation of trial results and how might such information be communicated to prospective patients? In the absence of a definitive answer, and in the presence of considerable differences of opinion regarding the superiority of primary versus secondary surgery following neoadjuvant chemotherapy, it is reason- able to conclude that the patient and her advisers should be provided with a balanced, objective summary of the existing data in this arena, along with the treating surgeon’s own opinion regard- ing what she/he believes to be the most reasonable therapeutic option. After the individual has had the opportunity to ask and hear responses to any questions, she can then decide the best course of action.
It is essential to acknowledge in this setting— and in an increasing number of clinical scenarios in oncology management—that there is no single “correct answer” or “correct decision” to the question of optimal management, other than the decision ultimately made by the individual patient.