Surgery in Oncology Is Not Always a Simple Decision

November 11, 2017
Shanel B. Bhagwandin, DO, MPH

Oncology Fellows, September 2017,

The personalization of cancer care is more elaborately expressed in multidisciplinary tumor conferences and clinical trials.

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.

Starting the Process: I’m Sorry We’re Meeting Under These Circumstances

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.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.

You Can’t See It All: Decisions for Surgery Are Complicated in Oncology

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.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.

Every surgeon will occasionally make an emotional decision about whether to proceed with an operation because of a patient. The current recommendation for the majority of stage IV or metastatic cancers is typically ongoing chemotherapy or enrollment in a clinical trial. Surgery is offered infrequently in these situations, depending on the type of cancer. When a young patient presents with an advanced cancer, the heroic efforts of a surgeon or other treating physicians may conflict with the standard of care, particularly if that patient shows some degree of stability or treatment response despite the relative contraindication to surgery.

The Patient Variable

It is hard to truly know if the cancer has responded to the chemotherapy and whether that will correlate to some degree of improved survival. Furthermore, if surgery could potentially remove all the remaining viable disease, when is the appropriate time to proceed if we aim to maximize the benefit of chemotherapy that may be working? These cases are best discussed in the setting of a multidisciplinary conference among experts in that specific cancer to determine a reasonable option. It’s important to anticipate the expectations of patients and their families preoperatively. Developing such an aggressive malignancy at a younger age increases the likelihood that the cancer will inevitably recur or progress despite our best efforts (patients included).I have learned not to try to prognosticate a diagnosis prior to understanding more about a patient’s cancer. It is inherent that when patients learn that they have cancer, they immediately want to know how “bad” it is. Not all cancers behave the same, nor will they respond the same to treatment. There are some cases of metastatic cancer that the patient will inevitably succumb to. It is important to discuss the likelihood of that happening if there is a valid argument regarding whether any treatment should be prescribed considering severe comorbidities and decompensation.

At the same time, assessing the appropriate stage of cancer is more accurately done following surgery, and that can allow for additional information to be shared with the patient about their prognosis. It has been shown multiple times in the literature that patients don’t retain much about a conversation regarding their prognosis, and I tend to defer it until the postoperative visit, when the cancer has been pathologically staged.

In certain cases, what I do offer is that most patients are typically unresectable at the time of diagnosis of “X” cancer, and the fact that we’re able to proceed to the operating room is optimistic. Whereas most medical or surgical oncologists will provide prognostic information to the patient as a median variable, most patients will take that as an absolute number. The addition of a best-case, worstcase, and most-likely case scenario is a strategy that addresses the perception of that patient’s survival. A best-case scenario also preserves hope without being overly optimistic, and it has been my observation that patients appreciate knowing that certain difficult life decisions need not be undertaken if they can wait.