Henry Ford Hospital Medical Journal

Volume 30 Number 3 Article 11

9-1982

The Surgeon and the Patient with Cancer: The Development of Surgical Oncology

Angelos A. Kambouris

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Recommended Citation Kambouris, Angelos A. (1982) "The Surgeon and the Patient with Cancer: The Development of Surgical Oncology," Henry Ford Hospital Medical Journal : Vol. 30 : No. 3 , 156-159. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol30/iss3/11

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med J Vol 30, No 3,1982 Sjf]iii;^c:iciiil ,iAijr'III:icic The Surgeon and the Patient with Cancer: The Development of Surgical Oncology

Angelos A. Kambouris, MD*

The role ofthe surgeon in treating patients with cancer to become familiar with radiotherapy, its capabilities has changed over the past 30 years. For many years the and its side effects, in order to serve the best interests of surgeon was traditionally viewed as the key clinician in their patients. Cooperative teams of surgeons and radio­ treating cancer. This role was strengthened by the therapists were established, and as the results of their development of the concept of local-regional resections combined modalities became publicized, traditional for treating cancers ofthe breast (Halsted, 1894), rectum surgical approaches were modified. Combining radio­ (Miles, 1907), and neck (Crile, 1906). Over the next 40 therapy with surgery for cancers of the breast, larynx, years this concept was enlarged to include treatment of and other head and neck cancers, pelvic malignancy, urological and gynecological cancers. The parallel and cancer of the esophagus are some examples of this development of institutions for categorical cancer approach. The best example of such cooperation was treatment and technological advancements in anesthe­ represented by surgeons (McComb, Jesse, White) and sia and blood replacement enhanced the role of the radiotherapists (Fletcher, Lindberg) at the M. D. Ander­ surgeon in cancer treatment, which culminated in the son Hospital in Houston, Texas. 1950s. The emphasis at that time was on extensive opera­ tions termed "radical" or "supraradical" because of However, the major factors in bringing about a reas­ their magnitude as well as the effects on the functional­ sessment of the surgeon's role in the cancer field have ity of the patients. The objective was to conquer cancer been the development and proliferation of anti-neoplastic through an ever-expanding surgical attack. Examples of agents, and to a lesser degree, the revival of the interest this approach can be found in operations for oropha­ in immunotherapy. The discovery of the anti-neoplastic ryngeal and thyroid cancers, supraradical and extended effectiveness of nitrogen mustard during World War II radical operations for breast cancer, extended total gas­ opened new vistas in the ongoing effortsto cure cancer. trectomy for stomach cancer and major disarticulations, Since that discovery, thousands of compounds have and even "hemicorporectomy" for treating melanoma been tested to assess their anti-neoplastic properties, of the extremities or sarcomas of the soft somatic tissues and research in cellular and molecular biology has and bones. Unusual expertise in surgical techniques was increased our understanding of cancer cells and their concentrated in a few specialized cancer institutions; response to drugs. Also, the inadequately explored the writings of George T. Pack, Jr, Hayes Martin, and potential of immunotherapy for cancer treatment has Cushman Haagensen, among many, were instrumental come to the forefront. Chemotherapy alone or com­ in affirming the role of the surgeon in the cancer field. bined with other modalities has been employed to cure However, since 1950, several new developments have certain cancers, such as leukemias, lymphomas, and sar­ modified or totally changed the surgeon's part in treat­ comas. In solid tumors its main function has been to treat ing patients with cancer. patients with symptomatic metastases and, more recently in the adjuvant setting, to eliminate micrometastatic dis­ The advent of megavoltage radiation added precision ease and enhance the role of traditional (usually surgi­ and effectiveness in tumor destruction, while it spared cal) therapy. Because of the many anti-neoplastic com- or minimized injury to normal tissues. Radiotherapy thus claimed an increasing role in treating localized cancers, either alone or combined with surgical proce­ Submitted for publication: June 30,1982 dures. Combination treatment schemes were devised to Accepted for publication: August 6,1982 Department of Surgery, Division of General Surgery, Henry Ford Hospital; increase cancer control and minimize disability and dys­ Member, Society of Surgical Oncology, Society of Head and Neck Surgeons function from extensive operations. Many surgeons had Address reprint requests to Dr. Kambouris, Department of Surgery, Henry Ford Hospital, 2799 W Crand Blvd, Detroit. Ml 48202

156 The Surgeon and the Cancer Patient

pounds, it was quickly recognized that appropriate arterial injections of nitrogen mustard. Later, in 1958 testing and accurate scientific recording of their effec­ Creech (2), a surgeon in New Orleans, and Stehlin in tiveness as well as of side effects and complications 1960 (3), a surgeon in Houston, developed and expanded would be needed. Well-controlled mechanisms for the concept of regional chemotherapy by transferring phased introduction of new agents was established and experience with extracorporeal circulation from cardiac implemented through multi-institutional collaboration. surgery to cancer treatment, using isolation perfusion of To that end, cooperative groups were formed, and ran­ the extremities and other regions of the human body. domized clinical trials were established on a national or Because isolation perfusion permitted cancer-bearing international basis to test multiple drugs and their com­ areas to be exposed to concentrated or even lethal binations on large numbers of patients. amounts of chemotherapeutic agents, effective tumor control was enhanced, while the patient was protected Encouraged by massive publicity and unlimited funding, from systemic toxicity and myelosuppression. During these developments were accompanied by the growth the same period, the concept of intermittent or contin­ of new training programs to meet manpower needs. A uous intraarterial infusion chemotherapy was devel­ new subspecialty of clinical oncology arose, as internists oped and clinically employed by surgeons (4) and pursued two or more years ofadditional training to meet medical oncologists (5). Regional chemotherapy, which training and credential requirements and to pass appro­ developed during the expanding era in medical oncology, priate certification. They assumed leadership roles in remains relatively unchanged except for new drug cancer-related affairs, including the total care of patients combinations or the addition of radiotherapy and with advanced cancers, and consultation and planning hyperthermia. for cancer programs, and treatment planning for patients with early cancers. Although most patients continue to Because of the continued emphasis on cancer biology present with surgically curable cancers, this new devel­ and on the role of chemotherapy during the 1950s, opment has overshadowed the traditional role of the surgeons became involved in clinical and basic research surgeon in the cancer field; this despite the fact that studies. Local wound applications, intraluminal irriga­ surgery remains the most effective means of treating tions, or systemic administration of cancer chemothera­ cancer, and that improved cure rates resulting from the peutic agents in the perioperative period were some of expanded role of medical oncology have been difficult the techniques surgeons used in adjuvant treatment of to document. patients with localized, surgically treatable cancer. Surgical adjuvant chemotherapy programs were slowly In response to these developments, surgical approaches but methodically developed in the late 1950s and found have changed considerably. Some changes occurred nationwide appeal in the 1960s and 1970s. The model of because more extensive operations failed to improve such a program is the National Surgical Adjuvant Breast cure rates. Supraradical mastectomy was abandoned, Project for studying the biology and treatment of breast and extended total gastrectomy was replaced with radi­ cancer, under the sustained leadership of a surgeon, cal subtotal gastrectomy. Other surgical procedures B. Fisher. were modified, as understanding of the biology of cancers improved, and earlier detection of neoplasms Furthermore, surgeons have become more familiar with became possible at a preinvasive or early invasive stage the concepts of immunotherapy, the role of tumor where more precise but less extensive operations are reductive operations, and the importance of using necessary. Controversies in treating breast, thyroid, and multi-modality approaches to achieve better results lung cancers are prime examples. through more precise and less disabling operations. The concept of limb salvage operations for sarcomas of the The main changes, however, occurred in response to extremities and the improved results in pediatric solid new developments in cancer treatment. Surgeons rapidly tumors are examples of such collaborative approaches. accepted and adopted the use of anti-neoplastic com­ pounds. They were thus able to observe at firsthand the Probably the most impressive change occurred when destructive effects of chemotherapeutic agents on malig­ surgeons became active participants in multi-institutional, nant neoplasms and also the attendant side effects and controlled clinical trials. Such massive participation toxicity on patients. In efforts to minimize such unde­ represented a change in philosophy and awareness sirable side effects while maximizing therapeutic bene­ among surgeons, brought about in part by the efforts of fits, surgeons modified the application of chemotherapy. medical oncologists to improvethe somewhat stationary In 1950, Klopp (1), a surgeon, introduced the concept of results of surgical treatment for patients with Stage II regional chemotherapy by employing fractionated intra­ cancers. However, credit also goes to the surgeons who

157 Kambouris

encouraged their patients to enter such clinical trials, ing to develop the surgical arm of the multi-disciplinary although they risked side effects and symptoms gener­ attack against cancer. Establishing a surgical subspecialty ated by a variety of treatment schemes without guaran­ that would prepare surgeons appropriately at a level tee of therapeutic benefits. In response to these changes comparable to that of their colleagues appeared attrac­ in attitudes, trends, and service needs, it has become tive. While the cancer-oriented nonsurgical subspecial- necessary for surgeons to expand their basic training and ists supported this effort, the surgeons themselves for gain an understanding of chemotherapy, immunother­ various reasons have been slow to endorse such a need. apy, radiation therapy, and hyperthermia, areas not As part of this ongoing assessment and after input from included in their traditional education. many professionals, a consensus conference was held in 1978 under the auspices of the National Cancer Institute. This course of events has been a blueprint for profes­ It affirmed the belief that "there is a need for a subspe­ sionals to develop recognized groups of specialists who cialty of surgical oncology, with members having sound commit themselves to dealing with the issue, to develop training in general surgery but additional training in an educational program to assure adequate training, and other specialties" (6) in order to complement their to develop a credentialing mechanism to evaluate and knowledge in the field of cancer. Training guidelines appropriately certify those who complete such training. were established at that meeting, and the effort for While this has occurred in the subspecialties of radiation implementation continues. oncology, gynecological oncology, and medical oncol­ ogy, a subspecialty of surgical oncology is only lately These intensified efforts to develop an identity within being discussed. Although many surgeons recognized the broad field of surgery are still in their formative such need on their own and obtained additional training, stages, and the role of the surgical oncologist is still only recently has an organized approach to that need being defined (7-13). Publications in the literature been identified. Educational programsaimed at updating emphasize sound surgical training, additional educa­ surgical knowledge in the field of cancer have prolif­ tional exposure in medical oncology, immunology,^ erated. The Commission on Cancer of the American radiotherapy, pathology, and other disciplines, and the Collegeof Surgeons has been influential in incorporating ability to assume leadership roles in clinical, research, postgraduate courses in cancer at each annual conven­ and educational aspects affecting the role of surgeons in tion and at many regional and local chapter meetings. In the field of cancer. In that capacity, a surgical oncologist response to public pressures, many consensus meetings would "complement rather than replace" (7) the sur­ have been held to address changing concepts and geon in his or her traditional role. Furthermore, the treatment approaches, many of them directly or indirectly surgical oncologist would be able to represent surgical involving the surgeon. Surgical publications stressing interests among other subspecialists at a comparable multi-modality approaches abound. A network of level. Viewed in its broad perspective, the need for a national centers was developed for consultation, referral, subspecialty of surgical oncology becomes obvious. The or expert information for surgical and multi-modal treat­ recognition of this need is best reflected by the fact that ment of cancer patients. many medical schools and academic centers have estab­ lished well-structured divisions of surgical oncology (6) and by the fact that the National Cancer Institute has This new role for the surgeon was facilitated in the early allocated modest funds to support research and devel­ 1970s when the prestigious James Ewing Society, a multi- opment in surgical oncology. specialty organization of traineesof the Memorial Sloan- Kettering Cancer Center in New York, and for many years the focus of exchange of scientific and clinical It is evident from this brief review that the surgeon will informat ion in the cancer field, became the Society of continue to play an important role in the cancer field, a Surgical Oncology. Membership was opened to sur­ role that will become more demanding as it becomes geons trained in other institutions but whose sole or more complex. Whereas in past years the surgical primary interest is the patient with cancer. The need to -emphasis was on technical ability, technical expertise in reassess the role of the surgeon in the expanding field of surgery, biology, and interdisciplinary studies will bethe cancer-related activities had been obvious to the Society hallmark of tomorrow's surgical oncologist. Such adap­ for many years. Surgeons were underrepresented in tation will assist in maintaining the surgeon as a leader in multi-specialty committees and policy-making activities a constantly changing and not always clear-cut field and at hospital, local, and national levels, and were not, as a will promulgate new concepts of surgical and nonsurgi­ consequence, being adequately recognized with fund­ cal applications of cancer treatment to surgeons in train-

158 The Surgeon and the Cancer Patient

ing. Most of all, it will contribute to optimal patient care treatment approaches based on scientific knowledge as by strengthening the ability of the surgeon to select well as technical expertise.

References

Klopp CT, et al. Fractionated intra-arterial cancer chemotherapy 7. Lawrence W, Jr. Is surgical oncology really a specialty? Arch Surg with methyl-bis-amine hydrochloride: Preliminary report. Ann 1979;114:659-61. Surg 1950;132:811-21. 8. Schweitzer RJ. The surgeon's role in cancer care. Bull Am Coll Surg Creech O, Jr, et al. Regional perfusion utilizing an extracorporeal 1979;64:3-5. circuit. Ann Surg 1958;148:616-32. 9. Holmes EC. What is new in oncology. Bull Am Coll Surg 1980;65:24-7. Stehlin JS,Jr, etal. Regional chemotherapy for cancer: Experiences 10. MooreC. Changing concepts in head and neck surgical oncology. with 116 perfusions. Ann Surg 1960;151:605-19. AmJ Surg 1980;140:480-6. Watkins E, Jr. Chronometric infusion — An apparatus for pro­ 11. Jesse RH. The head and neck oncologic surgeon: Self evaluation. tracted ambulatory infusion therapy. N EnglJ Med 1963;269:850-1. Am J Surg 1981;142:428-30. Sull Ivan RD, et al. Chemotherapy of metastatic liver cancer by 12. Moore C. Definition of an oncologist. Cancer 1982;49:1067-9. prolonged hepatic artery infusion. N Engl J Med 1964;270:321-7. 13. Baird RM. Evolving role of the surgeon in cancer treatment. Am J Scanlon E. Editorial: Surgical oncology as a subspecialty. CA Surg 1982;143:532-3. 1980;30:63-4.

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