Surgery, the oldest form of treatment for cancer, is the initial procedure in the diagnosis and/or treatment of many solid cancers. There are many cancers where the role of surgery is limited to a
biopsy
for diagnosis, since other therapies (
chemotherapy
and/or
radiation therapy) are more effective and less debilitating.
Two major developments have greatly increased the use and success of surgery. First was the introduction of anesthesia in 1846. Second was the adoption of antiseptic principles in 1867. Freeing surgery from pain and infection enabled its extensive use in the treatment of tumors.
Surgery and other invasive procedures work by removing cancerous tissues. The goal is to remove or reduce the total body tumor burden. When surgery is used to make a cancer diagnosis, the surgeon removes a tissue sample and sends it to a laboratory for examination and identification.
When determining if surgery is an option for you, your doctor will consider the location, type, and size of the tumor. In addition, how aggressively the tumor is capable of growing and whether or not it has already metastasized is considered. Finally, your doctor will assess your general health and how to best preserve your quality of life.
Surgery is used in cancer treatment for many different reasons, from curing your disease to easing your pain. These reasons are described here.
Preventive or Prophylactic Surgery
This procedure involves removing body tissue that is not cancerous but is likely to become cancerous. An example is using
cryosurgery
(using the extreme cold temperatures) to destroy and remove precancerous cells on the cervix.
Diagnostic Surgery
In diagnostic surgery, a tissue sample is removed and used to identify a specific cancer and make a diagnosis. The removed tissue is examined under a microscope to confirm the diagnosis and determine various features of the cancer that can be used to predict prognosis.
Staging Surgery
Staging surgery is used to determine the extent of the cancer in the body. While the physical exam, laboratory tests, and imaging studies are also used to stage a cancer, surgical staging often allows a more accurate assessment of how far the cancer has spread.
Curative Surgery
Attempting to remove the entire tumor when it appears to be in one area is known as curative surgery. It is thought of as a primary treatment for cancer, but it may be used with
chemotherapy
or
radiation therapy.
Debulking or Cytoreductive Surgery
When it is not possible to safely remove the entire tumor, debulking surgery is often done. In so doing, the surgeon attempts to remove as much of the tumor as possible, which can make the tumor more susceptible to
radiation
or
chemotherapy.
Palliative Surgery
Palliative surgery is not intended to cure cancer. It is used to manage pain and treat complications of advanced cancer, such as a life-threatening obstruction or bleeding.
Supportive or Combination Surgery
Supportive surgery is used to support other types of treatment. For example, surgery can be used to place a catheter into a vein, which then allows for the administration of
chemotherapy.
Restorative or Reconstructive Surgery
This procedure is used to restore your appearance after primary surgery. It can also be used to restore the function of an organ or body part. An example of this type of procedure is breast reconstruction after
mastectomy.
In a biopsy, your doctor removes a sample of tissue for diagnostic tests. It is not possible to make the diagnosis of cancer without a tissue biopsy. There are a variety of biopsy procedures, some require surgery and are performed by surgeons. Others are done in the doctor's office with little anesthesia. Usually, a biopsy removes just a sample of the affected tissue. Occasionally, the entire tumor is removed during the biopsy. Regardless of how much tissue is removed, it must be examined in a laboratory for an accurate diagnosis.
The following are some of the more common tissue biopsy procedures.
In an incisional biopsy, your surgeon cuts through your skin to remove a small part of a larger tumor. This is usually done with local or regional anesthesia, which is numbing medication used in the area of the biopsy. General anesthesia, which puts you to sleep, may be needed if your tumor is in the chest or abdomen.
In an excisional biopsy, your surgeon cuts through your skin to remove the entire tumor. This is usually done with local or regional anesthesia. General anesthesia may be needed if your tumor is in the chest or abdomen.
In a
fine needle biopsy, your doctor removes tissue or fluid samples through a very thin needle. Imaging techniques like
ultrasound
or
CT scan
can be used to help guide the needle to the tumor. The procedure does not require hospitalization and can be done with local anesthesia. An advantage to this procedure is that it does not require a large incision through the skin. However, in some cases, the needle cannot remove enough tissue for a definitive diagnosis.
A needle core biopsy is much like a fine needle biopsy, but the needle is slightly larger. This allows for removal of a larger sample of tissue.
In an endoscopy, the doctor uses a flexible tube with a video camera or a viewing lens and a fiberoptic light source on the end to view areas in the body. Using this procedure, your doctor can see the tumor directly and get an idea of its size and location. In addition, a biopsy can be taken through the scope for diagnostic purposes. The procedure usually does not require an open surgical incision or general anesthesia. However, you will be given medication that will make you sleepy and more relaxed before the procedure.
An endoscope can be passed through natural body openings and into the following areas:
- Esophagus
- Stomach
- Small intestine
- Rectum and colon
- Bladder
- Respiratory tract
Laparoscopy
is done to view and possibly perform surgery on the organs in your abdomen, such as the intestines, stomach, gallbladder, and pelvic organs. Your surgeon inserts a laparoscope (a long, thin tube with a fiberoptic light source and video camera) into your abdomen, which allows viewing of abdominal organs.
Several small (half inch) incisions are made just above or below the navel and carbon dioxide gas is injected through the incision to inflate the abdomen. This creates a larger space for your doctor to work. The laparoscope is inserted through one of the incisions and the camera transmits images of your organs on a video monitor. Your doctor may make additional small incisions in which other instruments can be inserted to move the organs around for better viewing and to perform any procedures, such as a tissue biopsy.
Because the incisions are very small, there is less pain associated with the procedure and recovery is faster than an open abdominal surgery. Laparoscopy may be performed under a local or general anesthetic and is usually done at a hospital.
A similar procedure involving the chest is called a thoracoscopy or mediastinoscopy.
Electrosurgery uses high-frequency electrical current applied by needles, blades, or electrodes to eliminate cancer cells. This procedure can be done in a doctor's office and with a local anesthesia. It is used for some cancers of the skin, oral cavity, anus, and rectum.
In cryosurgery, your doctor uses temperatures below -166.2ºF to freeze and kill abnormal cells. Carbon dioxide, Freon, and nitrous oxide are the three most common gaseous freezing agents. Or, your doctor can use a very cold probe, called a cyroprobe. This procedure can be done in a doctor's office and may involve local anesthesia. Cyrosurgery is used to treat surface lesions, like
skin cancer
and precancerous and cancerous gynecologic conditions. Newer innovations have enabled this technique to treat areas deep within the body, like metastatic
liver cancer
and
prostate cancer. The use of cryosurgery for the definitive or curative management of prostate cancer is investigational.
Laser surgery uses a powerful beam of light energy to kill and remove cancerous tissue. Because the beam is so highly focused, it can be used for precise surgical work, like repairing the retina of an eye. Lasers are used to remove tumors in difficult-to-access areas or to minimize blood loss in highly vascular (containing many blood vessels) tissue. Laser surgery is also called photocoagulation or photoablation.
In photocoagulation, tissues are heated to temperatures above 932ºF, which immediately destroys the tissue. This process is used to prevent blood loss when surgery is performed in an area with numerous blood vessels.
Photoablation occurs at temperatures above 1,832ºF, a temperature at which tissue water boils. This results in a "vaporization" of the tissue. This procedure is used for incision and removal of diseased tissue.
Laser surgery can be done in the doctor's office with a local anesthesia. Sometimes performed in a hospital setting, this procedure is used for cancers of the
cervix,
larynx, liver, rectum, and skin.
Mohs surgery, a procedure used with skin cancer, is a microscopically controlled surgery. After you are given local anesthesia, a specially trained surgeon shaves off the suspect tissue, layer by layer. After removal, each layer is examined under a microscope. The procedure ends when the excised tissue looks normal.
Chemosurgery is the combined use of layer-by-layer surgical resection of tissue and topical application of chemical agents.
When a less invasive procedure cannot provide adequate treatment, your surgeon may opt for open surgery. Open surgery always takes place in a hospital and with anesthesia (either general or local depending on the situation). In open surgery, an incision is made to remove part or all of the cancerous tissue.
Advances in surgical techniques, anesthesia, and the management of postoperative infections have greatly reduced the danger associated with surgery. However, there are some risks involved.
Possible complications during surgery can be due to the surgery itself, the anesthesia, or an underlying disease. Usually, the more complicated the surgery, the greater the risk.
Complications can include any of the following:
- Bleeding—This may require blood transfusions. The doctor will try to minimize your risk, but you may want to consider banking some of your own blood in the weeks before surgery in case you need it during your operation.
- Damage to internal organs or blood vessels—Your doctor will try to minimize this complication as much as possible.
- Reactions to anesthesia or other medicines—Although this complication is rare, it can be very serious. All your vital signs will be monitored throughout the procedure to watch for any signs of a reaction.
- Problems with other organs, such as the heart or kidneys—These are also very rare, but can be life-threatening. This type of complication is more likely to happen to a person who already has problems with these organs.
The following adverse effects may occur after surgery, but are usually not life threatening:
- Pain—Almost every person who undergoes surgery experiences some level of pain. Although some pain is normal, it should not interfere with your recovery. While there are many effective medicines for pain, usually it is the method of their administration that matters most. Patient controlled analgesia (PCA), for example, is a popular form of pain management that allows you to take charge of your own pain. If you are experiencing pain, it is essential that you talk with your doctor to make sure this issue is satisfactorily addressed.
- Infection at the incision site—Doctors take many precautions to minimize the risk of infection at the site of the wound, but it can occur. Antibiotics are usually given to treat these infections. It is important to let your doctor know if you detect signs of a possible infection at your incision site, such as increasing or thickening discharge, spreading redness, swelling, or increasing pain.
The following adverse effects are less common, but can be more serious:
- Pneumonia
—You are at a greater risk for this complication if you are a smoker, have compromised lung function, or had surgery done to your chest. To help minimize your risk, start deep breathing exercises and get out of bed as soon as possible after surgery.
- Other infections within the body—This is especially the case if your digestive tract was opened during surgery. Your doctor will take great care to prevent this effect from happening, and strong antibiotics are given if it does occur.
- Bleeding—This can occur either internally or externally, and can occur if a blood vessel was not sealed off during surgery or if a wound reopens.
- Blood clots—These can form in the deep veins of the legs after surgery, especially if you remain in bed for a long time. This can be a serious problem if the clot breaks off and travels to your lung. Try to get out of bed and sit, stand, and walk as soon as possible.
- Slow recovery of normal body functions—An example is movement in the intestines, which can result in constipation.
There are some side effects and complications that are specific to the type and location of cancer. For example, a man with prostate cancer may have a radical
prostatectomy
(removal of the prostate), which can cause
incontinence
and
impotence.
