Recognizing the Rapidly Changing World of Surgical Oncology

A modest modification of a rather old television commercial serves as a useful introduction to this commentary: “While I am not a surgical oncologist, some of my best friends/colleagues are, so I feel perfectly capable of providing an opinion on the evolution of this critically important medical subspecialty.”

In fact, from the perspective of either a surgical or nonsurgical oncologist, one might reasonably argue that the rather striking changes in surgical cancer management have not been adequately appreciated either within or outside the oncology community. This situation may at least partially be the result of the frequently widely publicized and often impressive effect of rapidly evolving antineoplastic therapeutic agents, including the ongoing revolution in precision cancer medicine. In addition, the benefits associated with major technological modifications and strategies employing radiation in the treatment paradigms for many cancers have generated considerable attention.

However, when one objectively reviews the evolution of the role of surgical management, comparing the present to the not-so-distant past, the changes are both impressive and highly clinically meaningful.

It was not that long ago when surgical resection was objectively the only treatment available for patients with solid tumors, whether malignant or benign. For cancers believed to be localized and potentially curable, surgeries were often quite extensive, frequently associated with considerable morbidity, and resulting in a major negative effect on the individual’s subsequent quality of life. Nevertheless, assuming appropriate informed consent was obtained, this strategy was generally acceptable, for if the surgery was “successful,” cure may have been a definite possible outcome. Unfortunately, in many settings, observing the natural history of the disease process was realistically the only alternative option.

To be clear, we speak here of the era of the radical (or super-radical) mastectomy for breast cancer as standard of care, routine limb amputations for sarcomas, and ultra-radical surgeries for intra-abdominal and pelvic malignancies.

With the subsequent introduction of the “tools” added to the oncologist’s armamentarium by the radiation and medical oncology specialties, surgical approaches to cancer began to change, even if slowly in some settings. However, in these earlier times, it would be overly generous to consider this care “multidisciplinary.” “Sequential interactions” with patients might be a more appropriate term to describe management with the surgical resection undertaken (if possible), followed by radiation for concerns related to microscopic/macroscopic residual disease or if surgery was deemed inappropriate as a primary local modality. This might be followed by some form of systemic therapy for known or suspected residual cancer or if recurrent disease was subsequently documented.

Systemic treatments would also be employed in the presence of metastatic disease at diagnosis, because surgical resection was in most circumstances felt to be restricted to the curative setting, or perhaps solely as a palliative option (eg, resection of a bleeding, previously radiated metastatic mass lesion).

With the demonstrated success of adjuvant antineoplastic drug regimens, medical oncologists began to be provided a seat at the table in discussions of optimal frontline disease management, but in most circumstances, the modalities were still delivered sequentially, with surgery followed by radiation, followed by any indicated systemic therapy.

Oh, how cancer care has changed! Today, in multiple settings, optimal disease management is truly multidisciplinary in nature, with the surgeon carefully considering options to reduce the extent of necessary resection to preserve normal function and optimize quality of life. This includes the concept that cancer known or suspected to remain following surgery can be successfully managed with subsequently delivered local radiation and antineoplastic drug therapy.

In addition, minimally invasive techniques (eg, laparoscopic and robotic-assisted surgery) are now widely employed, maintaining therapeutic efficacy while reducing the required extent of normal tissue damage. Further, surgeons may be called upon to actively participate in approaches to deliver antineoplastic drugs into localized body locations. Examples include intrahepatic artery infusions for colon cancer metastatic to the liver or intraperitoneal treatment of ovarian cancer.

Today, it is increasingly common practice to completely flip the standard treatment paradigm, where systemic therapy has routinely followed local management (surgery, radiation), to an approach where known active antineoplastic drugs are delivered prior to an attempt at curative surgical resection (“neoadjuvant therapy”). Clinical trial data have revealed that this strategy may permit the successful complete removal of a smaller malignant mass or masses while preserving more normal tissue, reducing surgical morbidity, and, in certain circumstances, even lowering the risk of postoperative mortality.

One might suggest that what has been highlighted in this commentary is a reduction in the overall aggressiveness of surgery in routine oncologic care. In fact, this is only part of the story. In the past, one would have appropriately challenged the wisdom of attempting to remove known metastatic disease (except, as previously noted, for short-term palliative benefit). However, today it is well recognized in multiple settings that such surgery, as a component of a well-designed multimodal approach (surgery, radiation, systemic antineoplastic therapy), may be considered a quite reasonable approach in the management of metastatic disease to maximize the opportunity for extended survival and possibly cure.1 

Concluding this all-too-brief discussion, it is necessary to acknowledge 2 particularly unique challenges within surgical oncology compared with the broad fields of medical and radiation oncology. The first is the unique opportunity within surgery to widely employ new/novel approaches and technologies quite early in their development outside the confines of carefully controlled clinical trials (or regulatory oversight) designed to critically evaluate both efficacy and safety. The reported negative survival outcomes associated with routine minimally invasive surgery for cervical cancer are an unfortunate but striking example of the potential risks of this state of affairs.2,3

Second, while quality control and the safety and adequacy of therapeutic paradigms employed by medical and radiation oncologists can be relatively easily evaluated (specific drugs/dosages administered/monitored treatment plans, documented modifications in the face of observed/measured toxicity, etc), optimal surgical skill and experience as well as decision-making before and during complex procedures arguably represent a more complex evaluation process.

Yes, postoperative complications, unplanned return to the operating room, or readmission to the hospital post-discharge can be measured, but these outcomes can be influenced by multiple factors that may legitimately challenge simple statements regarding quality. For example, a surgeon who agrees to undertake the most difficult cancer cases, older individuals with relevant comorbidities, or those with the most extensive disease may realistically experience a higher complication rate. But what is the appropriate balance between the willingness to employ a potentially beneficial surgical solution on behalf of an individual patient with cancer with a difficult clinical problem, vs the subsequent risk of a negative outcome?

References

1. Keller HR, Hanes DA, McCabe JK, et al. Metastatic melanoma outcomes and the evolving role of surgery in the immunotherapy era. JAMA Surg. 2025;160(9):1026-1029. doi:10.1001/jamasurg.2025.2335
2. Melamed A, Margul DJ, Chen L, et al. Survival after minimally invasive radical hysterectomy for early-stage cervical cancer. N Engl J Med. 2018;379(20):1905-1914. doi:10.1056/NEJMoa1804923
3. Ramirez PT, Frumovitz M, Pareja R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med. 2018;379(20):1895-1904. doi:10.1056/NEJMoa1806395