As a surgical oncologist who practices at a dedicated cancer center, I frequently receive surgical consults on patients with progressive cancer. These are some of the most complex situations I encounter. Often, there are no algorithms or consensus statements on these patients, and multiple clinical, social, and emotional factors must be considered. It is imperative that I have an understanding of the underlying tumor biology to improve my clinical judgment in managing these patients.
As a trainee in general surgery on different rotations, I would encounter patients that were labeled as “metastatic cancer” or “widespread disease” with the stigma that there was no hope and that minimal or no surgical intervention at all should be considered. This type of scenario is unfortunate, as many of these patients have a significant amount of time to live with potential treatment options if their acute issues can be corrected with surgical intervention.
Survival benefits with surgery for curative intent are well-established in the literature for patients with metastatic cancer. Limits are being stretched for patients with liver metastases resulting from colorectal cancer, neuroendocrine tumors, breast cancer, and melanoma, with larger, multifocal and bilobar lesions being treated with a combination of resection and ablative strategies. In patients with peritoneal-based disease such as ovarian cancer, appendiceal cancer, mesothelioma, and even colorectal cancer, debulking procedures with or without intraperitoneal chemotherapy or heated intraperitoneal chemotherapy (HIPEC) are either the standard of care or are being evaluated in clinical trials. Pulmonary metastasectomy is routinely performed for sarcoma and melanoma.
The literature contains less about palliative surgery in patients with cancer. I feel that multidisciplinary care is as important when confronting these patients who are being evaluated for palliative surgical options. I was recently discussing a surgical consult with my resident and fellow regarding a patient with metastatic breast cancer who presented with acute left lower abdominal pain after being treated with interventional radiology for a superior mesenteric vein (SMV) thrombosis related to progression of her cancer. She initially was presented to me by my staff as someone with end-stage, rapidly progressing cancer with multiple medical comorbidities; however, after further investigation and communication with her medical oncologist, it was clear that she was not ready to give up.
Prior to this event, and while on chemotherapy, she was a patient with hope who still had treatment options with a high likelihood of her HER-2 positive metastases responding to herceptin, as long as she could make it through this acute situation. She required an exploratory laparotomy and was found to have a segment of ischemic jejunum, which we resected. It was a difficult procedure, but without surgical intervention she would surely have died.
Some of the hardest decisions I make as a surgical oncologist deal with these types of acute surgical issues in very complex patients. Oncology patients present with appendicitis, cholecystitis, diverticulitis, gastric outlet obstruction, and bowel obstruction; however, these cases are rarely straightforward. It is often harder to make the decision not to operate than to operate. One also has to have a sound knowledge of chemotherapy agents and their side effects, which affect surgical outcomes as well.
Often, friends and family ask me about how difficult my job must be. I reply that it is difficult, but also extremely rewarding. It is important for me to be able to perform a palliative operation and to allow patients the opportunity to proceed with additional chemotherapy options, to eat, to decrease their pain, and to provide them with more time with their loved ones. I cannot stress enough how important it is to have a surgeon who is familiar and comfortable with treating our cancer patients, and to have open lines of communication between disciplines to provide the most effective palliative care for patients with metastatic disease.