Cancer, Surgical Techniques

If tuberculosis, with its treatments of rest and fresh air, was the dominant scourge of the nineteenth century; cancer, with its dramatic and often devastating surgical and pharmaceutical interventions, became the dreaded curse of the twentieth.

Medical understanding of the body had shifted from a humoral framework in which disease and illness, including tumors, were believed to be caused by imbalances of bodily fluids, to an anatomical-pathological framework in which tumors were understood as solid aberrations to the structure of a particular organ.

This shift, coupled with breakthrough developments of anesthesia, antisepsis and asepsis, dramatically increased the use of surgical intervention as a means of treating patients with cancer.

In the early part of the twentieth century, treatment of cancer tended toward radical surgery due to the belief that complete removal of the offending tumor—along with surrounding tissue, and often the entire organ—would prevent a recurrence of the cancer. The results were often hideous disfigurement and poor quality of life— many times with only marginal gains in length of survival.

In treating breast cancer, William S. Halsted (1852-1922), who spent much of his career at the Johns Hopkins Hospital in Baltimore, Maryland, was one of the earliest proponents of the radical mastectomy. Halsted reported his surgical findings to the American Surgical Association in 1898 and 1907. At the latter meeting, Halsted reported that two fifths of his patients who were followed more than three years after their operation were considered to be three-year cures.

Unfortunately, two thirds of his patients died of breast cancer despite the radical surgery. Notwithstanding these dismal statistics, Halsted’s approach was adopted as standard treatment due in large part to the fact that he trained numerous surgeons at Hopkins who perpetuated his technique of radical mastectomy as the first line of intervention for breast cancer. Even early on, however, the radical mastectomy endured its share of criticism, particularly from the English surgeon Geoffrey Keynes, who decried its disfiguring effects.

Despite criticism of radical surgery, surgical removal of cancers became even more aggressive by midcentury, leading to the ‘‘super-radical’’ mastectomy popularized by such figures as Owen Wangensteen of the University of Minnesota and George T. Pack of the Memorial Sloan-Kettering Hospital in New York City. Similarly, total excisions of lung and stomach cancers became the norm by the 1950s.

Gynecological surgery followed a similar path with super-radical surgeries of the uterus and vagina being the standard treatment at the turn of the twentieth century. Medical luminaries such as Drs. Christian Albert Theodor Billroth, Ernst Wertheim, and Alexander Brunschwig were themselves early proponents of this kind of radical surgery, despite statistics of high mortality.

By midcentury, a number of radical surgeries became commonplace: hemicorporectomy (surgical removal of the lower half of the body), hemipelvectomy (amputation of a lower limb through the sacroiliac joint), super-radical mastectomy, complete pelvic exenteration (removal of internal organs and tissues), and surgical removal, or resection, of head and neck tumors.

The search for a cure for cancer as well as the radical surgical interventions were replete with military metaphors—the war on cancer, a crusade for better health, battling the illness, advances in research—which characterized the aggressive assault on the disease while implicitly justifying the physical carnage that often resulted.

In the last few decades of the twentieth century, however, surgical techniques for the treatment of patients with cancer became more sophisticated and refined and also became more responsive to consumer demands. Ultraradical cancer surgery with its mutilating effects was, to a great extent, discontinued.

Where radical procedures were necessary, innovative developments in plastic and reconstructive surgery, coupled with intensive physical and occupational rehabilitation programs, strove to offset and diminish disfigurement and disability as lingering postsurgical effects. Methodologies to evaluate the morbidity and mortality of surgery patients improved during the twentieth century despite the fact that the gold standard double-blind research approach is not ethically applicable to surgery patients, in contrast to medical patients.

Surgical treatment of cancer is increasingly performed in concert with other kinds of treatment modalities, such as chemotherapy, radiation, hormonal therapies, psychosocial support, and rehabilitation. This sharing of responsibility for the cancer patient among surgeons and other specialists also illustrates the much greater input that nonsurgeons have with the care of cancer patients.

Surgical treatments of cancers have proven to be most effective when the tumor is discrete and located within one segment of the body. Other surgical treatments of cancer include preventive surgery (a partial or total removal of an organ where there is a high risk that a cancer will develop), diagnostic procedures (such as biopsies), cytoreductive surgery (where most of the cancer is removed surgically and the remainder is treated with radiation or chemotherapy), and palliative surgery (where the goal is to alleviate the symptoms of the cancer, rather than curing the cancer itself).

In the waning years of the twentieth century, laser surgery evolved as the latest innovation in treating cancer. The appealing possibilities of laser surgery echo those of the early decades of the century, when x-ray and radium treatments held the promise of removing the cancer without invasive surgery, resulting scars, or the possibility of disturbing the tumor site in such a way as to prompt cells to proliferate and metastasize.

However, radiation-induced injuries—including edema, sterility, flesh burns, and even death—and the difficulty in limiting radium treatments specifically to cancer cells without damaging the normal cells, posed challenges to these nonsurgical treatments. Laser surgery seems to answer these challenges by offering highly specific targeting and destruction of cancer cells, minimal invasiveness to the body, and a high degree of control by the surgical team. By the early twenty-first century, leading academic medical centers were running clinical trials to gauge the effectiveness of laser surgical intervention on the treatment of various cancers.

Conventional cancer therapy in the U.S. continues to revolve primarily around the three disciplines of surgery, oncology, and radiation therapy. However, with patient concerns shifting from mere survival of the disease to the quality of life during treatment of the disease, unconventional therapies have emerged as a complement to the standard approaches.

Often referred to as altenative, complementary, or unorthodox therapies, they include nutritional therapies, acupuncture, meditation, prayer, therapeutic touch, and herbal supplements to name but a few. Although the debate continues—particularly in the U.S.—over the efficacy of such therapies, patients often seek to integrate some combination of them along with conventional means.