While cancer treatment is progressing in many directions, surgery to remove the cancer is still the most frequently used approach to care for patients with solid tumors. Even if surgery is just one part of a more comprehensive treatment plan that involves other therapies, many cancer patients will have some form of surgery.
Surgery may be done at different points along your journey, whether the goal is to perform a biopsy to get a precise cancer diagnosis, to remove part or all of the tumor, to reconstruct the affected area after a tumor is removed, or to provide relief from symptoms (called palliative relief). Surgery for cancer is advancing rapidly, and in many cases you and your surgeon will have choices to make—sometimes multiple choices—about the surgical option that’s right for you.
“Surgical oncologists are not only specialized in how to technically perform cancer surgery, but also at understanding the biology behind the cancer we treat,” says Yale Medicine's Sajid Kahn, MD, a surgical oncologist, practicing at Smilow Cancer Hospital Care Center at Trumbull. “We understand and incorporate fundamental principles of medical oncology, radiation oncology, palliative care, and gastroenterology to provide the best outcome for each patient.”
What is cancer?
Cancer, in general, occurs at the cellular level. In a healthy body, new cells are generated to replace old, dying ones. But when there’s a disruption—new cells form unnecessarily or old cells don’t die as they should—a collection of extra cells can form a tumor, or growth, that is either benign (not cancerous) or malignant (cancerous). To better understand and properly treat cancer, doctors will need to know whether the cancer is primary (started in the organ where it was first discovered) or secondary (metastatic, meaning it is cancer that has spread from elsewhere in the body).
What role does surgery play in cancer care?
Surgery can play a variety of roles for a patient who has a solid cancer (as opposed to a hematologic [or blood] cancer). Some important roles are as follows:
Prevention: Some people know (usually through genetic testing) that they are at high risk for developing certain cancers. While this may be considered controversial, they may want surgery to remove the parts of the body where that cancer could develop. For instance, a woman may opt for a prophylactic mastectomy (removal of one or both breasts) if she learns she has a genetic mutation that puts her at high risk for breast cancer; or a hysterectomy (removal of the uterus) if she learns she has a precancerous condition affecting the uterus.
Diagnosis: Minimally invasive surgeries called biopsies remove small samples of tissue that a pathologist can examine under a microscope or perform lab tests on to determine whether it is cancerous and, if so, how advanced it is. Other diagnostic surgeries involve removing lymph nodes to determine whether a cancer has spread. What’s called sentinel lymph node biopsy involves removing the sentinel node (the first lymph node the cancer would have spread to) and examining it for cancer. (A negative finding suggests the cancer has not spread to other lymph nodes or organs.)
Staging: This is a surgery to look inside your body to assess the extent of cancer—how much cancer there is and how it may have spread.
Treatment: The goal of cancer surgery is to remove the entire cancer. Surgery used to remove as much cancer as possible is called “debulking.”
Palliative: If a cancer is not curable, doctors may use surgery to make the patient more comfortable. Examples include removing a tumor that is pressing on a nerve, or treating a hemorrhage or ulceration.
Reconstruction: This type of surgery restores function and appearance after cancer surgery, such as for breast cancer, skin cancer or some head and neck cancers. Reconstruction may be done in a single operation or it may take multiple operations. In some cases, it can be done at the same time as the surgery to treat the cancer.
How does surgery treat cancer?
Put simply, surgery is used to physically remove cancer from the body. It is most successful for solid tumors that are contained in one area, as opposed to, say, blood cancers, lymphatic cancers or cancers that have spread to other parts of the body. The surgeon will often remove not only the cancer, but some surrounding tissue (called the “surgical margin”) to make sure all of the cancer is eliminated.
He or she may also remove lymph nodes and send them to a lab to make sure they don’t contain cancer that has spread (or metastasized). If cancer is found in the lymph nodes, the doctor knows it may also have spread to other parts of the body. If the surgeon can confirm that the cancer has not spread, surgery may be the only treatment necessary.
The surgeon’s goal, typically, is to remove the entire tumor, or to “debulk” it, which means to remove as much of it as possible. Sometimes removing an entire tumor can damage nearby organs or parts of the body—so, by taking away as much of the tumor as possible, other treatments such as radiation therapy and chemotherapy are likely to work better. It can also have less of an impact on the body, and preserve appearance and function.
What special techniques are used in cancer surgery?
Surgical approaches to cancer range from conventional surgery, which is usually a major operation that involves large incisions, to less invasive approaches. Specialized surgical techniques you may not be familiar with include the following:
- Cryosurgery: This uses a cold probe or a spray of liquid nitrogen to kill abnormal cells by freezing them.
- Electrosurgery: This uses a high-frequency electric current to destroy cancerous cells.
- Laparoscopic surgery: The surgeon makes a small incision and inserts a thin, flexible tube with tiny instruments attached to it to obtain tissue samples and to remove some types of cancer.
- Laser surgery: This uses a strong, precisely focused beam of energy to cut through tissues—it may be used to vaporize a precancerous tumor.
- Mohs surgery: This skin cancer treatment shaves off one thin layer of skin at a time until the doctor reaches a layer that does not contain cancer cells.
- Radiofrequency ablation: This sends high-energy radio waves through a needle to heat and kill cancer cells.
- Robotic surgery: This is similar to laparoscopic or thoracoscopic surgery, except that the surgeon sits at a panel and controls the direction of robotic arms to do the surgery.
- Stereotactic surgery: This is a relatively new radiation technique that works almost as well as conventional surgery for some cancers. Machines such as Gamma Knife® and CyberKnife® are used to deliver precise doses of radiation to kill small tumors.
- Thoracoscopic surgery: This is a way to obtain tissue samples or to treat some lung cancers. The surgeon makes a small incision and inserts a thin tube with a small video camera on the end to look inside the chest.
What choices do I have in my cancer surgery?
Sometimes your choices in cancer surgery are limited. But advances are giving patients more options, so you should always ask your doctor what choices you have available to you. For example, women with ductal carcinoma in situ (cancer of the milk duct that hasn’t spread to nearby breast tissue) may be able to choose whether to have a mastectomy or a lumpectomy (removal of only the tumor and surrounding tissue), or another surgery that spares the breast.
Women with breast cancer also have choices as far as the type of breast reconstruction they can consider. Some of these choices are complex, so it’s important to talk to your doctor, educate yourself as much as possible and get a second opinion if you need one.
How successful is surgery for cancer?
This varies widely and depends on the type of cancer you have. But for some cancers, when the disease is diagnosed in the earliest stages, surgery is considered to be a cure. However, in other cases your treatment team may recommend additional therapy, such as radiation or chemotherapy, to eradicate those cells. Pathology reports and other information will help your doctor determine whether you need additional treatment.
What do I do after my surgery is over?
In many ways cancer surgery is like any other surgery. It’s important to follow up with your surgeon, and report any unusual pain, swelling, or bleeding. For cancer surgery, you will need to follow up with your cancer care team and follow any recommendations about continued monitoring to catch any recurrence early.
What is Yale Medicine’s approach to cancer surgery?
Yale Medicine surgical oncologists and Yale Cancer Center providers are dedicated to improving the lives of cancer patients through clinical practice and research endeavors.
According to Dr. Kahn, our doctors believe patients do best when medical professionals work cohesively as a team and that includes being able to draw upon the expertise of a variety of specialists to collaborate in identifying the best approach to each patient’s case.
“What distinguishes our providers is that we take the time to get to know our patients and provide each of them with a detailed description of their diagnosis and an explanation of how treatment will proceed. For surgery, in particular, we are careful to answer all of their questions about the surgery and other treatments they will undergo as part of their multidisciplinary cancer treatment plan. Our patient care is personalized—we make sure our patients are treated like individuals,” Dr. Kahn says.