Surgery is the oldest form of cancer treatment. It also has a key role in diagnosing cancer and finding out how far it has spread (staging). Advances in surgical techniques have allowed surgeons to successfully operate on a growing number of patients. Today, less invasive operations often can be done to remove tumors while saving as much normal tissue and function as possible.
Surgery offers the greatest chance for cure for many types of cancer, especially those that have not spread to other parts of the body. Most people with cancer will have some type of surgery.
WHY IS SURGERY USED FOR CANCER?
Surgery can be done for many reasons. Some types of surgery are very minor and may be called procedures, while others are much bigger operations. The more common types of cancer surgeries are reviewed here.
PREVENTIVE (PROPHYLACTIC) SURGERY
Preventive surgery is done to remove body tissue that is likely to become cancerous (malignant), even though there are no signs of cancer at the time of the surgery. For example, pre-cancerous polyps may be removed from the colon.
Sometimes preventive surgery is used to remove an entire organ when a person has an inherited condition that puts them at a much higher risk for having cancer some day. For example, some women with a strong family history of breast cancer are found to have a change (mutation) in their DNA in a breast cancer gene (BRCA1 or BRCA2). Because their risk of getting breast cancer is high, these women may want to consider prophylactic mastectomy (the breasts are removed before cancer is found).
This type of surgery is used to get a tissue sample to tell whether or not cancer is present or to tell what type of cancer it is. The diagnosis of cancer is often made by looking at the cells under a microscope. Many methods are used to get a sample of cells from a suspicious-looking area. These are described in the section, “Surgery to diagnose and stage cancer.”
Staging surgery is done to find out how much cancer there is and how far it has spread. While the physical exam and the results of lab and imaging tests can help figure out the clinical stage of the cancer, the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. For more information, please see the American Cancer Society document called Staging.
Examples Of Surgical Procedures Commonly Used To Stage Cancers, Such As Laparotomy And Laparoscopy, Are Described In The Section, “Surgery To Diagnose And Stage Cancer.”
Curative surgery is done when a tumor appears to be confined to one area, and it is likely that all of the tumor can be removed. Curative surgery can be the main treatment for the cancer. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation. Sometimes radiation therapy is actually used during an operation. This is called intraoperative radiation therapy.
DEBULKING (CYTOREDUCTIVE) SURGERY
Debulking surgery is done to remove some, but not all, of the tumor. It is done when removing all of the tumor would cause too much damage to an organ or near-by tissues. In these cases, the doctor may remove as much of the tumor as possible and then try to treat what’s left with radiation therapy or chemotherapy. Debulking surgery is commonly used for advanced cancer of the ovary.
This type of surgery is used to treat complications of advanced cancer. It is not intended to cure the cancer. Palliative surgery can also be used to correct a problem that is causing discomfort or disability. For example, some cancers in the abdomen may grow large enough to block off (obstruct) the intestine. If this happens, surgery can be used to remove the blockage. Palliative surgery may also be used to treat pain when the pain is hard to control by other means.
Supportive surgery is used to help with other types of treatment. For example, a vascular access device such as a port-a-cath can be surgically placed into a large vein. The port can then be used to give treatments or draw blood for testing, instead of having needles put in the arms.
RESTORATIVE (RECONSTRUCTIVE) SURGERY
This type of surgery is used to change the way a person looks after major cancer surgery or to restore the function of an organ or body part after surgery. Examples include breast reconstruction after mastectomy or the use of tissue flaps, bone grafts, or prosthetic (metal or plastic) materials after surgery for oral cavity cancers. For more information on these types of reconstructive surgery, please see the American Cancer Society documents Breast Reconstruction after Mastectomy and Oral Cavity and Oropharyngeal Cancer.
SURGERY TO DIAGNOSE AND STAGE CANCER
A biopsy is a procedure done to remove a tissue sample so that it can be looked at under a microscope. Some biopsies may need to be done in surgery, but many types of biopsies involve removing tumor samples through a thin needle or an endoscope (a flexible lighted tube). Biopsies are often done by surgeons, but they can be done by other doctors, too. Some of the more common ways to do a biopsy are reviewed here.
Fine Needle Aspiration Biopsy
Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out a small amount of tissue from a tumor. If the tumor can’t be felt near the surface of the body, the needle can be guided into the tumor by looking at it with an imaging method such as an ultrasound (US) or CT (computed tomography) scan.
The main advantage of FNA is that no surgical incision (cutting through the skin) is needed. A drawback is that in some cases the needle can’t take out enough tissue for a definite diagnosis. A more invasive type of biopsy may then be needed.
Core Needle Biopsy
This type of biopsy uses a slightly larger needle to take out some of the tissue. A core biopsy can be aspirated (removed) with a needle if the tumor can be felt at the surface. Core biopsies can also be guided by imaging methods if the tumor is too deep to be felt.
The advantage of core biopsy is that it usually collects enough tissue to find out whether or not the tumor is cancer.
Excisional Or Incisional Biopsy
For these biopsies a surgeon cuts through the skin to remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy). They can often be done with local or regional anesthesia. This means numbing medicine is used just in the area where the biopsy will be done. If the tumor is inside the chest or abdomen, general anesthesia (drugs that put you into a deep sleep) may be needed.
Laparoscopy, Thoracoscopy, Or Mediastinoscopy
Laparoscopy is much like endoscopy, but a small incision is made in the skin of the abdomen (belly). A thin tube called a laparoscope is then put through the incision and into the abdomen to look for possible areas of cancer that can be biopsied. When this type of procedure is done to look inside the chest it is called a thoracoscopy or mediastinoscopy.
Open Surgical Exploration (Laparotomy, Thoracotomy, Or Mediastinotomy)
When less invasive tests do not give enough information about a suspicious area in the abdomen, a laparotomy may be needed. In this procedure, a surgeon makes an incision, usually from the bottom of the sternum (breastbone) down to the lower part of the abdomen (belly), which allows him to look directly at the area in question. The location and size of the tumor and the surrounding areas can be seen and biopsies can be taken, if needed. Because this is a major surgical procedure, general anesthesia (medicines that put you in a deep sleep) is needed. An operation much like this can be done to open and look inside the chest. It is called a thoracotomy.
If lymph nodes near the trachea are swollen, a mediastinotomy is done. General anesthesia (medicines that put you in a deep sleep) is used for this procedure. A special scope (mediastinoscope) is put in the body through a small incision above the top of the sternum (breastbone) and biopsies are collected from the areas of concern.