A Look into the Future

Surgery has long been the cornerstone of cancer treatment, the most direct approach for wiping out a tumor. The field has made remarkable strides in the past 50 years and continues advancing at breakneck speed as new techniques enable surgeons to perform operations once considered impossible.

MSK Department of Surgery Chair Peter Scardino
Department of Surgery Chair Peter Scardino

But what does the future hold? How will surgery evolve to become even more effective? What new technologies will emerge to bring more tumors within reach? And will new drugs make cancer surgery less essential?

We turned to Peter T. Scardino, Chair of MSK’s Department of Surgery and a specialist in the treatment of prostate cancers, to forecast the future direction of cancer surgery.

Will surgery remain the main treatment for most cancers in the near future, or will other therapies assume a primary role?

I think cancer care is going to rely on surgery for a long time. Intuitively, it might seem that taking a drug instead of having an operation would be more appealing. But systemic therapies that affect the entire body, such as chemotherapy or even newer drugs, still have toxicity and side effects that can be long lasting or even permanent.

While surgery is a form of injury, the body has evolved to heal remarkably well from this kind of temporary wound. By contrast, the body is not used to being exposed to chemotherapy, other drugs, or radiation.

I believe the role of surgery will actually increase for certain cancers as we learn how to combine it with other therapies. A generation ago, we didn’t operate on a lot of people who were thought to have incurable disease because there was little or no chance of a cure from surgery alone. But this has been changed by the use of drugs as adjuvant therapy — given before or after the operation — that allows many of these cancers to be cured with surgery.
 
So the emergence of better systemic treatments, although they are not curative in and of themselves, has actually made surgery a more viable option in many cases.

Overall, surgery has a very successful track record — especially for cancers that are found early, before the tumor has spread, which is often the case. And another major trend has been the optimization of outcomes by surgeons who do huge numbers of these procedures and produce outstanding results.
 
What will be the biggest change in cancer surgery over the next 20 years?

The biggest change will be the use of intraoperative molecular imaging methods, which light up cancer cells so we can see them clearly and ensure we remove them all [during surgery]. We have already seen remarkable advances in imaging technology, which have enhanced our ability to visualize a tumor. For example, we can now link a radioactive tracer to antibodies that bind to cancer cells and see the cancer with a PET scan much better than with the standard imaging methods.
 
The next step will be to link the antibody to a light-emitting molecule called a fluorophore that can be activated to light up at the time of surgery. The patient would receive a dose of this tracer just before the operation so that when we begin the procedure, we can see the extent of the cancer — what we need to remove to make sure we’ve got it all — and which lymph nodes we may need to take out.
 
One problem with traditional cancer surgery has been that we usually know where a cancer is likely to spread, but we don’t know if it’s actually there, so we tend to remove as much tissue as we can without endangering the patient. I’d love to be able to say, “No, I don’t have to remove all of these lymph nodes; I’ll just remove this small cluster. And when I take out this tumor, I don’t need a wide margin, just enough to remove all the cancer cells.” That will be a remarkable advantage. 
 
Do you foresee an increase in the use of minimally invasive techniques, including robotic surgery?

Minimally invasive techniques are being used increasingly in cancer surgery, and I think their value will continue to grow. The surgical robot is a sophisticated instrument, but for now it’s really best for abdominal and chest procedures. It’s going to take some refinement of the instruments for other uses — such as head and neck cancers or pediatric tumors.
 
In cancer surgery, what’s important is that the right tissue is removed, regardless of the incision through the skin to get to the tissue. Because people think of minimally invasive surgery as a minor type of procedure, there is a tendency to overuse it. For example, it’s easy to take out an entire kidney with laparoscopic surgery [using an instrument to remove the organ through a small opening in the skin]. However, a patient with a small kidney tumor might be better off having the tumor removed with open surgery — leaving the rest of the kidney intact, which will preserve kidney function.
 
Having said that, we perform many minimally invasive and robotic procedures, and our surgeons are highly skilled at it. The key question is: What’s the best approach to curing your cancer and giving you a normal life afterward?
 
Beyond specific technologies, what long-term trends do you see for cancer surgery?

I see the focus of surgery shifting from the very early-stage, low-risk cancers to later-stage, high-risk cancers. In the past, our policy was to find the cancer very early and do a radical operation to remove it. Today we know that some cancers can be found so early that immediate treatment is not necessary, and these tumors can be monitored closely with active surveillance — a method we’ve pioneered very successfully here with prostate cancer that is being increasingly considered now for thyroid, kidney, and other cancers.
 
Initially some patients were not comfortable with this idea — when someone learns they have cancer, they want it out immediately. But many studies now support the safety and quality-of-life benefits of active surveillance, and more patients have come around. Of course, there are other cancer types — colon and lung cancer, for example, or those that are large or fast growing or cause symptoms — that should be treated immediately.
 
So surgery may be used less often in the future for very small, early cancers but more often for advanced cancers, meaning that cancer surgery will become more complex and will require highly experienced surgeons to get the best result.
 
Why would you recommend MSK to someone who needs cancer surgery?

Surgeons here focus only on cancer. They think about it constantly and care deeply about finding better ways to treat and cure the disease. In addition to saving lives by curing cancers, our surgeons also work hard to find ways to help patients fully recover their function and resume a high quality of life after treatment.
 
To give just one example, our gynecologic surgeons helped develop a new surgical procedure that preserves fertility in patients with early-stage cervical cancer. We now have one of the most active programs in the United States using this technique. You can imagine the impact of allowing these women to still have children when it would have been lost in the past.
 
The second aspect about MSK is that surgeons are part of the entire cancer treatment team. Even though a surgeon at another hospital may be equally adept at an operation, there are other questions that need to be asked: Did the pathologist make the correct diagnosis? Did the radiologist read the x-rays optimally? Did the medical oncologist come forward and say chemotherapy needs to come before surgery — not afterward? Are the radiation therapists highly skilled?
 
Having the entire team of experts allows us to know whether an operation is even necessary, and if it is, to perform it at the right time, in the right way, and combined with the right additional therapies.
 
This coordinated approach is what enables surgical treatment to be successful at MSK so patients can get their lives back without the need for even more interventions. The right treatment up front means that down the road there is less chance of recurrence and fewer complications. That makes all the difference.
 
To learn more about the history of cancer and what lies ahead for treatment, watch Cancer: The Emperor of All Maladies, a three-part, six-hour documentary presented by filmmaker Ken Burns in partnership with WETA, the public broadcasting station in Washington, D.C.