Conventional surgery by specialists is still the key to eliminating tumours, alongside adjuvant therapies, writes Geoff Watts

Even before the threat of individual performance league tables appeared on the horizon, surgeons were aware that those who specialise generally get better results than those willing to turn their hands to anything. Cancer is no exception.

'There are now target figures for what is a reasonable minimum number of cases annually for any one procedure, ' says David Rew, of the British Association of Surgical Oncology. 'In breast cancer, for example, surgeons should aim for at least 50 cases.'

Specialisation, especially when combined with innovation, can bring measurable improvement. In removing colorectal tumours, for example, the closer the surgeon has to work to the anus, the greater the likelihood that the patient will need a colostomy.

This may represent a good surgical result but remains, from the patient's viewpoint, a dismal outcome.

Colorectal cancer specialist Professor Bill Heald of Basingstoke General Hospital set out some years ago to devise a procedure that would leave more patients with an intact anus, yet without increasing the chances of their disease recurring.

Along with the tumour itself and the surrounding length of bowel, he removes the fatty tissue which supports the lower end of the gut.

This tissue, rich in blood vessels, tends to trap cancer cells that have been shed from the main tumour.

Total meso-rectal excision, as the technique is known, has not only slashed the colostomy rate from 70 per cent to 10 per cent, but actually reduced the risk of recurrence.

Surgery for breast cancer has always generated controversy. Some debates, such as the value of mastectomy, have been resolved. Lumpectomy is now more common - and where mastectomy is still necessary, reconstructive surgery can be performed at the same time.

However, a couple of uncertainties still remain. One is the claim that the phase of the menstrual cycle during which a woman undergoes surgery has an effect on its long-term success.

When this idea was first mooted, many surgeons dismissed it. But others, including Ian Fentiman of the Imperial Cancer Research Fund breast unit at Guy's Hospital, London, took it seriously. In his latest study, published last year, he and his colleagues once again found an effect.

1Commenting on the findings, Mr Fentiman said: 'This work shows that women having breast tumours removed during the follicular phase of their cycle (days three to 2) have a 10-year survival rate of 45 per cent, compared to a 10-year survival of 75 per cent for women having surgery during other phases of their cycle.'

Other studies, however, have reached different conclusions, and the issue remains unresolved. Any eventual consensus that timing matters would clearly have an impact on the work of hospital admissions staff.

Even less certain is the justification for performing prophylactic mastectomy in women at high risk of breast cancer. A woman with a family history of the disease, or who has been genetically tested, may face a dilemma: is it worth her trying to reduce the risk by having her breasts removed?

Doctors cannot yet offer much guidance; the evidence is patchy and inconclusive. A randomised trial might help, but the likelihood of a group of women with no evidence of Playing hard to get: lasers can be targeted at difficult-to-reach areas.

disease agreeing to randomisation involving a decision as emotionally charged as mastectomy is slim.

This is another area in which Mr Fentiman has an interest. He has pointed out that, although some women already choose prophylactic mastectomy, there are no systematic arrangements for following them up.

In a BMJ editorial he argued that a register of all such women might cast some light on the benefits of the procedure.

2'Unless action is taken another 10 years will see us in the same state of ignorance, ' he added.

As far as new technology is concerned, David Rew does not anticipate any revolutions. Even minimal access or laparoscopic methods - the biggest change to have overtaken surgery in the past couple of decades - has had little impact on operations for most common cancers.

The advent of the laser and much talk of using it as a 'light knife' seemed, at one time, to hold great promise. Lasers can be used to burn away diseased tissue or to activate cell-killing chemicals. Their precision and their capacity to seal cut blood vessels appeared to offer great advantages. Delivered through a fibre-optic cable, a laser beam can be directed to the cervix, vagina, vocal chords and otherwise difficult-to-reach organs such as the lung and bladder.

Lasers have had some success in, for example, the palliative treatment of patients whose tumours are blocking their windpipe. On balance, however, 'useful but marginal' is how Mr Rew describes laser surgery.

Much the same is true of cryosurgery, the use of a freezing probe to kill diseased tissue. It has found a place in dealing with cancerous or pre-cancerous growths of the cervix, skin, retina and liver.

But, although cheap to use, its effectiveness in most circumstances remains uncertain.

Conventional surgery remains the key to eliminating tumours.

Paradoxically, though, it is not technical improvements in surgery itself which Mr Rew is keenest to see.

'What surgeons most want are advances in chemotherapy and other adjuvant treatments that can mop up any cells or tissue which the scalpel has missed.'

REFERENCES

1 Cooper L, Gillett C, Patel N, Barnes D, Fentiman I. Survival of premenopausal breast carcinoma patients in relation to menstrual cycle timing of surgery and estrogen receptor/progesterone receptor status of the primary tumour. Cancer 1999; 86 (10): 2053-8.

2 Fentiman I. Prophylactic mastectomy, deliverance or delusion? Brit Med J 1998; 317 (7170):1402-3.