The Kindest Cut

JESSICA MARTIN, a full-time college professor, was midway through a busy year as president of the parent-teacher organization at her children’s elementary school when she began experiencing persistent stomach pain, constipation and diarrhea. A visit to a gastroenterologist in March 2013 led to a diagnosis of irritable bowel syndrome, brought on, the doctor said, by a stomach virus and an overtaxed immune system. He recommended a gluten-free diet for the then 38-year-old mother of two.

When Martin’s symptoms worsened despite changes to her diet, she returned to her doctor and insisted that they keep looking for answers. The doctor suggested a colonoscopy, which revealed a mass in her sigmoid colon. Additional scans showed metastatic lesions on her liver, and she was diagnosed with stage IV colorectal cancer in April 2013.

In early May, the Denver resident underwent emergency surgery to remove the tumor, which was obstructing her bowel, and part of her colon. After the operation, Martin met with an oncologist, who told her she wasn’t a candidate for surgery to remove the liver metastases. Instead, he recommended chemotherapy, starting immediately, to try to shrink the liver tumors.

Before Martin agreed to the treatment plan, her husband did some research on her condition. The couple learned that only about 10 percent of patients with stage IV colorectal cancer live five years or longer. They concluded that additional surgery to remove the liver metastases, combined with chemotherapy, offered the best chance for Martin to be declared NED, meaning no evidence of disease. Martin decided to seek a second opinion about whether more surgery was a good option. “I wasn’t ready to settle my affairs,” she says.

Surgery, alone or with other treatments, has long played a central role in treating cancer. For many patients with localized solid tumors, such as early-stage cervical, skin or lung cancer, surgery may mean they can live the rest of their lives cancer-free. But once cancer has spread to other parts of the body, the decision to operate becomes more complicated. Some oncologists take a dim view of surgery at this point because they believe the risk and negative impact outweigh the survival benefit. “The most important thing is recognizing when we should and shouldn’t be operating on patients,” says surgical oncologist Jeffrey Drebin, chair of the department of surgery at Memorial Sloan Kettering Cancer Center in New York City.

An Effective Cancer Therapy

More than 2,000 years ago, Hippocrates wrote that surgical treatment of cancer usually leads to a speedier death and that avoiding surgery was the best way to prolong life for people with cancer. Today, experts agree that surgery can mean long-term survival for many patients, especially in the early stages of their disease.

“Surgery is the most effective cancer therapy in history,” says Kelly McMasters, a surgical oncologist at the University of Louisville in Kentucky and president of the Society of Surgical Oncology. “The majority of patients with solid tumors who are cured of their cancer are cured because a surgeon cuts the cancer out.”

For early-stage cancer, surgery entails removing as much of the tumor as possible and often all or part of the organ where the tumor originated. The surgeon may also remove surrounding healthy tissue and nearby lymph nodes to check whether the cancer has spread through the lymphatic system.

“The goal is to get every last bit of cancer while doing as little harm to normal tissue as possible,” says Drebin.

Although traditional open surgery is still widely used, less invasive techniques are als​o available for some cancer patients. For example, laparoscopic surgery, which uses narrow tube-like instruments, tiny cameras and other tools inserted through small incisions, may be an option to find out the stage of cancer or sometimes to remove masses, such as gynecologic and gastrointestinal tumors. Some hospitals and cancer centers offer surgery performed by a minimally invasive, human-guided robot that can remove tumors from a variety of sites, including the pancreas, gallbladder, liver and ovaries. Cryosurgery, which may be an option for patients with some precancerous conditions and cancers of the eyes, skin or prostate, destroys abnormal cells by freezing them. Laser surgery uses focused beams of light that burn off localized gynecologic and colorectal tumor tissue. Some researchers are exploring surgeries that don’t require an incision at all, with entry to the body through the mouth or rectum.

Yet new techniques have important limitations. For example, laparoscopic surgery may not be an option for large tumors. In addition, patients who have had surgeries in the past may have scar tissue that can make laparoscopic or laser surgery difficult, if not impossible. Clinical trials using robotic surgery have not shown increased patient survival over open surgery.

The goal of new techniques is to safely minimize pain, speed up recovery times and reduce the risk of postoperative side effects associated with more invasive procedures, McMasters says. “There are a lot of people trying to push the envelope to figure out how to best use the technology, and where it has the most impact,” he says. At the same time, “we have to show that we’re adding value when we do these approaches, and not just cost.”

McMasters would like to see more clinical-trial evidence that demonstrates an improvement using newer methods over conventional surgery or other treatments: “There are plenty of times, in my estimation, that the best way by far to take care of the cancer is a good old-fashioned, open operation.”

Experience Counts

Patients should look for a surgeon with experience doing the type of procedure recommended to treat their cancer. “There’s very good data that high-volume surgeons in high-volume settings tend to have the best outcomes in surgery,” Drebin says. He recommends seeking out surgeons who work at cancer centers and specialize in treating specific cancer types.

From a patient’s perspective, feeling confident in your choice of surgeon and understanding your treatment plan can go a long way in bolstering morale, says Becky Sail, a 29-year-old corporate communications manager in Boston. In 2010, when she was 22, Sail was diagnosed with an aggressive angiomyxoma—an abdominal sarcoma so rare that only about 250 cases have been documented worldwide.

At the time of her diagnosis, the pelvic mass was the size of a softball. Although this type of growth almost never spreads to other organs, the tumor recurs in the same place after it has been removed surgically. Sail initially underwent exploratory surgery at a hospital in Albany, New York, where her parents lived. When her surgeon saw that the growth was not, as first suspected, a large cyst, he suggested Sail go to a cancer center, where specialists could offer treatment.

Sail ended up going to the Dana-Farber Cancer Institute in Boston, where she was planning to move for a new job. She consulted with Monica Bertagnolli, a surgical oncologist with experience removing tumors like hers. Bertagnolli clearly described her surgical approach and the associated risks. Trusting a surgeon, says Sail, can feel strange. “As a patient, you want them to care because this is your body. But on the table, you need them to emotionally separate, you need them to do that job,” she says. Sail notes that Bertagnolli was confident in her ability to remove the mass and provided a clear plan of what to expect before, during and after surgery.

After undergoing two additional surgeries, Sail is currently taking hormone therapy, which has controlled the tumor’s growth. She recommends that patients ask a lot of questions before undergoing surgery. “The fear of the unknown is hard for the average person, but for someone going through this, it’s even worse,” she says. Patients can ask what their scars will look like, what to expect during recovery, and what kind of professional help is available in the hospital and during recovery at home, Sail adds.

A Broader Approach

For Sail, surgery was the obvious choice. But for those with metastatic disease, like Martin, the decision isn’t always clear. Surgery is often not considered an option for metastatic patients because it may not extend survival or improve quality of life. However, advances in surgical techniques have made an operation a more viable choice for some patients with metastatic cancer. For example, surgeons once were reluctant to operate on liver metastases because the organ tears easily and contains many blood vessels. In recent years, thanks to more precise imaging and surgical techniques, a surgeon can better identify and remove cancerous cells without damaging the rest of the organ. Nearly 60 percent of colorectal cancer patients whose metastases are isolated to the liver and who undergo surgery to remove them live five years or longer, according to some recent studies.

Martin’s case fell into a gray area. She had tumors on her liver. Scans also showed small spots on her lungs that doctors felt were likely benign and not a concern. In early May 2013, she saw medical oncologist Wells Messersmith, director of the University of Colorado Cancer Center’s Gastrointestinal Medical Oncology Program in Denver, who gave Martin her first glimmer of hope.

Messersmith recommended Martin undergo chemotherapy over the summer. If, in the fall, computerized tomography scans showed that the tumors in her liver had become smaller, one of the cancer center’s surgeons would operate. Martin started on FOLFOX, a chemotherapy regimen that combines 5-fluorouracil, leucovorin and oxaliplatin. The tumors responded to the treatment, and in August 2013, Martin underwent open surgery to remove her gallbladder and more than half of her liver, where the cancer cells had spread.

Recovery was rough: After surgery, she gained 40 pounds in water weight and was admitted to the intensive care unit. She had a blood clot. To eliminate any traces of cancer in her body, she needed to undergo more chemotherapy. But two days after Christmas 2013, Martin was told she had no evidence of disease. “That was fantastic for me,” she says.

The years since have been a rollercoaster ride for Martin. Scans in February 2014 showed new lesions growing on her liver. Instead of more surgery, she underwent an intense targeted radiation treatment called stereotactic body radiation therapy (SBRT) to remove the tumors, followed by additional chemotherapy. Later that year, scans revealed that the spots on her lungs seemed to be growing. Her oncologists suspected the lesions were cancerous, so she underwent SBRT again. After the treatment, she suffered a series of four fractured ribs, a side effect of high-dose radiation, though doctors told Martin they weren’t certain that the SBRT was the cause.

Martin’s most recent scans show spots on her lungs, which could be scar tissue left behind from SBRT, Messersmith notes. Martin continues to explore her options and is currently enrolled in a clinical trial for an immunotherapy combination.

Martin and Sail have one important quality in common: They felt like participants in their own treatment plans, which they say raised their level of confidence in the care they were getting. “You’re the expert on yourself,” says Martin. “You know your body. Demand to be a part of that process.”

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