Since the last issue of Surgical Clinics of North America on the multidisciplinary approach to cancer care was published in April of 2000, the field of oncology has continued to evolve in the understanding of the biology of cancer and how biology impacts the treatment strategy in a given patient. The dynamics of this relationship are described in this issue’s article by Drs. Riley and Desai. Advancements in surgery, radiation, and chemotherapy have occurred across the spectrum of malignancies, and, as a result, cancer care is more frequently delivered in the setting of a multidisciplinary team of physicians. More and more evidence accumulates that suggests patients may be better served when cared for under a multidisciplinary paradigm. Furthermore, for certain complex tumor types such as pancreas and esophagus, patient outcomes may be improved when they receive care in higher-volume referral centers.
The concept of outcomes for cancer patients has expanded beyond the traditional endpoints of overall survival and disease-free survival, as discussed in the article by Drs. Oliver and Greenberg. Organ preservation, quality of life, pain control, and other patient-centered outcomes are now used in the comprehensive assessment of the quality of cancer care. Newer tools to reproducibly measure these outcomes have been developed and continue to be tailored and improved. In addition, palliation may be a treatment goal for those patients in whom a cure is not a realistic outcome. The field of palliative care is a relatively new one, and Dr. Thomay and colleagues discuss the approach to palliative care within the framework of the palliative triangle. Surgeons maintain a central role in the treatment of many types of cancer, often assuming a leadership position in the decision-making team. Therefore, it is critical for surgeons to have a comprehensive knowledge of the treatment modalities employed in the multidisciplinary approach to cancer care. Well-designed studies have shown that less invasive treatments can yield comparable oncologic outcomes to more radical treatments, allowing for organ preservation. One example includes treating certain early-stage squamous cell cancers of the upper aerodigestive tract with radiation instead of surgery, as discussed by Dr. Lango in this issue. Minimally invasive treatment may extend to local therapies, such as radiofrequency ablation in the liver or trans-anal local excision for early-stage rectal cancer, sparing patients larger surgeries or allowing for sphincter preservation.
Another impact of tumor biology on treatment strategy is the alteration of the order in which treatments are traditionally delivered. Chemotherapy or chemoradiotherapy prior to surgery may be employed in cancers of the esophagus, stomach, breast, liver, pancreas, or rectum, with the goals of decreasing the risk of positive margins, allowing for less radical surgery, serving as an ‘‘in vivo assay’’ of the effectiveness of the treatment (alternatively the behavior of the tumor), or realizing a benefit in overall or disease-specific survival.
The ultimate application of our increasing understanding of tumor biology is seen in the development and tailoring of targeted agents to patient- or tumor-specific factors. Targeted agents, such as imatinib for the treatment of gastrointestinal stromal tumors (GIST), represent an entirely new era in the delivery of optimally effective therapy with fewer side effects. Assessing tumor characteristics for particular gene expression such as Her2/Neu or mutations such as exon-11 mutation in GIST that render the tumor most susceptible to imatinib also allows for more specific selection of therapies most likely to be effective in a given patient.
As surgeons and other providers for cancer patients move forward, it is clear that tumor biology will play an increasing role in cancer-related research and clinical decision making. Surgery remains a cornerstone in the treatment of many cancer types, but the application of this therapy and the anticipated outcomes may be influenced by the underlying tumor biology, and an understanding of this can contribute to appropriate patient selection for surgery. The selection of patients for clinical trials may include stratification for underlying tumor characteristics, which may affect decisions such as whether to obtain a preoperative tissue diagnosis. Finally, with more widespread use of an ever-expanding array of preoperative therapies, it is important for surgeons to understand the impact these agents have on perioperative decisions. For example, operative timing may be influenced by the administration of bevacizumab, which has been associated with increased bleeding complications in certain situations.
Oncology is evolving as a multi-disciplinary field, and it is more important than ever that surgeons have a familiarity with other disciplines involved in cancer care. The articles presented in this issue of Surgical Clinics of North America serve to update the practicing surgeon on the recent changes in the multidisciplinary approach to cancer care.
Kimberly M. Brown, MD
Margo Shoup, MD, FACS
Contents
The Molecular Basis of Cancer and the Development of Targeted Therapy
KEYWORDS: Targeted, Molecular, Genomic oncogenes, Epigenetic, Breast tumor suppressor
Measuring Outcomes in Oncology Treatment : The Impor tance of Patient-Centered Outcomes
KEYWORDS: Patient-centered outcomes, Patient satisfaction, Decision regret, Patient preference, Health-related quality of life, Survey instrument design
Surgical Palliation: Getting Back
KEYWORDS: Surgical palliation, Palliative triangle, Advanced malignancy, Quality of life
Multimodal Treatment for Head and Neck Cancer
KEYWORDS: Head and neck squamous carcinoma, Multimodal treatment, Organ preservation, Radiation
The Role of Minimally InvasiveTreatments in Surgical Oncology
KEYWORDS: Laparoscopy, Endoscopy, Cancer, Minimally invasive surgery
Multidisciplinary Approach to Esophageal and Gastric Cancer
KEYWORDS: Esophageal cancer, Gastric cancer, Surgery, Chemotherapy, Radiation therapy, Neoadjuvant, Adjuvant
Liver-Directed Treatment Modalities for Primary and Secondary Hepatic Tumors
KEYWORDS: Liver-directed therapies, Hepatocellular carcinoma, Colorectal metastases, Ablation, Radiotherapy, Percutaneous ethanol injection, Embolization
Multidisciplinary Approach toTumors of the Pancreas and Biliary Tree
KEYWORDS: Pancreas, Pancreatic cancer, Pancreatic cyst, Gallbladder cancer, Cholangiocarcinoma
Multidisciplinary Care for Patients with Breast Cancer
KEYWORDS: Breast cancer, Chemotherapy, Staging, Neoadjuvant therapy, Radiation therapy, Breast cancer surgery, Breast imaging
The Multidisciplinary Management of Rectal Cancer
KEYWORDS: Multidisciplinary, Rectal cancer, Surgery, Radiation therapy, Adjuvant chemotherapy
Multidisciplinary Treatment of Gastrointestinal Stromal Tumors
KEYWORDS: Gastrointestinal stromal tumors, Diagnosis, Treatment
Soft Tissue Sarcomas: Current Management and Future Directions
KEYWORDS: Soft tissue sarcoma, Radiation, Cancer, Chemotherapy, Tissue sampling
The Surgical and Systemic Management of Neuroendocrine Tumors of the Pancreas
KEYWORDS: Neuroendocrine tumor, Surgical resection, Metastatic neuroendocrine tumor, Surgical intervention
Multidisciplinary Treatment of Primary Melanoma
KEYWORDS: Melanoma, Sentinel node, Immunotherapy, Interferon, Melanoma vaccine, Thin melanomas, Breslow thickness
The concept of outcomes for cancer patients has expanded beyond the traditional endpoints of overall survival and disease-free survival, as discussed in the article by Drs. Oliver and Greenberg. Organ preservation, quality of life, pain control, and other patient-centered outcomes are now used in the comprehensive assessment of the quality of cancer care. Newer tools to reproducibly measure these outcomes have been developed and continue to be tailored and improved. In addition, palliation may be a treatment goal for those patients in whom a cure is not a realistic outcome. The field of palliative care is a relatively new one, and Dr. Thomay and colleagues discuss the approach to palliative care within the framework of the palliative triangle. Surgeons maintain a central role in the treatment of many types of cancer, often assuming a leadership position in the decision-making team. Therefore, it is critical for surgeons to have a comprehensive knowledge of the treatment modalities employed in the multidisciplinary approach to cancer care. Well-designed studies have shown that less invasive treatments can yield comparable oncologic outcomes to more radical treatments, allowing for organ preservation. One example includes treating certain early-stage squamous cell cancers of the upper aerodigestive tract with radiation instead of surgery, as discussed by Dr. Lango in this issue. Minimally invasive treatment may extend to local therapies, such as radiofrequency ablation in the liver or trans-anal local excision for early-stage rectal cancer, sparing patients larger surgeries or allowing for sphincter preservation.
Another impact of tumor biology on treatment strategy is the alteration of the order in which treatments are traditionally delivered. Chemotherapy or chemoradiotherapy prior to surgery may be employed in cancers of the esophagus, stomach, breast, liver, pancreas, or rectum, with the goals of decreasing the risk of positive margins, allowing for less radical surgery, serving as an ‘‘in vivo assay’’ of the effectiveness of the treatment (alternatively the behavior of the tumor), or realizing a benefit in overall or disease-specific survival.
The ultimate application of our increasing understanding of tumor biology is seen in the development and tailoring of targeted agents to patient- or tumor-specific factors. Targeted agents, such as imatinib for the treatment of gastrointestinal stromal tumors (GIST), represent an entirely new era in the delivery of optimally effective therapy with fewer side effects. Assessing tumor characteristics for particular gene expression such as Her2/Neu or mutations such as exon-11 mutation in GIST that render the tumor most susceptible to imatinib also allows for more specific selection of therapies most likely to be effective in a given patient.
As surgeons and other providers for cancer patients move forward, it is clear that tumor biology will play an increasing role in cancer-related research and clinical decision making. Surgery remains a cornerstone in the treatment of many cancer types, but the application of this therapy and the anticipated outcomes may be influenced by the underlying tumor biology, and an understanding of this can contribute to appropriate patient selection for surgery. The selection of patients for clinical trials may include stratification for underlying tumor characteristics, which may affect decisions such as whether to obtain a preoperative tissue diagnosis. Finally, with more widespread use of an ever-expanding array of preoperative therapies, it is important for surgeons to understand the impact these agents have on perioperative decisions. For example, operative timing may be influenced by the administration of bevacizumab, which has been associated with increased bleeding complications in certain situations.
Oncology is evolving as a multi-disciplinary field, and it is more important than ever that surgeons have a familiarity with other disciplines involved in cancer care. The articles presented in this issue of Surgical Clinics of North America serve to update the practicing surgeon on the recent changes in the multidisciplinary approach to cancer care.
Kimberly M. Brown, MD
Margo Shoup, MD, FACS
Contents
The Molecular Basis of Cancer and the Development of Targeted Therapy
KEYWORDS: Targeted, Molecular, Genomic oncogenes, Epigenetic, Breast tumor suppressor
Measuring Outcomes in Oncology Treatment : The Impor tance of Patient-Centered Outcomes
KEYWORDS: Patient-centered outcomes, Patient satisfaction, Decision regret, Patient preference, Health-related quality of life, Survey instrument design
Surgical Palliation: Getting Back
KEYWORDS: Surgical palliation, Palliative triangle, Advanced malignancy, Quality of life
Multimodal Treatment for Head and Neck Cancer
KEYWORDS: Head and neck squamous carcinoma, Multimodal treatment, Organ preservation, Radiation
The Role of Minimally InvasiveTreatments in Surgical Oncology
KEYWORDS: Laparoscopy, Endoscopy, Cancer, Minimally invasive surgery
Multidisciplinary Approach to Esophageal and Gastric Cancer
KEYWORDS: Esophageal cancer, Gastric cancer, Surgery, Chemotherapy, Radiation therapy, Neoadjuvant, Adjuvant
Liver-Directed Treatment Modalities for Primary and Secondary Hepatic Tumors
KEYWORDS: Liver-directed therapies, Hepatocellular carcinoma, Colorectal metastases, Ablation, Radiotherapy, Percutaneous ethanol injection, Embolization
Multidisciplinary Approach toTumors of the Pancreas and Biliary Tree
KEYWORDS: Pancreas, Pancreatic cancer, Pancreatic cyst, Gallbladder cancer, Cholangiocarcinoma
Multidisciplinary Care for Patients with Breast Cancer
KEYWORDS: Breast cancer, Chemotherapy, Staging, Neoadjuvant therapy, Radiation therapy, Breast cancer surgery, Breast imaging
The Multidisciplinary Management of Rectal Cancer
KEYWORDS: Multidisciplinary, Rectal cancer, Surgery, Radiation therapy, Adjuvant chemotherapy
Multidisciplinary Treatment of Gastrointestinal Stromal Tumors
KEYWORDS: Gastrointestinal stromal tumors, Diagnosis, Treatment
Soft Tissue Sarcomas: Current Management and Future Directions
KEYWORDS: Soft tissue sarcoma, Radiation, Cancer, Chemotherapy, Tissue sampling
The Surgical and Systemic Management of Neuroendocrine Tumors of the Pancreas
KEYWORDS: Neuroendocrine tumor, Surgical resection, Metastatic neuroendocrine tumor, Surgical intervention
Multidisciplinary Treatment of Primary Melanoma
KEYWORDS: Melanoma, Sentinel node, Immunotherapy, Interferon, Melanoma vaccine, Thin melanomas, Breslow thickness