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Editorial |
Department of Surgery, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, UDP Suite 2500, 42 East Laurel Road, Stratford, New Jersey 08084
Correspondence: Address correspondence and reprint requests to: James L. Weese, MD, FACS; E-mail: weesejl{at}umdnj.edu.
As our ability to "treat" patients with advanced malignancies continues to progress, cancer surgeons are continually faced with the dilemma of how far to push the envelope of our capabilities. Because the cost of health care in America has now reached 14.9% of the Gross National Product, there will be increasing scrutiny of our activities as physicians. Despite Medicare regulations, more restrictions regarding payment for off-label use of chemotherapy agents and other drugs may be forthcoming.1 From a surgical perspective, the risk-benefit analysis for a given procedure in a given patient will become an increasingly important analysis in our approach to surgical therapy for patients with cancer. It is also obvious that quality indicators will soon be considered in reimbursement to hospitals and physicians.
The importance of these decisions magnifies the role that surgical oncologists must take in directing care for patients with cancer. I have always considered a surgical oncologist to be a surgeon who knows when not to operate on cancer. Although it is true that surgery has cured more patients with cancer than has any other modality, little attention has been placed on whether a given operative procedure is in the patient’s best interest. Certainly, with the ready availability of information, accurate or otherwise, that is found by patients or families on the Internet, surgeons are often put in the position of "trying something." If one surgeon turns a patient down, the patient will often find another willing and, it is hoped, equally or better qualified surgeon to safely care for him or her. Unfortunately, in times of reduced reimbursement and increased competition for patients, those less scrupulous of our colleagues have no qualms about taking on cases that may exceed their judgment or technical capabilities. Once a patient is asleep, the decision to open and close unnecessarily or, even worse, to start a procedure beyond a surgeon’s capability to finish safely has little oversight.
HOW SHOULD WE BE TEACHING JUDGMENT TO OUR RESIDENTS?
In an academic environment, the situation is potentially much worse. How should we teach our residents—limited to an 80-hour work week—to care for a patient with localized or advanced cancer? With the monetary requirements brought on by increasing expenses (malpractice, office staff, billing, collections, insurance issues, and so on), the drive to perform more operations more quickly has become an increasingly forced consideration of the times. The difference in time between performing a radical cancer operation versus a more limited procedure, such as one might consider in a patient with benign disease, is brought to our attention daily by our residents rotating with both private practice and university surgeons. The model of the financially very successful general surgeon who can perform 6 to 10 operations a day at various hospitals leaves little time for teaching and less time to handle a challenging problem with the best interest of the patient always in mind. It also provides little time for appropriate preoperative and postoperative management of their patients.
This issue, continuously raised at academic surgical case conferences, reinforces the problems faced in teaching surgical judgment. Under usual conditions, the proper surgical approach to a patient with a complex small-bowel obstruction should include an extensive lysis of adhesions that preserves all functional bowel. Assuming the ability to perform this and the time required, it provides the best chance to avoid the long-term problems of short gut syndrome. Such procedures often take many hours, but if they are performed properly, the patient can retain the entire small bowel and escape without an iatrogenic enterotomy or an unnecessary resection and anastomosis. Despite the patience and skill required to perform such a tedious operation, the reimbursement is quite low. A surgeon in a greater rush because of a presumed need to perform an additional series of operations the same day finds it much easier to resect the bulk of the affected bowel with either an anastomosis or an ostomy. Although this may result in a significantly higher payment, it often leads to further problems for the patient. They may require an additional operation (to reverse an ostomy), which can also require additional segmental bowel resections. More importantly, it increases the risk for the patient to develop short gut syndrome or malabsorption and subjects the patient to unnecessary morbidity and mortality. Comparing the surgeon who performs five fast procedures with the one who performs a long, tedious operation that might be in the best interest of the patient, which surgeon will tend to be the role model of today’s young residents? Because a critical part of resident training involves surgical judgment, this has the potential for disastrous judgment in our next generation of surgeons.
CHOICE OF OPERATION
There are numerous ways to solve most surgical problems. Many local recurrences can be traced back to at least an anatomically or technically compromised operation. How often does a reexploration for a locally recurrent rectosigmoid cancer demonstrate the presence of the entire sigmoid mesentery? Frequently the prior operative note describes a "radical left colectomy" when it is obvious that this was not performed. This abbreviated procedure may shave time off an operation but does so at the expense of a possible cure for a given patient.
Adjuvant and neoadjuvant therapy are combined-modality treatments coming of age as they are tested and refined. As surgical oncologists, we have been critical in the development of concepts and techniques to maximize cure while minimizing deformity and loss of function. In breast cancer, rectal cancer, pancreatic cancer, and other neoplasms, the value of neoadjuvant and adjuvant therapy has become more acceptable as part of combined-modality treatment. It is important that we be at the forefront of clinical trials—testing new treatments against standard therapy—in those diseases with <100% cure rates. It is also important that innovative therapy be developed in patients who still have tumors with dismal cure rates, such as esophageal and gastric cancer. The importance of these clinical trials needs to be reinforced as part of our residents’ education.
CURATIVE SURGERY FOR METASTATIC DISEASE
When patients with metastatic disease are evaluated, the intent of an operation must be clearly understood. The criteria for resectability for cure are well defined. When more extensive disease is found, the intent of an operation often shifts to a palliative mode. Because many of these patients do not have symptoms, it is critical to remember that it is hard to palliate an asymptomatic disease with an operation. In some cases, it is better to close rather than proceeding with an operation that offers a patient no chance for cure yet carries significant morbidity and mortality.
In certain highly selected patients, limited meta-static disease can be resected or treated for cure. Patients with four or fewer liver metastases from colorectal cancer that are limited in extent can undergo resection for cure.2 Recent data have also suggested that cryoablation3 or radiofrequency ablation4 in similar appropriately selected patients can also be curative. Likewise, patients with a limited number of lung metastases from colorectal cancer can be resected for cure.5 Multiple lung metastases in patients with osteosarcomas can be resected for cure.6 In all of these situations, it is critical that there be no additional metastatic sites and that the primary tumor be fully controlled.
With the reduced morbidity and mortality of lesser ablative operations, there is an increasing temptation to treat patients who would not be considered resectable for cure. Reports of ablation of >10 liver metastases have been presented, but the critical question of whether this benefits the patient or the surgeon’s ego must be asked.7 Just because an operation can be performed technically, it is important to ensure that the risk taken stands to benefit a patient in the short and/or long term.
PALLIATIVE SURGERY
The patient with terminal disease who presents with a surgical problem is often the greatest challenge to surgical judgment. When a surgeon is asked to evaluate a patient for palliative surgery, important questions need to be asked. Palliation refers to improvement in the quality of life. Most often this involves improvement of symptoms. One of the most frequent traps for a surgeon is the understanding that it is hard to palliate an asymptomatic disease. Therapy must be individualized for each patient. Radical surgery for a patient with a life expectancy measured in days to weeks makes little sense, and yet is an unfortunately common occurrence.
WHEN THE SITUATION IS HOPELESS
Surgeons don’t like to give up; therefore, I have defined a surgical oncologist as a surgeon who knows when not to operate on cancer. Patients with terminal disease make these decisions most difficult. Although our colleagues in medical oncology find it hard to stop therapy, with upcoming cost containment, there will be more utilization of evidence-based therapy. Whether appropriate or not, recent data suggest that insurance carriers will soon try to stop paying for off-label use of chemotherapy agents and for poor operative results. When this happens, surgical judgment will become even more critical.
The American College of Surgeons has recognized the importance of hospice and palliative care in the continuum of patient treatment. As surgical oncologists, we must take the leadership role in managing patients with terminal disease. End-of-life care must be incorporated into surgical residency programs. Residents must learn the importance of the transition from aggressive surgical care to operations for palliation to true end-of-life care, where the focus is on pain control and maintaining function and quality of life.
CONCLUSIONS
Although surgical oncology is not recognized as a separate discipline by the American Board of Surgery, the treatment of patients with cancer requires special skills and knowledge. This is not meant to imply that well-trained general surgeons cannot treat patients with cancer; however, the care of these patients must incorporate a thorough knowledge of the anatomy, etiology, physiology, prevention, and staging of cancer, as well as a thorough understanding of multidisciplinary management of malignant disease. Particularly in these difficult times of decreasing reimbursement and physician dissatisfaction with the profession, it is imperative that the future generations of surgeons have the critical skills and understanding for the overall treatment of patients with cancer. Most importantly, we must teach residents the surgical judgment to deal with these patients in the most appropriate manner according to the needs of each specific patient.
Our role as surgical educators and mentors cannot be understated. The next generation of surgeons must be well prepared and educated to understand malignant disease and care for this important group of patients.
Received for publication September 1, 2004. Accepted for publication December 22, 2005.
REFERENCES
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