Tuesday, February 20, 2007

Beating The Spread




If I could actually accomplish something with this blog, I'd like to put one notion forever to rest (I'm reminded of it by a commenter on a recent post.) There's an all-too-common conception out there; pernicious and pervasive, untrue as it can be, it's scared many prospective surgery patients nearly to death. In some cases, in believing it, it has quite literally done so. I've written the occasional humorous post: about this I'm deadly serious, so I'll say it very clearly:

Surgery does NOT cause curable cancer to spread.

I've heard the thought expressed a million times, and I have no doubt that every other surgeon has as well. "Doctor," they'll say, earnestly, fearfully, directly. "I heard that surgery makes cancer spread. Soon as they open your belly, when the air gets to it, it goes all over the place, and you die. I'm really scared to have an operation." Who wouldn't be, having heard such a thing? I think I know where it comes from: as with, I'd suppose, some other superstitions, there's a kernel of truth.

I've been there: operating with the intention of doing a curative (or at least durably palliative) cancer operation, only to find, entirely unexpected, that the cancer is widely spread throughout the abdomen. Sometimes the only option is to close up, accomplishing nothing. And surgery which doesn't do good is, by definition, bad. The effects of anesthesia, the demands of healing are, by themselves, adverse. So it's reasonable to think that the angle of decline could be made steeper by an operation that produces nothing positive, in the context of already far-advanced cancer. But it's not that surgery spread the cancer; nor that exposing it to air had an adverse effect. It's that it was too far gone at the time of the operation. Sadly, it happens. Even when palliation is attempted, it's not always as long-lasting as we'd have hoped. The stories, I think, are born of this.

When asked the question -- which I was, frequently -- I pointed out that everyone who's ever been cured of cancer -- and there are millions of them -- began with an operation. No cancer is treated without first being diagnosed in a laboratory, and that means, at minimum, getting a surgical sample for analysis. In most cases, it means an operation to extirpate the tumor. So clearly, surgery doesn't cause cancer to spread like wildfire: were that the case, there'd never have been a cure. Ever. Because virtually every cancer patient has had some sort of operation, often a major one, right at the start.

In approaching cancer, we are as far from the ideal as one can imagine. The day will come -- I'm certain of it -- when treatments will be devised based on a specific tumor -- quite possibly each individual one -- and which will attack only the cancer cells, leaving everything else undamaged. Radiation and chemo, if they exist at all, will be highly targeted and specific. The inklings are here already. Surgery, when needed, will be much more minimal than now; what we do currently will be considered, in a few decades, barbaric. But it does work. We all know people who've been cured, brutal as it may have been. I know lots of them, intimately.

Take it from me, who has been fortunate to have done many hundreds of curative cancer operations: when the timing is right, surgery works. If it happens to you, get yourself a surgeon and oncologist you trust, find out everything you need to know to get comfortable, and go for it. I want you around, so you can keep reading my blog.

25 comments:

enrico said...

This is one of the unfortunate things I had to explain to certain members of my wife's family when my sister-in-law died prematurely of ovarian cancer a couple of years ago. She had recently undergone plastic surgery being long done having her kids years ago, and some family members were convinced that either 1) the surgery (abdominoplasty+face lift) caused it directly, or more absurdly, that 2) "something" (using my words, an "infectious agent") "got in there while they had her opened up."

It's hard not to be judgmental about that kind of superstitious nonsense, but it doesn't take a stretch to see the obvious need to search for meaning at a time of profound loss--especially one so prematurely gone. (There is, however, a distinct line between "meaning" and "blame" which too often becomes blurred.)

But of all the things to be forgiven for in having irrational fears get the best of you, cancer is it. A good surgeon and a well-behaved tumor makes the odds night-and-day better.

Graham said...

I just had the President of the Society of Anesthesiologists give a talk who actually presented some data to the contrary, Sid--but this was related to actually the type of anesthesia used (not surgery itself), the thought being that the anesthesia weakens the immune system, and the immune system is the one thing keeping the cancer in check. Knock out the T cell and NK cell function for a bit and there's increased risk of metastasis and lower survival. No RCTs yet with published data, but it's an interesting idea.

Cathy said...

You remind me of a conversatin that my onc/surgeon and I had prior to my surgery. This was when we had been discussing options and I had chosen radical surgery.

I asked how long I would be in surgery. He told me he would reserve the OR suite for 4 hours. He then told us that if things were worse in there than he thought then he would just close me up and it would be a quick operation.

Time became the most important issue for me with this surgery. I had remembered I went into surgery at about 11:45 AM. When I again woke up, the only thing I thought was "I have to know what time it is"..I kept trying to focus on a clock and couldn't make it out and finally someone figured out what I wanted. When I was told it was then after 6:00PM and I was just getting ready to be transferred out of recovery, I relaxed. It was a wonderful gift.

Julia said...

I encountered that belief myself when taking care of an elderlyish patient this week. It was her daughter who brought it up... her daughter who was wearing nursing scrubs. She and her family had convinced mom for over a year that surgery for a pretty ugly stomach tumor would cause it to spread. They finally agreed when I stated that mom was going to get more frail and have more abdominal discomfort if it wasn't resected. A year. An entire year. I have little hope of her recovery.

Greg P said...

I am not a cancer expert.
While my sense is that what you're saying is true from the perspective you are talking about, it seems to me I have read that there may be some cancers, and I think prostate cancer was one, in which there may be some humoral or other feedback which may cause tumor which has spread already to be rather indolent because of the total mass of tumor present. Then when there is a significant reduction in mass by whatever means tumor previously quiet becomes more aggressive.
Do you think there is any truth to this? Does it make sense to you?

may said...

i guess some people just want somebody to blame when a surgery does not totally cure cancer.

it is jsut unfortunate that you surgeons get the pointing finger, when really, it is the ugly cancer that is the culprit.

may
www.aboutanurse.com

Sid Schwab said...

Greg: the specific thought that tumor reduction is harmful is counter-intuitive, in the sense that "debulking" is a supported concept for many tumors: studies have shown (perhaps a bit questionably in some cases) that reduction of the tumor "burden" increases effecacy of certain chemo recipes. The think that bothers me more is the possible seeding of the bloodstream with non-excisional biopsies. There have been studies of that however (specifically in regard to needle biopsies) that haven't shown a risk. I wouldn't be surprised to find that certain combinations of surgery and tumor in specific instances (more likely with palliative surgery) end up doing more harm than good. My point was to address the folklorish fear of any surgery for any cancer, by pointing out that all cures involve surgery of some sort.

Graham: I've heard such thoughts, and imagine good data is needed. I've "felt" (being a "feeler") that the longer the anesthetic the worse it is in many ways, which is why I think surgical speed is an issue sometimes. Something that really disturbed me was a study that in colon surgery, patients who had anastomotic leaks had a better cure rate than those who didn't; the implication being that infection turned on an immune response. It made me wonder if I should become a shittier surgeon. I don't recall seeing that study confirmed....

beajerry said...

Cutting open the body lets out organ spirits which later hide things like your car keys. True fact!

Stephen said...

So that's where my car keys are!

Anonymous said...

my husband works in pathology. And I could be wrong but I thought there are many times that his pager went off to do an OR lung lavage for suspected malignancy to see if the lung could be successfully resected. I could swear that one of the indicators for non-resecting was a type of cancer that could not be exposed to air.....or is that not considered a curable cancer?

Maybe I am one of those people who has heard this in the wrong context. I often misunderstand my husband....and sometimes it is my fault to.

Anonymous said...

( I meant too - that is one of my pet peeve spelling errors so I couldn't let that pass).

My husband is here now and he says it is small cell (aka: oatcell, neuroendocrine carcinoma) cancer of the lung is what he works under the impression that it cannot be exposed to air during surgery - they limit fine needle aspirates for this reason.

But again, he says maybe new evidence has shown that this does not apply anymore (?)

(chemo is usually the therapy of choice? rarely if ever are these malignancies surgically removed in his opinion, but like I said wrongness is in the genes)

Sid Schwab said...

I only did lung surgery in training, but I know enough to find it entirely incredible (meaning not credible) that there's an issue of small cell and air. It's the LUNG, which is FULL of air! It's possible that air-drying some cells disrupts them in terms of lab diagnosis (your husband ought to know about that.) I've never heard ANYTHING about fear of exposing small cell tumor to air in terms of cure.

Anonymous said...

So all those years of missed birthdays, anniversaries, vacations etc was based on a myth?

How low can a husband be? using the excuse that he was saving a life.....

What category for the divorce papers does this fit into? malpractice or fooling around? I guess I have to do an indepth literature search at this point to find the proof.

Here's hoping that your training was missing this characteristic of small cell cancer......

Anonymous said...

The confronted husband in pathology responded thusly:



"....it was believed that exposing small cell carcinoma to air during surgery caused a rapid dissemination of the tumor throughout the body.
This was believed because the tumor is so aggressive that after doing lung surgery several weeks later the tumor would be found in the brain, liver, etc so the thought was that the surgery attributed to this, not realizing the aggressive nature of the cancer......"

(Edited to protect the guilty)

So whadya think: does this let him off the hook?

I was worried that I was going to have to choose between him or you!

emmy said...

On the day of my mastectomy my sister asked my surgeon "Do you really think you should cut on that: it might cause the thing to spread?" I was in stage III cancer as it was! I was dumbfounded! I started to laugh hysterically and my surgeon looked at me and said "well, at least you see the humor in it." Where does that notion come from?

Greg P said...

There is an article in the current issue of Science talking about the problem of cell line contamination of various cell cultures around the world, particular some cancer cell cultures -- the most famous being the HeLa cell line from long ago. (Named for Helen Lasker, a cancer patient who died a long time ago, yet her cancer's cells live on today.) It's mainly an issue for laboratories doing research on cancer cell cultures, but it does lend some support to the idea that some cancer cell lines have an enormous ability to survive beginning with a minor contamination. It would seem that biologically and in vivo this must be true as well.
The problem is, we do not yet have sufficient understanding of why some cancer cells have this property.

Jaysson said...

I'm in no ways a surgeon...I was actually just accepted to medical school. But I was reading an article this morning about TGF-beta, and how its levels increase following surgery, chemotherapy, and radiation. I'm not sure what this really means for what you were saying, but it is interesting nonetheless:

http://www.reuters.com/article/healthNews/idUSN0523151220070406

Sid Schwab said...

It is indeed fascinating: thanks for the link. I hope more comes lf it.

Greg Pawelski said...

Surgeons are the true advocates for the best cancer care for patients. Surgery is the most integral part of the multimodality treatment of many cancers. The surgical oncologist is the first specialist a cancer patient should see before any other oncologic specialists. I would not be surprised that if cancer patients don't get to a surgeon first, the patient loses his/her chances at a successful prognosis because of it. When surgeons are first in command, I'm sure many of them brow beat their medical oncologists to look at cell culture assays very carefully in the context of other known prognostic factors and often choose chemo agents based on their profiles.

I've been invited by a surgeon, who with several of his colleagues have utilized cell culture assays in their clinical judgements, to support a campaign to encourage surgeons to obtain and analyze fresh tissues for both cell culture assay and genetic testing. To look at the results of these assays very carefully in the context of other known prognostic factors and choose agents based on the patient's profiles. He has been promoting public awareness that can ultimately lead to philanthropy to support a major multi-institutional research effort, spearheaded by surgeons.

As increasing numbers and types of anti-cancer drugs are developed, oncologists become increasingly likely to misuse them in their practice. There is seldom a "standard" therapy which has been proven to be superior to any other therapy. When all studies are compared by meta-analysis, there is no difference. What may work for one, may not work for another. Cancer chemotherapy could save more lives if pre-testing were incorporated into clinical medicine.

Donna said...

If I understand correctly, you mentioned something about a biopsy of a tumor, possible loosening cells into the bloodstream---that is if not done with a needle biopsy. If someone is having digestive problems and that scope procedure is done and a small tumor is found between the stomach and esophagus---should or do they do needle biopsies in that area because poking at the tumor to test the cells for malignancy will loosen and spread the cells? Thanks, Donna 12-28-08

Sid Schwab said...

Donna: I re-read my original post and my comments and can't find anywhere that I said what you inferred about needle biopsy. Which is good, because it's not something I believe.

As I said -- and it was the whole point of the post -- every cancer that was ever cured had some sort of procedure to remove all or part of it for sampling.

The type of sampling -- biopsy with needle or knife, removing the whole thing or just a part -- depends on the type of tumor and location, and does not, as far as anyone has been able to determine, affect the success of treatment.

Kamboja said...

For those of us who worry and who have heard the rumors... thank you very much for this blog topic and follow on comments!

Sid Schwab said...

I'm glad you found it helpful.

Jo said...

A good friend sent me this site and I am so very glad she did. I have stage III clear cell ovariancarcinoma with a very large tumor (17x17x10cm)of omental caking, fortunitley there is no invasion in any other organs. As one of Jehovahs Witnesses I do not accept blood products but things as ringers solution, cell salvage et al.....my onc/surgeon (who does perform bloodless surgery) was unable even to attempt this due to the high level of blood loss so he suggested chemo to shrink the tumor and then remove it. The tumor has responded to the extent of "softening" and he has suggested partial removal after a series of EPO treatment for blood building as the chemo has reduced my all around blood numbers. Then more chemo and finally remove the rest of my evil twins! Now this is where you come in....I had heard the "rumors on tumors" and was scared to death...it will spread!!!!! The sky is falling! So here I am reading your blog and feeling my stress diminishing by the moment. Thank you so much, you have given me the freedom to make a choice...sugery!

Sid Schwab said...

I continue to be pleased that my aging blog is still helpful.