The role of surgery in the treatment of cancer has seen a dramatic change over the past century, from that of the only chance for cure to becoming one weapon in an armamentarium of oncologic therapies. As the role of surgery changes, so has the role of the surgeon, evolving from cancer surgeon to surgical oncologist. This role continues to evolve, as the management of cancer is altered by increased knowledge of genetics, molecular biology, and tumor immunology. Although surgery has historically been the first line of defense against a tumor, the escalating use of neoadjuvant therapies often shifts surgery to the second or third line. The role of surgery has expanded from that of purely therapeutic to include both palliation and prophylaxis. Inasmuch as surgeons are the ones with direct access to tumors, they have cemented their role as physician-scientists, investigating novel molecular and immunologic therapies. As new discoveries continue to transform our approach to cancer, the field of surgical oncology will continue to evolve (Table 4.1).
The surgical treatment of superficial cancers is clearly not a new concept. Some of the oldest medical records in existence, Egyptian papyri dating back to 1700 B.C., describe the cautery destruction of the breast.1 Celsus and Galen, Roman physicians of the first and second centuries A.D., wrote about breast cancer operations, and the Greek physician Lenoidas described a mastectomy for breast cancer, including the use of cautery for hemostasis, in the 5th century A.D. Surgery was obviously limited to superficial tumors, and even that approach was halted throughout the dark ages of medicine. Ultimately the humoral theories of disease (blood, phlegm, white bile, and black bile) were replaced by scientific experimentation, and the principles of modern medicine began to take shape.
The principles of surgical oncology, along with several other fields, found their start with John Hunter (1728-1793), often referred to as the father of surgery. He first described many of the concepts of surgical oncology, including the idea that cancer could be a localized process that was potentially amenable to surgical cure. He stressed the need for total removal of the cancer along with the potential areas of lymphatic spread a century before Halsted's theory. These theories would not realize themselves, however, until the surgery itself became more feasible through a better understanding of anatomy and pathology through autopsies, the introduction of general anesthesia in 1842, and the principles of antisepsis, first described by Lister in 1867. This knowledge allowed surgical oncology to expand beyond superficial tumors, such as breast cancer, to the treatment of intraabdominal malignancies.
The next few decades would see the description of several major operations for cancer, including many by Theodore Billroth of Vienna, who could probably be considered the first surgical oncologist. He is most well known for the first successful partial gastrectomy for cancer (1881), but he also described the first total laryngectomy (1873), the first hemipelvectomy (1891), and the first suprapubic removal of a bladder tumor.2 Other notable milestones include the resection of colon cancer (Weir, 1885),3 the radical mastectomy (Halsted, 1891),4 the radical hysterectomy for cancer (Kelly, 1895),5 the first radical neck dissection (Crile, 1906),6 and the first abdominoperineal resection for rectal cancer (Miles, 1908).7
Throughout the first half of the 20th century, surgery remained the mainstay of cancer treatment. Although these major operations were not without significant mortality and morbidity, the risks of surgery were still outweighed by the potential for cure or palliation of symptoms. It is during this time that the phrase cancer surgeon was popularized, as the only major advances in cancer care were surgical. Cancer surgeons were in abundance at the major medical centers and were the clinical leaders at the few dedicated cancer centers.
The mid-20th century saw advances in cancer therapies outside the realm of surgery. Roentgen's discovery of X-rays in 1896 ultimately led to radiation treatments for surface cancers such as those of the cervix, head and neck, or breast. Chemotherapy entered the scene with the discovery of the alkylating agent nitrogen mustard in WWII,8 the folic acid antagonists reported by Farber in 1948,9 and the concept of hormonal alteration proposed by Nobel laureate Charles Huggins in 1941.10 It soon became apparent that cancer could be treated using more than one modality. It was at this time that the field of oncology began to mature, with clinical chemotherapists becoming known as oncologists. James Ewing, a pathologist who had experimented with immunotherapy, chemotherapy, and radium, established the multidisciplinary approach to the treatment of cancer with his book entitled Neoplastic Diseases.
In the mid-1960s, the term surgical oncology first arose; however, this phrase served to differentiate not between
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