August 2019, Volume XXXIII, No 5
Multidisciplinary tumor conferences
A surgeon’s perspective
ancer is a complex diagnosis, with more treatment opportunities than ever before. Advancements are most apparent in three areas: oncology medication, including neoadjuvant therapies and bio-markers; radiological technology, such as 3D imaging and tomography; and surgical techniques, including robot-assisted and laser surgery. Surgical treatment may vary significantly, depending on the type of tumor and the decision about adjunct therapies.
Because of these rapid developments, surgeons are becoming further involved in a patient’s care, both before and after surgery. Our input can help determine whether a patient is a surgical candidate at all, or if it is in the patient’s best interest to operate first versus providing chemotherapy and/or radiation therapy first. More and more, we find ourselves providing the counseling, screening, prevention, resource management, and palliative care.
Providing the best care in conjunction with the patient’s wishes requires collaborative thinking from a multidisciplinary team of physicians, advance practice providers, non-physician caregivers, and support systems representing the full scope of cancer care. This team is often called a multidisciplinary tumor conference.
Value of a multidisciplinary tumor conference
A high-functioning cancer care team needs to talk often, not only because of the rapid changes in technology, but also because of changes in a patient’s condition. Most often, this occurs in the formal setting of a regularly scheduled multidisciplinary tumor conference. At Specialists in General Surgery, all of our stage 3 and 4 patient cases are presented at such a conference on a weekly basis. The Commission on Cancer (CoC) requires such a conference for all accredited cancer centers, and we are lucky to have 28 such accredited centers in Minnesota.
According to the CoC, required cancer committee members must include at least one physician representing each of the diagnostic and treatment services. Other required physician members include diagnostic radiologists, pathologists, surgeons, medical oncologists, radiation oncologists, and cancer liaison physicians.
A multidisciplinary tumor conference for an accredited facility also requires several non-physician members, such as cancer program administrators, oncology nurses, and palliative care professionals.
We work as a multidisciplinary team with primary care physicians and oncologists.
These conferences help members of the care team conduct meaningful conversations with patients and their families. Our goal is always to empower our patients with information to help them understand the risks and options of their unique treatment plan in order to achieve their specific goals. For some, this may be to preserve life at whatever cost. For others, it might be to manage pain, avoid chemotherapy, or reduce life-threatening side effects. For those patients who have not set specific goals, we can help them gain clarity and direct them to resources such as advanced directives, living wills, and physician orders for life-sustaining treatment (POLST). As surgeons, our role is to ensure the team, the patients, and their families understand the “why” behind our recommended approach.
Reasons for surgery in cancer patients
As surgeons, our discussion encompasses the many reasons to consider or not consider surgery in the treatment of cancer, explaining our objectives to:
Reduce cancer risk. For some patients, surgery can be used to reduce their risk of developing cancer. Women with a strong family history of breast or ovarian cancer, for example, or those who carry the BRCA1 and BRCA2 breast and ovarian cancer genes, may choose prophylactic surgery to reduce their risk. Patients with a family history of colon cancer often choose to have more frequent colonoscopies to remove precancerous polyps before they develop into colorectal cancer.
Locate a cancer. Once cancer has been suspected, surgery is important at several stages of a patient’s diagnosis and treatment. In some cases, surgery is necessary simply to locate the cancer and determine how far it has spread.
Diagnose and stage. For most types of cancer, a biopsy is the primary diagnostic tool. We also frequently remove lymph nodes for testing. For some tumors, the method of biopsy can affect the staging of the tumor, which, in turn, affects the intensity of the treatment.
Remove the cancer. When cancer is found in only one part of the body, our goal is to remove the entire cancer. When that’s not possible because removal would cause too much damage to nearby organs or tissues, we debulk it to remove as much as possible to minimize side effects.
Reconstruct tissue. Some cancers can be more disfiguring than others, especially tumors around the head and neck. Melanomas found deep within the skin often require the removal of significant amounts of tissue and may require reconstructive surgery. Breast cancer patients who have had a mastectomy also may choose to have reconstructive surgery. Reconstructive surgery can be performed at the same time as the initial surgery or later.
Provide palliative care. Cancers that cannot be removed can grow and cause pain and loss of function unrelated to the cancer itself. Nerves can be compressed. Intestines can become blocked. Bleeding can occur. Palliative surgery is performed to help relieve some of these symptoms and improve a patient’s quality of life.
Surgical techniques for patients with cancer
We also discuss the many different surgical techniques used to treat cancer today. More and more surgeries are taking place in doctor’s offices, clinics, and ambulatory surgery centers instead of hospitals, thanks to new surgical techniques that are less invasive. Our surgeons perform several different kinds of surgery on patients with malignancies, depending on the patient’s medical condition, the extent of the cancer, and the patient’s preference.
Our goal is always to empower our patients.
Open surgery is usually the preferred option for large tumors, those that involve a large portion of the body, or those that involve complex surgeries. Pancreatic cancer, for example, is often treated with an open surgery procedure called a Whipple or pancreaticoduodenectomy. During this operation, we remove the head of the pancreas, as well as nearby bile ducts and lymph nodes, the gallbladder, and sometimes part of the stomach.
Minimally invasive laparoscopic surgery, in which we insert a small camera along with the surgical instruments, involves only small incisions. This leads to faster recoveries, less blood loss, shorter hospital stays, and often less need for pain medication. Laparoscopic surgery is often used for cancers of the colon, liver, prostate, uterus, and kidney.
Robot-assisted minimally invasive surgery has seen a significant growth in the past few years. Many robotic surgeries today are performed with the da Vinci Surgical System. Robotic surgery has many patient advantages, including a shorter length of stay. Many patients go home the same day of the operation. The incisional scars are smaller and less visible. Studies also have shown that surgeries using a robotic procedure result in fewer complications and less pain medication. The 3D visualization of a robot provides surgeons a better view of the surgical site when compared to laparoscopic procedures. This is especially important for obese patients or those with scar tissue or tortuous blood vessels. Robotic instruments also have a greater range of motion, resulting in greater surgical precision and access. At Specialists in General Surgery, we have performed many oncologic operations using the robotic platform, including colon, liver, and even the Whipple procedure for pancreatic cancer.
Endoscopic surgery can remove samples of suspicious tissue in the esophagus, stomach, and duodenum through an endoscope inserted into the mouth. No incisions are needed.
Laser surgery is most often associated with eye surgery, but surgeons also use this narrow beam of high-intensity light to remove cancerous cells in soft tissue, such as the skin, the lungs, and the gastrointestinal system. With fiber optics and special scopes, the laser can be introduced through natural body openings without having to make an incision. Lasers also are used in photoablation and photocoagulation procedures to destroy tissue and relieve symptoms. An example might be a tumor that blocks the trachea or esophagus and interferes with breathing and swallowing.
Cryosurgery uses liquid nitrogen to freeze and destroy abnormal cells. It sometimes is used to eliminate pre-cancerous conditions of the skin, and also can be used to treat cancers in the liver and prostate.
Mohs surgery, also called micrographic surgery, is a process that shaves off skin cancer a layer at a time until microscopic inspection detects no abnormal cells. It is the gold standard for treating many squamous cell carcinomas.
It takes a team
Today, we work as a multidisciplinary team with primary care physicians and oncologists to approach the cancer patient’s disease process and treatment under a holistic model.
We even have created pre-optimization clinics to help improve nutrition, taper medications, create healthy expectations, and get the patient mentally and physically ready for his or her operation.
Cancer is a complex disease. The more we can do to make the diagnosis and treatment options easy to understand, the more we can maximize a patient’s experience and optimize his or her outcomes.
© Minnesota Physician Publishing · All Rights Reserved. 2019
Kamrun Jenabzadeh, MD, FACS, is a surgeon with Specialists in General Surgery. He performs more than 400 surgeries every year and has performed more than 900 robot-assisted operations. Dr. Jenabzadeh is board-certified in general surgery by the American Board of Surgery and is a member of the American College of Surgeons, the American Medical Association, and the Americas Hernia Society Quality Collaborative.