Surgical Oncology -Procedures, Side effects, Recovery time, Costs and alternatives

Over the years the treatment of cancers has become a specialty requiring its own area of surgery due to the advancement in the diagnosis, biology, and malignant tumours staging. Traditionally the surgeons treated cancer with either resection or radical surgery for the tumours. Surgical oncology is a field of cancer care that concentrates on making use of surgery for the staging, diagnosing and treating cancers affecting a patient. Surgery has been the oldest form of treatment for cancer.

Surgical oncology is a cancer care field that focus on using surgery to diagnose stage and treat cancer. The oncologists perform palliative surgeries to help control pain and increase comfort level of patient and manage cancer-related symptoms and side effects. Some of the patients may have cancer surgery combined with other treatments, such as chemotherapy, radiation therapy and/or hormone therapy. Depending on cancer type, the tumour size and its location, surgery is performed using techniques, such as laparoscopy or robotic surgery.

A surgical oncologist may be required to conduct palliative surgery. This type of surgery is very helpful in enhancing the comfort level of the patient, managing the symptoms and side effects associated with the cancer treatment, and helping in controlling the pain. Surgery is very commonly used in combination with other oncologic treatments like chemotherapy, and hormone therapy along with radiation oncology for treating a patient suffering from cancer. The non-surgical treatments that are given before a patient undergoes a surgical procedure are termed as neoadjuvant therapy. This therapy helps in reducing the size of the tumor which provides the surgical oncologist with more surgical options. Adjuvant therapy, on the other hand, refers to treatments which are given after the surgery for decreasing the risk associated with the reoccurrence of cancer.

The surgical oncologist usually performs surgery for the following reasons:

• Identifying the region in the body that is affected by cancer.
• To diagnose whether the cancer is affecting the other organs of the body or is it spreading.
• Providing relief from the side effects of radiation therapy, chemotherapy and other non- surgical treatments of cancer.
• Eliminating some or entire cancer-causing tumors.
• Restoring the function and appearance of the body.

A surgical oncologist can perform traditional surgery which is also referred to as open surgery, minimally invasive surgery, and robotic surgery based on the requirement in a patient.

• Appendectomy: - Surgery done to remove an appendix is called appendectomy.
• Bowel resection: - It is a surgical procedure used to treat and prevent cancer and other diseases of the colon by removing part of the large intestine.
• ERBEJET: - ERBEJET2 uses a high-pressure water jet to selectively target and dissect water-soluble tissue and provide precise margins along the line of dissection.
• Flexible robotic surgery: - It is a surgical system with a flexible robotic endoscope.
li>Pneumonectomy: - A surgery in which an entire lung is removed.
• Robotic surgery: -This surgical System offers a minimally invasive alternative to both open surgery and laparoscopy.

There are various surgical techniques which can be adopted by the surgical oncologist based on the need.

Minimally invasive surgery: a surgical oncologist may treat cancer through minimally invasive surgical technique. In this type of surgery small incisions are made through special instruments instead of large incisions which were traditionally made. Some oncologic surgeries which belong to the category of minimally invasive surgery are

• Video-assisted thoracoscopic surgery: it is a minimally invasive surgical technique which is very helpful in both diagnosing and treating lung cancer. In this surgery, either one or smaller incisions are made in the chest followed by insertion of thorascope and surgical tools through the incision. An image of the chest cavity is transmitted to the video monitor for guiding the procedure.
• Endoscopic surgery: this surgery is done on the similar pattern as VATS surgery is performed but instead of making small incisions the scope is inserted through natural openings like mouth, and, nose. This surgery is helpful in the removal of the tumors in colon, esophagus, throat and several other parts.
• Robot-assisted surgery: for performing the robot-assisted surgery the surgical oncologist make use of Gundersen's da Vinci surgical system. The surgical oncologist performs the operation at the state-of-the-art platform designed specifically for this purpose. Making use of this surgical technique helps the surgical oncologist in completing tedious and delicate procedures by making small incisions with unmatched precision. Some of the examples of robot-assisted surgeries are:
• Robotic hysterectomy: in this procedure, the surgeons remove the uterus with enhanced precision and with great control by making use of the da Vinci system.
• Transaxillary robotic hemithyroidectomy for cancer of thyroid: in this surgical procedure the da Vinci system is used for removing half of the thyroid through minimal incisions made in the underarm of the patient.
• Open surgery: this is a type of surgery has been performed for many years by the surgical oncologists. In this surgery a long incision is made to observe and conduct the procedures required for staging, diagnosing and treating cancer. In case of a complex procedure, open surgery is preferred over the approach of minimal invasion.
• ERBEJET: - ERBEJET2 uses a high-pressure water jet to selectively target and dissect water-soluble tissue and provide precise margins along the line of dissection. It is designed to help spare critical structures, like nerves, blood vessels and ducts and may help reduce the potential for blood loss.
• Pneumonectomy: - In this procedure, the patient will be given a general anaesthesia to put the patient to sleep, and an endotracheal tube will be placed through the mouth to allow a ventilator to breathe for the patient during surgery. A long incision will be made along the side following the curve of patient’s ribs. The surgeon will spread patient’s ribs and may remove a portion of a rib to gain access to patient’s lung. When the lung is adequately exposed, the surgical team will collapse patient’s lung that contains the cancer. The major blood vessels traveling to patient’s lung will be tied off, and the bronchus leading to the lung will be tied off and sewn shut. After the lung is removed, the surgeon will carefully check to make sure all bleeding is controlled, and then the incisions will be closed. The remaining space where the lung had been will gradually fill in with fluid.

Persons having any of the symptoms of any of the cancer whether it is of lung cancer, breast cancer, bladder cancer or any other is considered to be eligible for this treatment. Persons, having such symptoms, should inform the doctor as soon as possible and should take treatment procedures. The eligibility of a candidate to undergo cancer surgery depends on several factors like

• Type of cancer: a candidate is eligible for the surgery if cancer which the patient is suffering from is contained locally in the specific area and has not metastasized.
• Location: a candidate becomes eligible for the cancer surgery if the chances of damaging the nearby organs are considerably reduced due to its location.
• Stage of cancer: a candidate becomes eligible for the cancer surgery if the cancer is in its initial stages.
• Age: a candidate is eligible for surgery if the age of the patient is below 60 years.
• Therapies: a candidate is eligible for surgery of cancer if he/she has previously undergone either radiation or hormone therapy.

A person who is suffering from cancer is not eligible for the surgical treatment if he/she satisfies the following condition:

• A patient is considered ineligible if he/she is in the last stage of cancer.
• A patient is considered not eligible for the surgery if the average life expectancy is less than 5 years of age.
• A patient is not eligible for the surgical option if he/she is suffering from other complex medical conditions like hemophilia.
• A patient is considered ineligible for cancer surgery if the surgery risks damaging the vital organs of the body.

Besides these conditions, it is the doctor who decides whether a candidate is eligible for surgery or not.

Any type of cancer treatment has some side effects associated with it. In cancer surgery, the side effects can be experienced by a patient at any time such as during the surgery, immediately after the surgery and in some cases weeks after surgery. The minor side effects that are experienced usually go away after a short duration of time while some major side effects require immediate medical attention. The side effects of the cancer surgery depend upon certain factors like type and location of the cancer surgery, the effect of other cancer treatment, and what is being removed after the surgery. The minimally invasive and robotic surgery procedures for cancer surgeries have minimal side effects like reduced pain and less scarring. The general side effects which may be associated with open cancer surgery irrespective of the location are given below

• Nausea
• Vomiting
• Difficulty urinating
• Surgical site infection
• Bleeding
• Gastrointestinal disorders
• Nerve damage
• Swelling of the limbs
• Allergic reaction to anesthesia
• Scaring

In case any of these side effects persists or there any other health issues arising during or after treatment, kindly consult the doctor immediately.

The post-treatment guidelines help in the recovery of the patient after cancer surgery. The post-treatment guidelines contain a to-do list which must be followed by the patient. Patients are provided with these guidelines after they are discharged from the hospital following their cancer surgery. Some post-treatment guidelines that are required to be followed by the patient after cancer surgery are given below

• A complete course of antibiotic must be done by the patient.
• After surgery once he/she has started eating and walking, the patient is discharged. This depends on other factors too, such as the results of the surgery and tests done afterward. Pain killers will be given in the hospital, and will be given a prescription for medicines to take at home.
• Patients should clean their surgical wounds with sterile bandages.
• Proper hygiene must be maintained by the patient.
• A should continue with their other treatments for cancer like radiation therapy or chemotherapy as advised by the surgeon.
• In case a patient feels any discomfort then it must be immediately brought to the notice of the doctor.
• The patient is encouraged to do deep breathing exercises. This helps fully inflate his/ her lungs and reduces the risk of lung infection (pneumonia).

The complete recovery from cancer may take several months or in some cases, it may take a few years. The recovery time for the patient varies from patient to patient based on his or her health condition. However, a patient undergoing surgery recovers from the surgery within 3 to 4 weeks. One thing that is important to note here is that this recovery time is for the surgical procedure and not for the complete recovery of cancer.The recovery from surgery depends on the kind of surgery the patient had and his/ her overall health. It depends on many factors, including the patient’s health before the operation and how extensive the operation was.

The health care team will try to have the patient move around as soon as possible after surgery. They may even have the patient out of bed and walking the same day. While this may be difficult at first, it helps in speed recovery by getting the patient’s digestive tract moving. It also helps circulation and helps prevent blood clots from forming in legs. The doctor should be informed if having lot of pain so they can give medicine to control it.

The consultation fees for the surgical oncologist in India range from 1000 to 2000 rupees per consultation depending upon the experience and location of the surgical oncologists. A minimally invasive cancer surgery using laparoscope in India costs around 1.5 lakh rupees in a government hospital based on the location of the cancer. In a private hospital, the surgery costs approximately 3 to 5 lakh rupees based on the location and why the surgery is being conducted.The treatment price depends on what treatment is done and what is the problem.

Treatment prices are as follows:-

• Price for lung cancer treatment ranges from 4 to 5 lacs.
• Price for oral cavity treatment ranges from 4 to 4.5 lacs.
• Price for breast cancer treatment is around 6 lacs.
• Price for colorectal cancer treatment is around 5 lacs.
• Price for cervix cancer treatment is around 5 lacs.

The overall cost of cancer treatment in India inclusive of chemotherapy, radiation therapy and surgical procedures is approximately 23 lakh rupees.

The result of the cancer surgery depends on the cause for which the surgical procedure is being done. If the cancer surgery is being done for the treatment then the result is not permanent. A patient may further be required to undergo chemotherapy or radiation therapy sessions after the surgery for complete treatment still there is a chance that cancer might reoccur in the near future.

However, in some cases, the treatment can be permanent if the patient is suffering from prostate cancer and it is not spreading then surgery for removing the cancerous prostrate yield permanent result.

A patient who is suffering from cancer may opt for other modes of treatment apart from surgery. A patient may opt for radiation therapy or chemotherapy for the treatment. A patient can also include some natural remedies for their treatment like drinking green tea. A patient can also make use of ayurvedic herb Ashwagandha for reducing the symptoms of chemotherapy. Some of the alternative treatments are mentioned below but it is advised that the doctor should be consulted before trying anything.

• Acupuncture. During acupuncture treatment, tiny needles are inserted into the patient’s skin at precise points by practitioner. Acupuncture can be helpful in relieving nausea which are caused by chemotherapy. It also helps in relieving certain types of pain in people with cancer. It isn't safe if the patient is taking blood thinners or having low blood counts.
• Aromatherapy. It uses fragrant oils to provide a calming sensation. Oils, infused with scents such as lavender, can be applied to the patient’s skin during a massage, or the oils can be added to bath water. Fragrant oils can be heated to release their scents into the air. It is helpful in relieving pain, nausea and stress. Aromatherapy is safe, though oils applying to the skin can cause allergic reactions. People with cancer such as some breast cancers, should avoid applying large amounts of lavender oil and tea tree oil to the skin.
• Exercise. Exercise help manage signs and symptoms during and after cancer treatment. Gentle exercise may help relieve stress and fatigue and help the patient sleep better. Exercise program helps people with cancer live longer and improve their overall quality of life. Starting slowly, more exercise can be added further.
• Hypnosis. It is a deep state of concentration. During a hypnotherapy session, a therapist may hypnotize the patient by talking in a gentle voice and helping him/her relax. Hypnosis is helpful for people with cancer who are experiencing anxiety, pain and stress. It can also help prevent anticipatory nausea and vomiting that can occur if chemotherapy has made the patient sick in the past.
• Massage. During a massage, the practitioner kneads the patient’s skin, muscles and tendons in an effort to relieve muscle tension and stress and promote relaxation. Several massage methods exist. Massage can be light and gentle, or can be deep with more pressure. Massage is helpful in relieving pain in people with cancer. It also helps in relieving anxiety, fatigue and stress.
• Meditation. Meditation is a state of deep concentration when the patient focus his/her mind on one image, sound or idea, such as a positive thought. When meditating, he/she might also do deep-breathing or relaxation exercises. Meditation helps people with cancer by relieving anxiety and stress.
• Music therapy. During music therapy sessions, the patient might listen to music, play instruments, sing songs or write lyrics. A trained music therapist may lead through activities designed to meet the specific needs of patients. Music therapy helps in relieving pain and control nausea and vomiting.
• Relaxation techniques. Relaxation techniques are ways of focusing attention on calming the patient’s mind and relaxing his/ her muscles. Relaxation techniques includes activities such as visualization exercises or progressive muscle relaxation. This techniques may be helpful in relieving anxiety and fatigue.
• Tai chi. It is a form of exercise that involves gentle movements and deep breathing. Practicing tai chi may help in relieving stress. The slow movements of tai chi don't require much physical strength, and the exercises can be easily adapted one’s own abilities.
• Yoga. Yoga is a combination of stretching exercises with deep breathing. During a yoga session, it requires various body positions in various poses that includes bending, twisting and stretching. It provides some stress relief for people with cancer. Yoga also improves sleep and reduce fatigue.