At the outset, it is important to clarify the difference between cancer surgery and surgical oncology. The former is a process by which a surgeon separates a tumor from a patient, whereas the latter is a cognitive discipline in which the practitioner provides care as an oncologist who uses surgery as her or his main modality of therapy. By implication, the surgical oncologist not only knows how to perform a given surgical procedure but also, equally important, knows when to perform that procedure, taking into account the role of other modalities of treatment, the natural history of a malignant disease, quality-of-life implications, and related issues, as will be discussed below. It is of note that providing this type of expertise is independent of board certification status in complex surgical oncology because many general surgeons have not undergone formal surgical oncology training per se yet have extensive experience from which to draw. The discipline of surgical oncology is a cognitive as well as a technical approach to the solid tumor patient.
Multidisciplinary care of cancer patients incorporating medical oncology, radiation oncology, immuno-oncology, and surgical oncology care is paramount to optimal patient outcomes. There are key oncologic principles and concepts that all surgeons should consider in the surgical care of cancer patients. These concepts span the continuum of care from patient workup, to selection of treatment modalities, to technical aspects of surgery, and to the perioperative and postoperative care of cancer patients.
SURGICAL EVALUATION AND WORKUP
Patient history and physical examination remain invaluable in providing a clinical background needed to understand the current disease status of a specific cancer patient. Specific details related to patient history and, importantly, pathology help to inform cancer clinicians about the natural history, stage of malignancy, and anticipated cancer course. Hence it is paramount to establish an unequivocal pathologic tissue diagnosis; this also accounts for what we increasingly appreciate is the reality of significant tumor macroscopic and molecular heterogeneity between and within tumors. Likewise, an awareness of underlying genetic and epigenetic differences within and between tumors will facilitate personalized treatment strategies that can overcome confounding issues, now and in the future.
Given the importance of pathologic diagnosis, it is helpful to collaborate closely with disease-specific surgical pathologists. Clinical perspectives conveyed by the surgeon may inform and influence pathologic workup, for example, selection and interpretation of specific pathology testing that may include immunostaining, immunohistochemistry, receptor status, and testing for genomic alterations or signatures to optimize treatment choices, especially regarding systemic therapy.
In the past, our understanding of a given cancer was based increasingly on light microscopic, but now molecular diagnostics help inform cancer clinicians about the potential utility of various treatments in a multidisciplinary strategy involving optimal sequencing of therapeutic modalities. Given that the biopsy can sometimes disrupt the tumor even under the best of circumstances, with resulting hematoma or normal tissue ...