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CANCER TREATMENTS: SURGERY

Why is surgery needed?

Surgery remains an important element in the treatment of many cancers and it may be proposed for several reasons:

to remove the primary tumour entirely and thereby establish a diagnosis;

to remove as much cancerous tissue as possible before proceeding to other forms of treatment;

to alleviate symptoms or the effects of your cancer, such as a bowel obstruction, even if surgery is not the main form of treatment.

There are some types of cancer such as leukaemias and lymphomas for which surgery is not appropriate because the cancer is, by definition, not restricted to a localized and operable site in the body.

While surgery may be helpful in many cases, there are circumstances where an operation is not a practical option. This may be because it is felt that the risk to you as the patient would be too great or because it would not be possible to remove enough of the tumour to make surgery the most effective treatment at this stage. This might be the case if your cancer has already spread, making cure by surgery alone impossible, while the lump itself is not causing you problems. It does not necessarily mean that surgery is completely ruled out later, but rather that alternative forms of treatment are felt to be more appropriate at this stage. It is worth reiterating that your doctors will propose the treatment which they feel is likely to be most effective for your particular circumstances.

What will surgery entail?

If the cancer is confined to a localized site, it may be possible to remove the diseased tissue surgically, together with part or all of the affected body organ. If the cancer has spread to other sites in the body, then it is more likely that either surgery will not be recommended at all, with the focus on treating the whole body, or the surgery will be designed to remove the primary tumour (the ‘source’ of the cancer) before using other forms of therapy to treat the secondary cancer. In all cases, the decision to operate will depend upon where your cancer is situated and whether your oncologist and surgeon feel it is safe and reasonable to operate on it. Before surgery goes ahead, tests and scans will be carried out to build up as detailed a picture as possible about your cancer, but it is obviously not possible for a surgeon to assess exactly what will be found once the operation is underway.

Some forms of surgery are obviously more complex and invasive than others: an operation for melanoma (skin cancer) differs greatly from surgery for cancer of the bowel. It is therefore very important to discuss your operation in advance, and to be clear about the possible implications. By definition, surgery involves some degree of physical damage to the body. This may be limited to an inconspicuous scar which will fade in time and cause no long-term distress, but in some cases the damage will be more severe. There may be more obvious physical impairment, which can be difficult to accept at first, such as the removal of a testicle in cases of testicular cancer. We are all concerned to some degree by physical appearances, and if your operation will necessarily cause some change to the appearance or behaviour of your body then it is important to understand this in advance. For example, it may be possible to insert a prosthesis in cases where a testicle has been removed. Sometimes the consequences of surgery will have a more far-reaching effect on your life.

For example, one of the possible outcomes of surgery for certain types of cancer, where part of the bowel or bladder is removed, is that the body can no longer deal with its waste products in the normal way, either temporarily or permanently. To allow the body to get rid of its waste, the surgeon has to create a ‘stoma’, a small opening on the surface of the abdomen. There are three types of stoma:

a colostomy is a stoma in the large bowel (colon);

an ileostomy is a stoma in part of the small bowel (ileum);

a urostomy is a stoma in the urinary system.

A stoma is created during the operation. The surgeon will bring a healthy part of your colon, ileum or urinary system to the new opening on the surface of the skin. A bag is attached to the opening into which the bowel or bladder contents can pass.

This procedure will only be necessary in certain specific cases. However, if there is a possibility that it is needed, it is very important to discuss it in advance so that you have the opportunity to prepare yourself for its effects. The prospect of living with a stoma can be distressing at first, but the majority of stoma patients can manage to adapt so that their lives are as near normal as possible. You will be taught how to empty and look after your bag, so that it becomes a normal part of your daily routine. A stoma nurse will be able to talk to you about your stoma and advise you about, for example, dietary considerations or any fears you may have about its effect on your life and how you can best cope.

If your operation will have specific effects on your life in the future, you may need extra support and information about how best to adapt and cope. The medical team attached to the ward where you have your surgery will be experienced in helping patients come to terms with these changes, and it makes sense to draw on their knowledge and expertise and to ask them how other people cope best. Many specialist wards also keep a range of leaflets dealing with the particular issues their patients are likely to face. If these are not obviously available then do ask, or approach your GP if you prefer.

Are there any alternatives to surgery?

The very nature of surgery can make it a frightening prospect, and you may wonder whether less invasive alternatives exist to treat your cancer. This is very much a matter for consideration on a case by case basis, and should be discussed with your team of doctors. Surgery will not be recommended without good and specific reasons. If alternative treatments are available for your type of cancer, then these will be explained to you and the relative chances of a successful outcome assessed. The final choice to have surgery or not will always be yours, but based on as much information as you wish to be given.

Coping with surgery

Before you undergo surgery, it is important to understand not only the physical nature of the operation, but also its more general effects. You may need to make arrangements for extra support and care while you are convalescing, for example, or to let your employer know for how long you may be unable to work. It can be useful to prepare a list of questions to ask the surgeon when you meet him or her and to have a member of your family or a close friend with you for extra support. The idea of a list of questions may seem over-formal, but it is very easy to forget issues which are important to you when you are feeling worried and possibly very unwell. They might include:

How long will I be in hospital? This will depend both on the type of operation and on your own physical state: a young, basically fit young man may recover more quickly than someone older and in less good general health.

How long will I be convalescent? Again, this varies between individuals, but you will cope more easily and be in a better position to make appropriate arrangements if you know that you will need more help and support than usual for, say, a week or a fortnight or a month.

How much pain or discomfort should I expect, and what sort of pain relief will be provided?

What can I expect when I wake after the operation?

How much scarring will there be?

What other physical effects can I expect?

Will there be any impairment of my sexual function?

What sort of post-operative follow-up will there be? (check-up by your surgeon, further tests, X-rays or scans, etc). How soon?

What will happen next? (additional chemotherapy or radiotherapy treatment, monitoring, etc).

Who will perform the operation?

Surgery is necessarily an invasive procedure and it is natural to have qualms about agreeing to an operation. If you are as well-prepared for it as possible by talking it over beforehand, then you are likely to find its effects easier to cope with afterwards.

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