It doesn’t necessarily take a village to care for a child with cancer. But it does take a team—one that brings together a variety of specialists that can address the whole patient, not just her tumor.
When it comes to patients with solid or brain tumors, the surgeon continues to play an important role as part of that team. But how has the surgeon’s role evolved? And when is the right time to bring a surgeon into the treatment process?
Notes asked Robert C. Shamberger, MD—a surgical oncologist at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, chief of the Department of Surgery at Boston Children’s Hospital, and the Robert E. Gross Professor of Surgery at Harvard Medical School—six questions about what the present and future hold for the practice of pediatric surgical oncology.
Q. Ideally, when should the surgeon be brought in during the care of a child with cancer?
A. I think it’s critical that surgeons be included very early on with the rest of the multidisciplinary team and actively participate in the early evaluation of patients.
First, it’s important to get both medical and surgical input regarding the possible diagnosis. Treatment approaches differ greatly depending on the tumor type. Take the two dominant abdominal tumors, neuroblastoma and Wilms tumor. Do we treat with neoadjuvant chemotherapy before the resection or do an up-front resection? Knowing based on imaging what a child likely has will affect how we approach the order of therapy.
Second, surgeons know best what it will require to obtain a biopsy. For some tumors, how you biopsy them will affect the staging of the tumor, which will determine the intensity of the treatment they will receive. Thus, an improperly biopsied tumor may require more intensive therapy for cure.
In short, the patient benefits greatly from early involvement of the surgeon.
Q. How has surgical oncology evolved over the years?
A. Surgical resection is one of the main pillars of successful treatment in some tumors. In osteosarcoma, for example, we know the chances of local control (cure) with chemotherapy and radiation alone are very low, so surgical resection is critical.
But advances in both medical and surgical technique have led to dramatic changes. It wasn’t too many decades ago that many osteosarcoma patients were faced with amputation as the only feasible option for cure. But neoadjuvant chemotherapy and new techniques for surgical reconstruction have allowed preservation of many children’s extremities.
There’s also greater emphasis on less invasive procedures. In the past, it may have required fairly significant procedures just to obtain diagnostic tissue because of where a tumor is located. Today, interventional radiology techniques and minimally invasive surgery for obtaining biopsies have clearly improved and carry very low risk to patients, thanks to improvements in both instrumentation and imaging.
Molecular technologies have also advanced such that pathologists can look for characteristic chromosomal translocations, such as in Ewing sarcoma and oncogene amplifications—both of which may have major prognostic implications predicting the behavior of a tumor—and make a diagnosis with a very small amount of tumor.
Q. Is there anything unique or uniquely challenging about surgical oncology in children, as opposed to adults?
A. A patient’s size can make surgery challenging. We can remove tumors in children all the way down to early infancy, but that requires expertise specific to a pediatric center. Also, the spectrum of tumors seen in children is quite different from that in adults. They require totally different care.
The fact that children are still growing also presents special challenges, especially for tumors in the extremities. Many bone replacement approaches that might be fine in an adult, for instance, won’t work for a child who is still growing.
And for solid tissue tumors, you have to account for the fact that the organs have to continue to grow with the child. A major liver or kidney resection followed by radiation will affect the major long-term function of those organs and their ability to grow. In children, we also have to consider the long-term implications or side effects of our treatment, which may not appear until decades later.
This is why I think it’s so important for children to be treated at centers with pediatric expertise. Children clearly do best in that setting.
Q. We’ve covered diagnosis, treatment planning and front-line therapy. Does surgery play a role in palliative or end-of-life care?
A. The most challenging patients we all work with are those requiring palliative care. For these children, the quality of life becomes the dominant concern.
It’s one thing to recommend a gastrostomy tube (feeding tube placed surgically into the stomach through the abdominal wall) for a child who is just starting chemotherapy, knowing that it will help her get though the therapy and will be important for her successful treatment. But for palliative care, you really have to consider what are the potential downsides of an intervention or procedure and make sure they don’t outweigh the benefits the child may gain.
Q. What do you think the future holds for surgical oncology?
A. The surgeon will continue to have a critical role in assessing and planning the primary management of a tumor, even as we move into an era of personalized medicine using agents that attack tumor-specific genetic defects. Rarely do these agents make tumors disappear; they may halt growth, but they are rarely curative.
Q. Would it be fair to say that surgeons have always practiced personalized medicine, in oncology and beyond?
A. That’s true. Every patient’s anatomy is different, and the location of every patient’s tumor is different. I’d say that surgeons have long practiced personalized medicine on a macroscopic rather than a microscopic level.