Chapter 2: Evolution of Surgical Oncology

INTRODUCTION

Whether considering the practice of bloodletting or the concept of balancing of the four humors, the practice of medicine dates back centuries to the time of Hippocrates. Early physicians managed what were considered to be internal diseases, giving rise to the term “internal medicine.” Conversely, due to the extreme morbidity and mortality associated with an operation, surgeons were restricted to the management of superficial or external conditions. Sir James Simpson, a prominent Scottish physician in the 19th century, famously stated, “A man laid on the operating table in one of our hospitals is exposed to more chances of death than the English soldier on the field at Waterloo.”¹ It was not until the advent of antisepsis, antibiotics and the introduction of modern anesthetic techniques that the abdominal cavity could be approached with an acceptable degree of success. These innovations brought about a revolution in the field of surgery. In less than a century the practice of surgery transformed from one restricted to procedures of necessity to elective procedures including life-saving resections of malignant tumors.

From a historical perspective, surgical approaches to cancer existed far before the discipline now known as “Surgical Oncology.” The surgical treatment of cancer originated as an approach focused on radical and debilitating tumor resections and extended lymphadenectomies. These "bigger is better" procedures focused on removing all locoregional tissues including those with any potential local extension in order to eradicate all cancer cells and draining lymph node basins. Much has changed over the last several decades that has made Surgical Oncology an academic and evidence-based specialty. What has led to modern Surgical Oncology being the field it is today is the development of large prospective databases, the design and participation in randomized controlled trials, and the translational research that has ushered specialized and customized patient cancer therapy.

Historical reports of oncology date back to 1600 BCE taken from accounts of Egyptian writers that describe surgical techniques to treat a variety of disorders including solid tumors.² Hippocrates, the namesake of our oath as physicians, initially had a negative view on surgical therapy for solid tumors and believed that surgery would actually worsen survival (approximately 400 BCE). Hippocrates also defined the term carcinoma “crab-leg tumor” and sarcoma “fleshy tumor.”³ Galen described cancer as a systemic disease in the 3rd century.⁴ The first mastectomy for breast cancer was reported by Lenoidas, a 5th-century Greek physician. More significant advances came in the 1700s when John Hunter, who many consider to be one of the Fathers of Surgery, detailed concepts that would apply to both surgery and cancer.⁵ LeDran in the 18th century proposed the lymphatic spread of breast cancer and that in early stages was a local disease that could be treated effectively with surgery.⁴ At the end of the 19th century, Halsted popularized the radical mastectomy and was able to achieve a very low local recurrence rate by extending the resection margins in the mastectomy ...