Surgery - Management of Cancer

SURGERY

Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. The specific surgical ap-proach, however, may vary for several reasons. Diagnostic surgery is the definitive method of identifying the cellular characteristics that influence all treatment decisions. Surgery may be the primary method of treatment, or it may be prophylactic, palliative, or reconstructive.

Diagnostic Surgery

Diagnostic surgery, such as a biopsy, is usually performed to ob-tain a tissue sample for analysis of cells suspected to be malignant. In most instances, the biopsy is taken from the actual tumor. The three most common biopsy methods are the excisional, inci-sional, and needle methods.

Excisional biopsy is most frequently used for easily accessible tumors of the skin, breast, upper and lower gastrointestinal tract, and upper respiratory tract. In many cases, the surgeon can re-move the entire tumor and surrounding marginal tissues as well. This removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic disease cells may lead to a recurrence of the tumor. This approach not only provides the pathologist who stages and grades the cells with the entire tissue specimen but also decreases the chance of seeding the tumor (dis-seminating cancer cells through surrounding tissues).

Incisional biopsy is performed if the tumor mass is too large to be removed. In this case, a wedge of tissue from the tumor is removed for analysis. The cells of the tissue wedge must be rep-resentative of the tumor mass so that the pathologist can provide an accurate diagnosis. If the specimen does not contain represen-tative tissue and cells, negative biopsy results do not guarantee the absence of cancer.

Excisional and incisional approaches are often performed through endoscopy. Surgical incision, however, may be required to determine the anatomic extent or stage of the tumor. For ex-ample, a diagnostic or staging laparotomy, the surgical opening of the abdomen to assess malignant abdominal disease, may be necessary to assess malignancies such as gastric cancer.

Needle biopsies are performed to sample suspicious masses that are easily accessible, such as some growths in the breasts, thy-roid, lung, liver, and kidney. Needle biopsies are fast, relatively inexpensive, and easy to perform and usually require only local anesthesia. In general, the patient experiences slight and tempo-rary physical discomfort. In addition, the surrounding tissues are disturbed only minimally, thus decreasing the likelihood of seed-ing cancer cells. Needle aspiration biopsy involves aspirating tis-sue fragments through a needle guided into an area suspected of bearing disease. Occasionally, radiologic imaging or magnetic res-onance imaging is used to help locate the suspected area and guide the placement of the needle. In some instances, the aspira-tion biopsy does not yield enough tissue to permit accurate diag-nosis. A needle core biopsy uses a specially designed needle to obtain a small core of tissue. Most often, this specimen is suffi-cient to permit accurate diagnosis.

In some situations, it is necessary to biopsy lymph nodes that are near the suspicious tumor. It is well known that many cancers can spread (metastasize) from the primary site to other areas of the body through the lymphatic circulation. Knowing whether adjacent lymph nodes contain tumor cells helps physicians plan for systemic therapies instead of, or in addition to, surgery in order to combat tumor cells that have gone beyond the primary tumor site. The use of injectable dyes and nuclear medicine imag-ing can assist the surgeon in identifying lymph nodes (sentinel nodes) that process lymphatic drainage for the involved area. This procedure is used in patients with melanoma and is being used with increasing frequency in patients with cancers of the breast, colon, and vulva, although it is still considered investigational.

The choice of biopsy method is based on many factors. Of greatest importance is the type of treatment anticipated if the cancer diagnosis is confirmed. Definitive surgical approaches in-clude the original biopsy site so that any cells disseminated during the biopsy are excised at the time of surgery. Nutrition and hematologic, respiratory, renal, and hepatic function are consid-ered in determining the method of treatment as well. If the biopsy requires general anesthesia and if subsequent surgery is likely, the effects of prolonged anesthesia on the patient are considered.

The patient and family are given an opportunity to discuss the options before definitive plans are made. The nurse, as the patient’s advocate, serves as a liaison between the patient and the physician to facilitate this process. Time should be set aside to minimize interruptions. Time should be provided for the patient to ask ques-tions and for thinking through all that has been discussed.

Surgery as Primary Treatment

When surgery is the primary approach in treating cancer, the goal is to remove the entire tumor or as much as is feasible (a proce-dure sometimes called debulking) and any involved surrounding tissue, including regional lymph nodes.

Two common surgical approaches used for treating primary tumors are local and wide excisions. Local excision is warranted when the mass is small. It includes removal of the mass and a small margin of normal tissue that is easily accessible. Wide or radical excisions (en bloc dissections) include removal of the primary tumor, lymph nodes, adjacent involved structures, and surround-ing tissues that may be at high risk for tumor spread. This surgi-cal method can result in disfigurement and altered functioning. Wide excisions are considered, however, if the tumor can be re-moved completely and the chances of cure or control are good.

In some situations, video-assisted endoscopic surgery is replac-ing surgeries associated with long incisions and extended recovery periods. In these procedures, an endoscope with intense lighting and an attached multichip minicamera is inserted through a small incision into the body. The surgical instruments are inserted into the surgical field through one or two additional small incisions, each about 3 cm long. The camera transmits the image of the involved area to a monitor so the surgeon can manipulate the instruments to perform the necessary procedure. This type of procedure is now being used for many thoracic and abdominal surgeries.

Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of the cancer after a less extensive primary approach is used. A mastec-tomy to treat recurrent breast cancer after primary lumpectomy and radiation is an example of salvage surgery.

In addition to the use of surgical blades or scalpels to excise the mass and surrounding tissues, several other types of surgical interventions are available. Electrosurgery makes use of electrical current to destroy the tumor cells. Cryosurgery uses liquid nitro-gen to freeze tissue to cause cell destruction. Chemosurgery uses combined topical chemotherapy and layer-by-layer surgical re-moval of abnormal tissue. Laser surgery (l ight amplification by stimulated emission of radiation) makes use of light and energyaimed at an exact tissue location and depth to vaporize cancer cells. Stereotactic radiosurgery (SRS) is a single and highly pre-cise administration of high-dose radiation therapy used in some types of brain and head and neck cancers. This type of radiation has such a dramatic effect on the target area that the changes are considered to be comparable to more traditional surgical ap-proaches (International Radiosurgery Support Association, 2000).

A multidisciplinary approach to patient care is essential during and after any type of surgery. The effects of surgery on the patient’s body image, self-esteem, and functional abilities are addressed. Ifnecessary, a plan for postoperative rehabilitation is made before the surgery is performed.

The growth and dissemination of cancer cells may have pro-duced distant micrometastases by the time the patient seeks treat-ment. Therefore, attempting to remove wide margins of tissue in the hope of “getting all the cancer cells” may not be feasible. This reality substantiates the need for a coordinated multidisciplinary approach to cancer therapy. Once the surgery has been com-pleted, one or more additional (or adjuvant) modalities may be chosen to increase the likelihood of destroying the cancer cells. However, some cancers that are treated surgically in the very early stages are considered to be curable (eg, skin cancers, testicular cancers).

Prophylactic Surgery

Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. The following factors are con-sidered when electing prophylactic surgery:

·      Family history and genetic predisposition

·       Presence or absence of symptoms

·       Potential risks and benefits

·       Ability to detect cancer at an early stage

·       Patient’s acceptance of the postoperative outcome

Colectomy, mastectomy, and oophorectomy are examples of prophylactic operations. Recent developments in the ability to identify genetic markers indicative of a predisposition to develop some types of cancer may play a role in decisions concerning pro-phylactic surgeries. Some controversy, however, exists about adequate justification for prophylactic surgical procedures. For example, a strong family history of breast cancer, positive BRCA-1 or BRCA-2 findings, an abnormal physical finding on breast examination such as progressive nodularity and cystic disease, a proven history of breast cancer in the opposite breast, abnormal mammography findings, and abnormal biopsy results may be fac-tors considered in making the decision to proceed with a prophy-lactic mastectomy (Houshmand, Campbell, Briggs, McFadden & Al-Tweigeri, 2000; Zimmerman, 2002).

Because the long-term physiologic and psychological effects are unknown, prophylactic surgery is offered selectively to patients and discussed thoroughly with the patient and family. Preopera-tive teaching and counseling, as well as long-term follow-up, are provided.

Palliative Surgery

When cure is not possible, the goals of treatment are to make the patient as comfortable as possible and to promote a satisfying and productive life for as long as possible. Whether the period is ex-tremely brief or lengthy, the major goal is a high quality of life— with quality defined by the patient and family. Honest and informative communication with the patient and family about the goal of surgery is essential to avoid false hope and disappointment.

Palliative surgery is performed in an attempt to relieve com-plications of cancer, such as ulcerations, obstructions, hemor-rhage, pain, and malignant effusions (Table 16-5).

Reconstructive Surgery

Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or obtain a more desirable cosmetic effect. It may be performed in one operation or in stages. Patients are instructed about possible reconstructive surgical options before the primary surgery by the surgeon who will perform the reconstruction. Reconstructive surgery may be indicated for breast, head and neck, and skin cancers.

The nurse must recognize the patient’s needs and the impact that altered functioning and altered body image may have on quality of life. Providing the patient and family with opportuni-ties to discuss these issues is imperative. The needs of the indi-vidual must be accurately assessed and validated in each situation for any type of reconstructive surgery.

Nursing Management in Cancer Surgery

The patient undergoing surgery for cancer requires general peri-operative nursing care, as described in Unit 4, along with specific care related to the patient’s age, organ impairment, nutritional deficits, disorders of coagulation, and altered immunity that may increase the risk for postoperative complications. Combining other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of deep vein thrombosis. In these situations, the nurse completes a thorough preoperative as-sessment for all factors that may affect patients undergoing sur-gical procedures.

The patient undergoing surgery for the diagnosis or treatment of cancer is often anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body func-tions, and prognosis. The patient and family require time and as-sistance to deal with the possible changes and outcomes resulting from the surgery.

The nurse provides education and emotional support by as-sessing patient and family needs and exploring with the patient and family their fears and coping mechanisms, encouraging them to take an active role in decision making when possible. When the patient or family asks about the results of diagnostic testingand surgical procedures, the nurse’s response is guided by the in-formation the physician previously conveyed to them. The pa-tient and family may also ask the nurse to explain and clarify information that the physician initially provided but that they did not grasp because they were anxious at the time. It is important for the nurse to communicate frequently with the physician and other health care team members to be certain that the informa-tion provided is consistent.

After surgery, the nurse assesses the patient’s responses to the surgery and monitors for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and elec-trolyte imbalance, and organ dysfunction. The nurse also provides for patient comfort. Postoperative teaching addresses wound care, activity, nutrition, and medication information.

Plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient’s local hospital and health care provider. Patients and families are also encouraged to use community resources such as the Amer-ican Cancer Society or Make Today Count for support and information.