Is Smaller Better? Minimally Invasive Oncologic Surgery Options Discussed

Cutting-edge surgery with less cutting is appealing for many, but how do minimally invasive surgical offerings rate in terms of outcomes for people with cancer? At the National Comprehensive Cancer Network's (NCCN) 14th Annual Conference, Dr. Thomas D'Amico, MD, of Duke Comprehensive Cancer Center discussed the pros and the cons of minimally invasive oncologic surgery alternatives.

D'Amico acknowledges the tremendous technological advances that have resulted in minimally invasive offerings, but emphasized three guidelines that physicians need to be aware of when presenting the option to patients; the minimally invasive option must be oncologically equivalent or superior to the open procedure, the procedure should offer quality of life outcome advantages, and cost effectiveness needs to be considered, according to a statement from the NCCN, a not-for-profit alliance of 21 of the world's leading cancer centers.

Five minimally invasive procedures for oncologic surgery including robotic prostatectomy, laparoscopic colectomy, laparoscopic adrenalectory, minimally invasive esophagectomy, and thoracoscopic lobectomy were presented by D'Amico. In each procedure, he provided a comparison of the minimally invasive option versus the traditional open approach to surgery noting operating time, cost, recovery rates, length of stay, and oncologic outcomes.

Overall, the benefits to the minimally invasive options were a shorter hospital stay, faster recovery, and less pain. However, except for the thoracoscopic lobectomy, there is no data from randomized controlled clinical trials on minimally invasive options to provide any insight into oncologic outcomes or survival rates.

"The lack of evidence-based data for the majority of minimally invasive surgical options is one of the current shortcomings in the field," says D'Amico.

Another cause of debate includes the training and credentialing of physicians who perform minimally invasive procedures. D'Amico says that the learning curve for physicians being trained needs to be addressed. Lastly, D'Amico touched upon the controversy of using minimally invasive surgery as a marketing tool particularly in the field of robotics, which can lend itself to eye-catching publicity.

The future of minimally invasive surgery will likely see an expanded use of robotics as well as an increased interest in a new technique called natural orifice surgery. D'Amico explains that natural orifice surgery is when surgeons conduct surgery through the natural orifices in the body such as the mouth, nose, or rectum. Since there are no incisions made on the body, the benefits are a reduced risk of infection and a quicker recovery, says D'Amico.

In conclusion, D'Amico emphasizes that improved outcomes should drive the utilization of minimally invasive procedures and that oncologic principles must be preserved.

"There is continued progress of minimally invasive oncology surgery," says D'Amico, "but also the need for further evolution to optimize morbidity and oncologic outcomes. The question we need to ask ourselves is not 'what can be done', but 'what should be done'."

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