Recent Trends in Surgical Oncology

The recent trends in surgical oncology share one objective: more cures with a better quality of life. Dr. Rajesh Kumar Jain, Principal Director - Surgical Oncology, BLK-Max Super Speciality Hospital, New Delhi, India, names four: robotic surgery that shortens recovery, molecular testing that replaces some chemotherapy with targeted tablets, circulating tumour DNA that tracks cancer in the blood, and immunotherapy that retrains the patient's own immune system.

Alongside them sit the multidisciplinary tumour board and a trend that needs no special equipment: earlier diagnosis. Dr. Jain has practised surgical oncology for nearly 30 years, across head and neck, breast, thoracic, gastrointestinal, urogenital, gynaecological, and soft tissue and bone cancers. He conducted this session without slides, as an open discussion with doctors from Ethiopia, Tanzania, Nigeria, Kenya and Egypt; their questions and his answers are on the masterclass Live Discussion. This guide sets out his view of where cancer surgery and cancer care are heading, across breast and gastrointestinal (GI) oncology, and links to two deeper articles:

• Breast cancer treatment protocol by stage and subtype: the triple test, staging without PET-CT, sequencing by ER, PR and HER2 status, oligometastatic disease, breast conservation, the axilla, and two cases.
• Early warning signs of cancer, organ by organ: the symptoms of oral, lung, gastric, hepatobiliary, colorectal, testicular and soft tissue cancers that general practitioners should never dismiss, and the awareness model that shifted the stage at diagnosis.

Recent trends in surgical oncology: the two objectives behind them

Every recent trend in surgical oncology serves two goals that Dr. Jain says must be pursued together: to achieve more cures and, at the same time, a good quality of life. Medicine is a progressive science, and the advances he describes matter because they improve one or both. A cure achieved through a long, painful recovery is still a cure, but it is not the best outcome available.

Robotic cancer surgery: faster recovery than open surgery

Robotic surgery is the clearest example of a trend that improves quality of life: in Dr. Jain's account, it shortens recovery from about ten days to one or two. An open operation involves a long incision, extensive dissection and a slow recovery. Performed robotically, the same operation can have the patient recovered and back at work on the third or fourth day, with minimal pain. Complications are less frequent, including bleeding and infection.

The cure rate may be comparable. What changes is the quality of life during and after treatment. In Dr. Jain's view, that difference is reason enough for patients with access to an equipped centre to be treated there.

Molecular testing and next-generation sequencing in cancer

Molecular diagnosis characterises a cancer precisely enough that, in some patients, a targeted drug can replace chemotherapy. Many hospitals can perform a biopsy or fine-needle aspiration but lack immunohistochemistry (IHC), which stains tumour tissue to show which proteins it carries, and molecular testing. Without them, a cancer can be suspected but not characterised.

Dr. Jain's example is adenocarcinoma of the lung. Next-generation sequencing (NGS), a test that reads many genes at once, can identify in the biopsy sample a mutation that a targeted drug acts on. Some of these patients are then treated with a single tablet a day, without radiation, chemotherapy or surgery, and live for years on that tablet. That change is the product of science and of access to newer techniques.

Personalised cancer treatment is already here

Asked how far oncology is from truly personalised treatment, Dr. Jain's answer is that it is already underway, though there is a long way to go. He compares it to a urine culture and sensitivity test: just as the antibiotic for a urinary tract infection is chosen by testing which drug the organism is sensitive to, molecular sequencing identifies which drug a tumour is sensitive to, and only that drug is given.

• Lung cancer has seen a sea change. If EGFR is mutated, for example, EGFR-targeted tablets such as gefitinib, and several related tyrosine kinase inhibitors, can be given.
• Pancreatic cancer, among the deadliest cancers, now has a tablet option for a small subset of metastatic disease: patients with an inherited BRCA mutation whose cancer has been controlled by platinum chemotherapy can continue on a PARP inhibitor tablet as maintenance.
• Breast cancer is also now undergoing molecular sequencing to identify the appropriate drug.

His forecast is unambiguous: the next ten years in oncology will be the decade of personalised cancer treatment. He describes himself as a cancer doctor first: his aim is to cure the patient, by whatever means, and personalised treatment may take the form of a pill or of surgery.

What molecular analysis can and cannot replace

A doctor from Tanzania asked how far molecular analysis can replace other treatments. Dr. Jain draws clear lines:

• Systemic treatment: molecular analysis can replace a chemotherapy drug with targeted therapy, as tablets or injections, or with immunotherapy, which has excellent results in certain cases.
• Surgery: for localised cancer, surgery remains the mainstay and the most curative treatment. It cannot be replaced.
• Radiotherapy: adding certain drugs that increase the sensitivity of tumour cells to radiation can sometimes allow the radiation dose to be reduced.

What is circulating tumour DNA (ctDNA) and how is it used?

Circulating tumour DNA (ctDNA) is DNA released into the bloodstream when tumour cells break down, and it can be detected in a peripheral blood sample. It comes from the nuclei of the tumour cells. In Dr. Jain's explanation, its presence indicates that the person has cancer, or has had it. He describes four uses:

1. Screening: a positive blood test prompts a search for the source, for example colonoscopy, scans or mammography, until the cancer is found and correlated.
2. Response to treatment: ctDNA is measured quantitatively before systemic therapy (chemotherapy, immunotherapy or targeted therapy) and again after about three months. If it has become absent or minimal, the patient is responding.
3. Confirming clearance: an absent result after completed treatment supports the conclusion that the disease has been controlled.
4. Surveillance for recurrence: testing every six months for years after treatment can show ctDNA reappearing in the blood, which signals recurrence.

He is candid that the test is not yet fully specific and that research is ongoing. Blood-based ctDNA screening is not yet part of standard cancer screening guidelines. As it is refined, he expects ctDNA to be used more often in screening, diagnosis, prognosis, assessment of treatment response and detection of recurrence.

How immunotherapy and CAR-T cell therapy work

Immunotherapy does not kill the tumour directly: it retrains the patient's own immune cells to recognise and attack the cancer. Dr. Jain explains immunotherapy, including CAR-T cell therapy, with a military analogy. The body has its own army: immune cells competent enough to fight infection and cancer. When cancer develops, immunity falls and that army is defeated. The drugs retrain the remaining immune cells, the soldiers who had forgotten how to fire the rifle, so that they recognise the cancer as the enemy and attack it again. CAR-T cell therapy specifically collects the patient's own T cells and genetically engineers them in a laboratory to recognise a target on the cancer cells before they are infused back; it is used mainly for certain blood cancers.

Why does cancer come back after treatment?

A doctor from Kenya asked why dormant cancer cells survive treatment, hide for years and then cause a recurrence. Dr. Jain is direct that the exact mechanism is still not known. A patient can achieve radiological and clinical cure, yet some cells survive and later return. One factor is clear to him: genetic aberrations accumulate over time through environmental exposure. A patient who is cured but resumes smoking or drinking alcohol exposes the DNA to the same carcinogens again, and dormant cells can be reactivated. Most of the time, however, the reason for a particular recurrence is not known.

What a multidisciplinary tumour board does

A multidisciplinary tumour board brings every relevant specialist into one room to agree the best treatment for a patient, especially in complex cases that fall outside standard guidelines. Dr. Jain gives the example of a pregnant woman with ovarian cancer: the questions of how to treat the cancer, how to protect the baby and whether to continue the pregnancy cannot be answered by one specialist. They need an obstetrician, an oncologist, an oncosurgeon and good investigations, so that the tumour can be analysed and a plan made that cures the cancer while the pregnancy continues.

A tumour board brings pathology, radiology, surgical oncology, medical oncology, radiation oncology, social work and administration into one room. Where there are no standard guidelines, the surgeon may want to operate, the radiation oncologist to irradiate and the medical oncologist to give chemotherapy. At the board, each presents the evidence from the literature, the case is discussed comprehensively and the team reaches the treatment that is best for that patient.

BLK-Max is a 750-bed hospital whose cancer centre combines surgical, radiation, medical and palliative oncology, a tumour board, a comprehensive pathology laboratory, around 24 operating theatres, intensive care units and a robotic surgery programme. It also trains National Board of Examinations super-specialists in surgical, medical and radiation oncology, and treats many patients from African countries.

Early cancer diagnosis and cancer vaccines

The most powerful trend requires no technology: diagnosing cancer at stage 1 or 2, when it is curable, through public awareness and a high index of clinical suspicion, as set out in the article on early warning signs of cancer.

Beyond early detection lies prevention. A vaccine already exists for cervical cancer. Dr. Jain hopes for a vaccine against breast cancer within the next few years and, over 10 to 15 years, vaccines against cancer more broadly, which would make cancer comparable to polio or diphtheria. In his words, that would be the golden day of mankind.

Breast cancer treatment sequencing in brief

For breast cancer, the session's practical core was the order of treatment: which subtypes start with chemotherapy, which with surgery, and how to stage without PET-CT. The full protocol is in the article on breast cancer treatment by stage and subtype. Dr. Jain's earlier masterclass, on breast cancer diagnosis and surgical management, covered imaging, reconstruction and genomic testing; see the complete guide to breast cancer diagnosis and surgical management.

Surgical oncology fellowships and observerships at BLK-Max

Dr. Jain's department offers fellowships in surgical oncology across sub-specialties, including head and neck, breast, gastrointestinal and gynaecological oncology. A fellow must hold a postgraduate qualification in the relevant discipline, but need not be a surgeon. A doctor with an MBBS alone cannot join as a fellow but can come as an observer for one or two months, rotating through the oncology departments to gain a working understanding of cancer management.