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The history of cancer surgery

SurgeryFor many centuries, surgery was the only treatment for cancer. The famous 18th century surgeon, John Hunter, suggested that surgery might cure cancer if the tumour had not invaded the surrounding tissue. He remarked that "if the tumour is moveable... there is no impropriety in removing it".

But early surgery was a risky procedure. Pain, infection and bleeding limited its usefulness and success until anaesthetics were discovered in the 1840s. In 1846, John Collins Warren performed what is thought to be the first major cancer operation under general anaesthesia - the removal of a patient's cancerous salivary glands.

The next century saw rapid progress and is often referred to as "the century of the surgeon". These advances led to a large increase in the number of people who survived surgery. The development of antiseptic techniques by Joseph Lister in 1867, the ability to transfuse blood in the 1930s and the discovery of antibiotics in the 1940s are all landmarks in the history of surgery.

The field of cancer surgery, or 'surgical oncology', grew in line with these advances. Pioneering work by Theodore Billroth in Austria between 1860 and 1890 led to the first successful operations to remove the stomach, voicebox and foodpipe.

In the USA in 1889, William Halsted noticed that breast cancer recurred more often in women who had had their tumour removed but not the surrounding tissue. He developed a technique called the 'radical mastectomy', the surgical removal of the tumour, breast, overlying skin and muscle.

This procedure remained the mainstay of breast cancer treatment until very recently. Nowadays, the use of chemo- and radiotherapy, and the ability to diagnose breast cancer earlier thanks to screening programmes, means that radical mastectomy can often be avoided.

At around the same time, the English surgeon Stephen Paget discovered that cancer cells could spread through the blood and lymph systems, but could only grow in a few organs. He drew the brilliant analogy between cancer spread ('metastasis') and 'seeds that are carried in all directions, but they can only live and grow if they fall on congenial soil'.

This work laid the foundation for another landmark in the history of cancer surgery, the development of 'regional lymphadenectomy'. This involves the removal of the lymph nodes surrounding the affected organ. This technique led to a drastic reduction in tumour recurrence rates for these cancers, which include breast, bowel and stomach cancers.

Despite these advances, surgery remained a fairly drastic and disfiguring cancer treatment until the 1950s. By this time, radiotherapy and chemotherapy had become widely available, and could be used in combination with surgery. This allowed doctors to target cancer cells that may have escaped the surgeon's knife.

Treatment given after surgery, to kill any cells that might have broken away from the tumour during the operation, is called adjuvant therapy. Treatment given before surgery to shrink a tumour and make it easier to remove is called neo-adjuvant therapy.

Recently, cancer surgery has benefited from the use of high-tech imaging techniques such as ultrasound, MRI and CT scanning These procedures allow a surgeon to find out the exact size and shape of a patient's tumour. And the widespread use of keyhole surgery allows surgeons to operate on a patient's tumour without leaving large disfiguring scars.

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