In ancient times, physicians and surgeons possessed an understanding that cancer often recurred after surgical removal. The Roman physician Celsus, in his writings, remarked that even when a scar formed post-excision, the disease frequently reappeared. This notion persisted for centuries and was significantly influenced by the medical authority of Galen, a prominent 2nd-century Greek doctor. Galen’s perspective on cancer aligned closely with Hippocrates’ beliefs, considering cancer incurable upon diagnosis. This perspective shaped cancer management for ages and contributed to the prevailing fear surrounding the disease, with some individuals still perceiving cancer as an insurmountable affliction even today.

However, a lot has changed with the modern evolution of surgical oncology. As an experienced surgical oncologist in Kolkata, I will share some glimpses from that historical development.

Surgery in the history of cancer treatment

Historical advances in cancer treatment were modest, as the prevailing approach remained largely Hippocratic or Galenic. It was widely accepted that once cancer had spread, curative interventions could be more detrimental than no treatment at all. Early surgical attempts, as recorded, were often fraught with complications such as excessive bleeding, and not until the 19th and early 20th centuries did substantial progress occur in both general and cancer surgery.

The discovery of anaesthesia

Anaesthesia’s discovery in 1846 significantly accelerated surgical advancements, leading to what came to be known as “the century of the surgeon.” Pioneers like John Hunter, Astley Cooper, and John Warren gained acclaim for their swiftness and precision in surgical procedures. However, the real transformation occurred in the 19th century, led by the three key surgeons: Bilroth in Germany, Handley in London, and Halsted in Baltimore. Their contributions laid the foundation for surgical techniques aimed at complete tumour removal, along with adjacent lymph nodes.

The first leap forward: Local removal of the tumour

William Stewart Halsted, in particular, developed the radical mastectomy in the late 19th century, based partially on the work of W. Sampson Handley, who posited that cancer spread radially from the original site. Halsted believed in the curability of cancer through local removal and considered any subsequent appearances as new occurrences. This approach dominated cancer surgery for nearly a century until the 1970s when clinical trials demonstrated the efficacy of less extensive procedures.

Breakthrough in the concept of metastasis

Around the same time, Stephen Paget, an English surgeon, formulated the idea that cancer cells spread via the bloodstream but could only thrive in specific organs, similar to seeds falling on fertile soil. This groundbreaking hypothesis was confirmed much later by modern cellular and molecular biology, and it prompted the development of systemic treatments to target dispersed cancer cells. These treatments are now frequently used before and after surgery.

Minimal removal of healthy tissues

Towards the end of the 20th century, surgical techniques evolved to minimize the removal of healthy tissue during cancer operations, mirroring the shift from radical mastectomy to lumpectomy in the case of breast cancer. Likewise, progress was made in the treatments of other cancers as the surgeons increasingly focused on removing the bone and soft tissue tumours of the arms and legs instead of total amputations.
This progress was aided by an improved understanding of cancer, enhanced surgical instruments, and the integration of surgery with chemotherapy and radiation. Diagnostic methods advanced as well, with imaging techniques like CT scans, MRI scans, and PET scans replacing exploratory surgeries. Laparoscopic and thoracoscopic surgeries, using fibre-optic instruments and miniature cameras, enabled less invasive interventions. Additionally, cryosurgery, laser therapy, and radiofrequency ablation offered alternatives to tumour removal.

Today, the scene of surgical oncology is as fertile as it is brimming with promises. We are about to see further developments in the field of robotic and minimally invasive surgeries. Moreover, the margin excision of cancer, when detected early, proves extremely effective and delimits any further chances of recurrence. In a nutshell, surgical oncology is the earliest discipline in the history of cancer treatment and is set to go a long way into the future.