This module on cancer surgery and radiotherapy covers:
Types of surgery
Types of radiotherapy
Accessing the best surgeons and radiotherapists
This is module 4 of the “Make Cancer History” cancer course. The topic is surgery and radiotherapy. Recently, radiotherapy has become quite a viable alternative for surgery in some situations. In the past, radiotherapy was associated with inoperable cancer. So this idea where you were told “we can’t do surgery, it’s too dangerous” or “it wouldn’t help enough to justify the risk”. But now recently, with new types of radiotherapy and with also better cancer treatment and better cancer testing in general, it means that sometimes radiotherapy can be an alternative to surgery.
Radiotherapy does have some benefits. Typically we think of surgery as the Gold Standard of cancer treatment, because you’re physically removing the cancer, and if the cancer hasn’t spread too much, hopefully the surgeon can safely remove all the cancer and get clear margins. This means they take some healthy tissue from around the cancer and they test the tissue around the cancer, and hopefully find it’s cancer-free. If not, they have to remove a bit more. But they do that so they can be confident of removing all the cancer. This is why surgery is seen as something that we try to get to, especially if we have late stage cancer.
You might be diagnosed at stage 4 like I was, and you’re told “You can’t have liver surgery, you have an unresectable liver” and we might want to be working towards liver surgery or any other kind of surgery. But that is changing now with these gentler radiotherapies and more accurate radiotherapy. More accurate meaning it’s more accurate at targeting the cancer and avoiding the healthy tissue.
We could look at surgeries in terms of their purpose, and we could also look at surgery in terms of the methodology. Some surgery is diagnostic – to actually diagnose the cancer, for some types of cancer.
A very common surgical procedure, which I think as patients we wouldn’t even think of as surgery, but surgeons certainly consider surgery, is the biopsy. There are various types of biopsy, like the needle biopsy, where the needle is inserted in to reach the tumor and take out some cells and some liquid, which is then analyzed.
There’s of course a biopsy during an endoscopy. In the case of, for example a gastroscopy, which is when a camera is used to investigate your stomach, the endoscopist may find some suspicious looking things in your stomach, and grab them with a little wire lasso on the end of the endoscopic device, and remove them. These will be biopsied in a histology lab. The tissue is actually cut up and examined under a microscope to see if it’s cancerous or not, and stained with various things that will show up against cancer. So biopsy is really considered in the medical world a kind of surgery, although for patients we usually wouldn’t think of it as a surgery.
There’s also surgery for staging, so assessing how much the cancer has spread, and for finding the size of the cancer, maybe in a situation where the scanning is not clear because of the positions of the tumors, it’s hard to scan clearly.
We often want to know if the surgery is curative or palliative. Curative means the intention is that you will be cured. Many early stage cancers fortunately can be cured by single surgery. In late stage cancers, unfortunately the surgery is often going to be palliative, which means extending life, reducing side effects, reducing damage that the cancer is doing to your body. If a tumor is pushing against an organ, pushing against a nerve, that kind of thing, irritating a nerve, you might have palliative surgery. But recently again, the line is blurred.
If you are in a country with exceptionally good surgical technique, then palliative surgery could actually be a step towards curative treatment. It may be combined with some other treatments and other surgery later on, or follow-up chemo, molecular targeted therapy, radiotherapy and that kind of thing.
As I mentioned before, this idea of clean margins – when the surgeon removes the tumors, they’re looking for getting enough tissue out, so they’ve got all the cancer and they’re confident that the tissue around it is clear. That’s what surgeons talk about when they say they have nice clean margins.
One thing to bear in mind with the surgery, is that when tissue is removed, it’s all tested. There’s testing in the surgery: during the surgery, tissues are being tested then and there, liquids are being tested.
I had abdominal surgery three times, and in part of the surgery they washed the abdomen. That liquid is kind of collected and tested at the lab, to see if there are cancer cells floating around. Checking the abdominal washings is very important for abdominal surgery, because if the surgeon confidently removes all the cancer, but there are cancer cells found in that fluid around the abdomen, then potentially the cancer can spread back into the body. That might affect the decision to do chemo or not, after surgery. That’s a really key thing, is whether you do chemo after the surgery or not, to try and deal with the microscopic disease.
When a surgeon is doing surgery, they can see and remove down to about 2mm. Typically they’ll be removing it with an electrical device, not cutting out when it’s that kind of size. I’ve seen some video from my first surgery, and it was very weird to see this probe device used to ablate the little tumors. The surgery I had was a left colectomy, so that means the left hand side part of my large intestine was removed, but also the surgeon did cytoreductive surgery (CRS). Cytoreductive surgery is for when the cancer spreads, and the surgeon tries to remove as much cancer as is safe to do.
Cytoreductive surgery takes quite a while. In my case, there was six hours of surgery for that initial first surgery. Some of that of course is removing a primary tumor, and in my case I had a colostomy formed, where the cut end of the large intestine is brought out through the wall of the abdomen and terminated in a colostomy bag. Quite a lot of the time would have been spent hunting around my abdomen for tumors, and then cutting them out if they were larger, and ablating them if they’re smaller.
When you hear about CRS – cytoreductive surgery- it just means trying to reduce the amount of cancer in the body.
As I said, tissues and liquids are tested during the surgery, but you do need a proper report, like a pathology report, and that will come some days later from the pathology lab.
It’s really worth getting copies of this kind of thing. Typically in surgery when the tissue is taken, the surgeon is going to be doing biopsies, they’re going to be removing samples of tissue and getting them tested, and they’ll be obviously removing big tumors and things like that. That tissue is washed and then pickled, essentially with formaldehyde, and that can be used for genetic testing. But what it can’t be used for, or not well generally, is to prepare immunotherapy treatments.
So if you are planning to have immunotherapy treatments, a typical one would be dendritic cell therapy, you need to arrange that with the surgeon beforehand. Ask them to keep some of the tissue for you unpickled, (so not stick it in the formaldehyde), and instead have that cryogenically frozen.
Most surgeons will be cooperative. The only sticking point is if they’re doing genetic testing, and they say “we need all the tissue for genetic testing”. So that could be an issue. But the volume of tissue you need for dendritic cell therapy and other kinds of therapies where they’re using tumor tissue, is about a cubic cm or something, (10 ml by 10 ml by 10 ml). So just just a little bit, but if you don’t arrange that with the surgeon, then all the stuff taken from your body is going to be washed in acid and pickled, and it’s not going to be good for preparing those immunotherapies, because you do need to arrange that in advance of the surgery.
Now the real challenge that the surgeon has in doing the surgery, apart from just achieving the goal of the surgery, the real challenge is the tension between access and damage to your body. The surgeon is always trying to get good access to safely remove the cancerous tissue, but they’re trying to minimize the damage to your body and especially minimize the incision. This is a big problem, because you can imagine they want as much access as possible, but they don’t want to cut a massive hole in you.
When we talk about the methods of surgery, we usually think of open surgery and keyhole surgery (also called laparoscopic surgery). Keyhole surgery was originally developed for knee joints, I think was the original use. But now many surgeries can be done by keyhole surgery, and some can’t. Liver surgery generally can’t, because your liver is right up inside your ribs, on the right hand side and the liver is massive, it’s the third biggest organ in the body (after the skin and brain). So keyhole liver surgery is very unusual. Maybe that will change in the future, but that would be open surgery. Open surgery is going to get a big incision. Keyhole surgery can have much smaller incisions. Keyhole lung surgery, if it’s removing a single tumor, that might be a 3 cm cut, (so that’s 1 inch and a quarter, I’m not good on Imperial), but it is a small incision and small scar.
Also with keyhole surgery, it’s generally safer because the wound healing is better, because it’s a smaller wound. I’ll explain the procedure in a second, but there are definitely cases where keyhole surgery has to turn into open surgery during the surgery. The surgeons plan to do it by keyhole surgery, and then during the surgery they find that’s not possible because of needing more access. Just because the surgical plan says keyhole surgery, don’t be surprised if you wake up with a big scar, as it was changed to open surgery.
For keyhole surgery, a few holes are made in you, a few incisions. Generally it’d be 3, so one for the camera, one for putting the tools in, and then one for putting the gas in. In some cases there might be a device with tools and gas and the same thing. The gas is just carbon dioxide, so it’s just to inflate that bit of the body.
If you think of abdominal keyhole surgery, they’re going to puff you up with carbon dioxide to make enough room for putting the tools in, and hopefully successfully cutting out all the cancer and getting those clear margins.
In my case, I’ve had one keyhole surgery which was my colectomy, and cytoreductive surgery. I’ve had 2 open surgeries- I had a liver resection where about half my liver was removed and also the gallbladder. Then 6 years after my colectomy, I had a stoma closure, sometimes called a colostomy reversal. That was when my intestines were reconnected, and that was an open surgery, that could have been done as a keyhole surgery. Mine had to be done as an open surgery, because access was poor and it was my third abdominal surgery, so there were concerns about adhesions.
In abdominal surgery, adhesions are a very big issue. This is where scar tissue forms between organs that should be able to move freely, or between just another part of the body and the organs. Adhesions, as the name implies, stick together and they’re not good. It’s unclear why adhesions form. They’re caused by trauma it seems, so surgeons try to touch your insides as least as possible. Surgeons try to use talc-free gloves and all this kind of thing, but still for some reason, some people get bad surgical adhesions and some don’t.
There is at least some evidence that taking the drug metformin, can either prevent the formation of adhesions, or even reverse them. So that’s something to look into, if you’ve had multiple surgeries like I have.
Other options for surgery, related to the first two (open surgery, keyhole surgery): you’ve also got Robotic surgery. The most famous robotic surgery system at the moment is the DaVinci machine, which is a bunch of robotic arms that’s controlled by a surgeon. They’re looking at a screen and they’re manipulating these robotic arms that are doing the surgery. I guess at some point in the future, the robot itself will do the surgery using AI, but at the moment my understanding is that in all use around the world, it’s human controlled. According to the companies behind robotic surgery, there’s less damage, more precision, less chances of adhesions, quicker recovery.
According to most of the independent research I’ve seen, this is not in general the case. There doesn’t seem to be much difference between a really good human surgeon doing open or laparoscopic surgery, or the robot assisted surgery like the DaVinci machine. But in maybe some difficult complex surgeries, the robot assisted one would be better.
Another common thing now is Stereotactic surgery, also called scanner-assisted / scanner guided surgery. It’s very common for surgery to use an ultrasound scan in the surgery, to look at what needs to be cut out, but also even to guide the surgery. But now it’s also possible to do MRI guided surgery, or CT scanner guided surgery. Those are the usual benefits you can imagine, of having something that’s scanner guided – being able to see smaller things, they’re going to do it more accurately and they’re going to do less damage to the body.
So that was going over a few common surgeries, just as examples of how surgery works. But the first thing I’m going to talk about is a laparoscopy. A laparoscopy is like the keyhole surgery, but without the surgery bit. That’s just to check to have a look inside the body, because there are many situations where a scan or multiple scans are not going to be sufficient. For example, in the case of where cancer spreads onto the abdominal membrane, the tumors in that case tend to be spread over the abdominal membrane, they tend to be flat and they tend to be small – around 2-3mm size. That means they typically will not show up on a scan. Scans are not good at seeing flat things. MRI scans, CT scans, PET scans – they work best when there’s some kind of depth to the thing they’re scanning. Also, most of the scans, their maximum resolution is ~ 5mm, so they’re not going to be able to see something that’s 2mm. So in the case of the peritoneum (that’s the abdominal membrane), you’ll see this thing written on the CT scan report, where it says “ irregular thickening”. It’s a hint that the cancer spread or probably spread to the abdominal membrane. But what they’re saying is that it looks bumpy, so it could have these little tumors on, but they didn’t see a big tumor where they could say that it has spread to the peritoneum (abdominal membrane).
In that case, a laparoscopy may be a good option. But you would need that done by someone who’s very familiar with assessing the abdominal membrane- ideally a surgeon who specializes in HIPEC, which is that special treatment for cancer that has spread to the peritoneum, using a variation of the Sugarkaker protocol, invented by Dr Sugarbaker.
A very common surgery is a lymph dissection. This just means removing lymph nodes and is often done during other cancer surgeries. Typically, any cancer surgery is going to involve removing lymph nodes, to just see if they’re cancerous or not. But for us late stage patients, the cancer has often spread into the lymph nodes and they have to be removed. Depending on where they are removed from, it may be an issue for you or may not.
For breast cancer surgery, unfortunately the lymph nodes that need to be removed are in the armpit, and that can often cause lymph fluid building up in the armpit and in the arm, which is uncomfortable and irritating, and has to be dealt with with massage or elasticated supports and things, which is not nice.
Many lymph nodes are in places in the abdomen where there’s lots of nerve tissue. Nerve tissue isn’t really easy to identify during surgery. For example, I’ve had a lot of some quite important nerve tissue cut out in my abdomen, when the surgeon was doing the retro-peritoneal lymph dissection, which means getting the lymph nodes from behind the peritoneum (that abdominal membrane I mentioned). Lymph node dissection is very common.
One of the most common cancer surgeries is the liver resection. Cancer often spreads to the liver, because the liver is unique in the body in that it has two blood supplies. The liver is also very attractive for surgery, because the liver is the only organ in the body that can regenerate essentially completely. At the moment, the top liver surgeons are able to take something like 60% of the liver. They can safely remove that, and it will regenerate. Liver surgery can also be done in two steps, because it regenerates within a few weeks. In cases where there’s a lot of tumors and large tumors in the liver, it’s possible to do liver surgery, wait a few weeks, do liver surgery again and hopefully get a lot of the cancer out. Although in the case of liver surgery for lots of tumors, even if all the tumors are safely removed it will typically be considered palliative treatment, because it’s very likely that there’s cancer spread throughout the liver.
As I said before, liver surgery has to be done as open surgery in almost all cases, because it’s tucked up behind your ribs on your right hand side. One issue around liver surgery is that your liver is the organ that deals with the chemo, so if you’ve had a lot of chemo you might have poor liver function, and you need to stop the chemo for quite a while before it’s safe to do the surgery. You have to wait quite a while before you can restart chemo after the surgery, and that’s scary when you’re depending on the chemo to stay alive essentially.
Alternatives to liver surgery could be radiotherapy. I had proton beam therapy for the liver and Tomotherapy as well for the liver, which are both types of radiotherapy. Radio frequency ablation (RFA) – I’m not giving any medical advice, but RFA may be a treatment you want to look at as an alternative to liver surgery. RFA does not affect the function of the liver, so you can do it while on chemo, without taking a break with your chemotherapy. RFA is where a needle is inserted into the tumors. It could be scanner guided, it could be ultrasound guided. Then that needle is heated with radio waves to ablate the tumor, which means it’s going to be destroyed by heat.
Cryotherapy is another alternative. So a similar needle, but freezing the needle to freeze out the tumor.
HAI (hepatic arterial infusion) – putting chemo directly into the liver with a device that’s implanted under the skin.
TACE – Transcather arterial chemoembolization. That’s where a catheter is put into your blood vessel in your leg, and chemo is pumped in and delivered that way. TACE also involves putting little beads into the blood vessels that are supplying the tumor, so it cuts off the blood supply, and puts a lot of chemo into the liver.
So those are alternatives. Another place cancer spreads to often is the lung. Cancer spread to my right lung, but I haven’t had surgery for it. I had radiotherapy, and so far it seems to be OK. Maybe I’ll find out soon if it’s not okay, but at the moment it looks ok on the scans.
If you remember, your lungs have lobes. We’ve got two lobes on the left and three on the right – the reason is because our heart is a little bit to the left of the center of the body. If you’ve got lung tumors and they’re on one side, you may have them removed by surgery.
So the three possibilities are if it’s just a one tumor, or a couple of tumors very close together, you could do what’s called a “Wedge resection”. As I said before, a wedge resection for one small lung tumor could be done by keyhole surgery in many cases, and you’d have about a 30 mm cut for that, so a little scar. When I was looking to have that surgery done, the predictive success rate for me was about 100% to remove a single lung tumor that was I think 3-4mmm, so quite attractive.
But instead I had radiotherapy which had about an 80% chance of working effectively and so far it seems to have worked. The reason I made that decision is that if I did the radiotherapy and the tumor returned or cancer recurred in that part of the body, I could still have that surgery. So that’s a consideration for lung surgery. One alternative might be radiotherapy. Another alternative could be radio frequency ablation – putting in the needle and heating it up. Cryoablation is another option. Of course, chemotherapy plus molecular targeted therapy can be an alternative for surgery.
If there are more tumors split over a bigger area, then you need a lobe of the lung removed – that’s called a lobectomy. You can have one lobe removed from the left side, which would be half of that lung, or a lobe removed from the right side, which should be a third of that lung. If the cancer spreads more, then you’re going to be having a whole lung removed, which is called pneumonectomy.
With cancer unfortunately, organ removal is relatively common. Of course, you can have a kidney removed, it won’t grow back. With the liver, if you remove a lot, even quite a lot of the liver, it will grow back.
The liver is one of the seven vital organs for life, so they won’t remove too much, but they can safely remove half at the moment. You can lose a kidney, but if you have to lose both kidneys, then you’re going to be on dialysis. For gynecological cancer, then removing ovaries or removing a womb, is unfortunately common in later stage cancers.
The alternative is called “organ sparing surgery”. For example, when I had my liver surgery, on the scan, it looked like potentially the cancer had spread from liver to the kidney. But I discussed with the surgeons, and they said if that had happened, if they found that to be the case during the surgery, then they would do an organ sparing partial nephrectomy – which means basically cutting a little bit off the kidney, but leaving the kidney there, because I’m very attached to my organs.
I always look for non-surgical alternatives. Surgery does suppress the immune system quite a lot, and obviously it’s a lot to deal with, having your body cut up, spending time in hospital, maybe spending quite a lot of time in hospital. For my third surgery, that was in Covid time in Japan, so no visitors were allowed at the hospital. I had to spend 18 days in hospital without friends and family being able to visit, which was pretty tough.
If you’re talking with a surgeon and they’re talking about removing an organ, you might want to ask them about the possibility of doing an organ sparing surgery. If they say it’s not possible, then you need to push them on that and say “Is it not possible medically?” or “Is it not possible because they’re unable to do it at their hospital with that team?”
Another thing to push them on is, could it be possible in the future if I do another treatment first? For example, if I am able to successfully shrink the tumors with chemo and targeted therapy, could I then have the surgery and spare the organ?
Surgeons like to do surgery, understandably in the best possible situation, which means typically early, when you’re in good physical condition. But sometimes we could have other treatments and then do surgery, and the surgery would be less damaging to our body. So that’s always something to look into.
Another common type of cancer surgery is removal of bits of intestine. I’ve had a colectomy, which means removal of some of the large intestine. There is a duodenectomy, jejunectomy, and then ileectomy. So depending on which bits of the small intestine are removed, there are those surgeries. They could be carried out and then your intestine could be reconnected during the surgery. If not, then the upper end of the intestine is going to come out through the abdominal wall, and it’s going to be tied into a colostomy bag or an ileostomy bag.
Then hopefully later on, you can have a stoma closure. A stoma just means the hole where the intestine comes out. It’s sometimes called like an ileostomy reversal or colostomy reversal, which is another surgery that can be quite big and difficult depending on the situation.
In my case, the colostomy reversal was a big surgery and difficult, because the connection point was very low, deep in my pelvis. I was rejected for surgery by 12 surgeons, and the lucky 13th agreed to do it, and it was fine. It was a year and a bit ago, but it’s just been fantastic not having a colostomy bag .
For breast surgery, there’s the lumpectomy where a small part of tissue is removed. The bigger one would be removal of the whole breast, which is the mastectomy of course. That surgery, especially if it is a mastectomy, is often going to include some kind of reconstruction afterwards, so another surgery you have to deal with.
I’ll just briefly go over some of the issues with surgery. You have morbidity and mortality. Morbidity is the serious complications that cause some kind of disability afterwards. Mortality is either not surviving the surgery, or you often talk about the 30-day mortality which is the survival rate. I think probably the number given is the % that don’t survive the 30 days after the surgery. Surgeons like to have risks down quite a bit <1%. When they see a surgery is safe, they’re going to be looking at 0.1% (1 in 1000) patient mortality. That’s the thing they look for.
There are lots of issues and discomforts after surgery that are temporary e.g. problems eating of course. If it’s abdominal surgery, your intestines might stop working for a bit. This is called “ileus”, also known as “lazy intestine”. You might be having CT scans every day and various things to try and get your intestines working; mainly early walking and early standing.
Sleep issues are very common – that’s really difficult to sleep through the night after surgery. Some of that is to do with bladder control, because you’re often on a drip and you’ve had a catheter to empty your bladder during the surgery. A catheter is traumatic anyway, particularly when the nurses remove it the first time, that’s incredibly painful.
A very sore throat for quite a while after surgery is common. That’s just from having the artificial airway put in your mouth, held open for 2, 3, 4, 5, 6, 8 hours or however long the surgery lasted.
Pain, swelling and burning around the wound is common. As it starts healing up, you still might get irritation, itching and that kind of thing.
There are more serious things such as going into shock after surgery. I remember after my liver surgery, I was shaking uncontrollably, which I now know was shock, and I was terrified that my teeth were going to break because they were smashing together with shivering.
Unfortunately when I woke up from the liver surgery, the first thing that happened was I vomited in my oxygen mask, which is very unpleasant. If you do vomit easily, or if you’ve ever vomited before or after a surgery, when you do surgery, tell them that beforehand and they’ll give you anti-vomit medicine.
Another serious problem after surgery is of course some kind of infection. I had a drip in my neck after the liver surgery and got an infection there. That was quite serious and had to be treated with a lot of antibiotics and it was fine. It was a terrible thing and then it was fine.
After surgery, they’ll be taking your temperature all the time. There’ll be a nurse who should be asking you to measure how much you urinate, that’s really important to record that accurately, because if you have an infection, one symptom will be of course high temperature, but also things like urinary retention, when you can’t urinate.
Another serious issue is some kind of bad reaction to the anesthesia.
Another common thing, or relatively common, is lung issues. I’ve got pneumonia twice after surgery. After my liver surgery I had pneumonia and a collapsed lung. A collapsed lung sounds very dramatic but it usually fixes itself in a few days. Pneumonia is quite unpleasant. When you have big surgery, you’ll be encouraged to cough. Early coughing after surgery is really important. You’ll be given deep breathing exercises, to try and get air deep into the lungs. That’s very painful if you’ve had a big abdominal surgery, but it’s very important because it prevents pneumonia. But if you do get pneumonia like I did, it will clear it up a bit quicker maybe.
Deep vein thrombosis are blood clots in your legs. Typically with surgeries of any reasonable length, you’ll have to wear stockings to stop the blood collecting in your legs. When you’re woken up from surgery, you may find your legs in a strange massage machine, to try and prevent blood clots forming in the legs. Another serious issue related to that, is blood clots going to your lungs. Of course, bleeding and wounds not healing well after surgery is an issue as well.
I think if you’re going to do a surgery, it’s always worth looking for surgical trials, especially ones where the trial is just to make the recovery easier. If they’re looking at a change to surgery that should get you out of hospital quicker, it will be less damaging to you. That’s really worth looking at.
I will briefly talk about radiotherapy and go into it. It will come up in future sessions as well, especially about making treatment decisions. Radiotherapy, as I said, can be a good alternative to surgery in some cases.
Radiotherapy is kind of tricky to understand because it uses radiotherapy machines. These are made by companies, and companies want to sell their machines, and there’s a lot of nonsense around radiotherapy, like the naming of things and marketing. So it can be very difficult to know what mode of radiotherapy is best for you.
Briefly we think of radiotherapy in two groups- there’s the ones that use radio waves, which are called gamma rays (also known as X-rays), and there’s ones that use particles. If you remember from school, we’ve got 3 forms of radioactive radiation. There are gamma rays, which are just waves of energy; beta waves which are those electrons, streams of electrons and they go quite far; and there’s the alpha particles, which are the helium nuclei and they’re big and heavy.
With radiotherapy, we can use gamma rays which go forever. They get weak as they go along, so they attenuate. With the particles, there’s this weird thing that happens, that you can get the particles to stop suddenly, which means they do less damage coming out of the back of the tumor. But the really strange thing is that you can also get them to start suddenly, a few cm away from the source. So that means you can really target the energy well into the tumor, and damage less healthy tissue around.
Sometimes radiotherapy is marketed as if it’s like a type of surgery, so they call it a stereotactic surgery or stereotactic radiosurgery. It’s radiotherapy, it’s clearly not a surgery, but what they’re trying to emphasize is maybe a single treatment (one session) to completely destroy a small tumor.
Typically radiotherapy though, is given over several sessions. I had Proton Beam therapy which was 40 sessions. It was Monday to Friday for 8 weeks, 1 session a day. Tomotherapy I had was 20 sessions for one treatment. I had 20 sessions which were for the lung and liver, and 20 sessions for lymph nodes.
With radiotherapy, they’ve got all these annoying commercial names like CyberKnife, Gamma knife, Tomotherapy, Truebeam, View Ray. These are typically scanner guided machines with various advantages and disadvantages. Gamma rays are ancient now. It was made in 1967. I think gamma rays couldn’t have originally been scanner guided, because that was maybe before CT scans existed.
Gamma Knife is now an old one that probably shouldn’t really be used. That’s used for head and neck cancers, but you need to immobilize the patient with a metal frame that’s pinned into the head and it’s unpleasant.
CyberKnife and Tomotherapy would be better, more modern alternatives, where you’re kept still by a mat that you lie on, and maybe some foam blocks around you. With head and neck cancers though, you’re going to have some kind of mask to protect healthy tissue and important organs in your head, and keep you still.
A really important radiotherapy that is becoming usable, is Boron Neutron Capture therapy, which is a particle-based radiotherapy, where you have a drug that builds up in tumors. That then is irradiated with a ray of neutrons, a stream of neutron particles, and they do the damage where that boron-based drug has been. That allows the radiotherapy to target local spread and is an amazing treatment. That’s just being used in Japan at the moment for head and neck cancers. I don’t think it’s used much in the rest of the world, but it was only approved in Japan last year, but hopefully it will be used for a lot of things in the future.
An issue with it though is currently, it can’t be done very deeply in the body, just a few centimeters.
Another issue is with head and neck cancers, you’ve got the lining of your mouth and throat and stuff that gets damaged easily by radiation.
Another place where radiation is a big issue is the small intestine. When you’ve got radiation for the abdomen, there’s restrictions because the small intestine and also the stomach get lesions very easily from radiation. The stomach gets stomach ulcers very easily, and you could even potentially get bowel perforation from radiotherapy to someone’s intestines. So the radiotherapist has to plan that kind of thing very carefully.
If you’re going to have radiotherapy, two things to consider to make it work better are radio- sensitizing drugs. I don’t think any are in standard use, but a whole bunch exist, so you ask if that’s possible as either part of a trial that’s going on, or if your radiotherapist could do it as a case study. That’s using drugs that make the cancer cells more vulnerable to radiation.
A similar thing is using Regional hyperthermia therapy which heats up the tumors and increases the blood flow. Increased blood flow means increased oxygen in the tumors, and oxygen in cancer cells makes the cancer cells weak to radiotherapy. Because the way that radiotherapies work, is they knock electrons off oxygen cells, if it’s gamma radiation and that’s what does the damage, the oxygen ions. If you have more oxygenated cells, then you’re going to get more damage from the radiotherapy.
Following on from that, how do you get the best radiotherapy? Typically what you need to do is search your cancer type for radiotherapy, and see what modes of radiotherapy have been used and the results. Let’s say you’ve got primary lung cancer and you’re wondering if you can have radiotherapy to the lung, you’re going to look for lung cancer radiotherapy. You’ll find papers that are comparing the results of standard crude radiotherapy with CyberKnife, or comparing CyberKnife with proton beam therapy. You need to look at those papers for your specific cancer type. Then you need to search for your country, for that type of machine.
Say you’re based in the UK, if you look at the manufacturer’s website for the CyberKnife machine, they’ll typically have a list. You might have to email them for it, but often it’s just a publically available list on the website, where all those machines are in the UK. Then you’re going to look for those places and contact them, and see if they will do your radiotherapy, or if your oncologist can refer you to that place.That’s why it’s really important to have a good relationship with your oncologist, to get them to fight for access for you.
For surgery ideally, you want to do surgery at a high volume treatment center. For your surgery type, they’re doing it a lot, day in and day out. It’s a hospital where, let’s say you’re doing liver surgery, where they have a bunch of liver surgeons who are doing a lot of liver surgery, because you want the most experienced surgeon possible.
You want to check that the surgeon has been at that hospital for quite a while, because you could have a very good surgeon who’s recently moved to the hospital, which means that the cohesion with the surgeon and the team might not really be there yet and that can result in poorer surgical outcomes. You can ask about the stats. You can ask the stats for their hospital.
For example, when I had my colostomy reversal, there’s a danger of leakage after they connect your intestines again. It can leak and that’s potentially fatal, and requires emergency surgery to fix. But the department at the University Hospital I had that surgery done, their leakage after surgery was ~ half of the national average, or may have even been a tenth of it or something like that. The national average for Japan is kind of similar to or even a bit lower than the international average anyway. This essentially meant that this was a good place to do the surgery, because my situation was particularly difficult. It had a high chance of leakage, so I had to go to a department where they’re getting really good results without leakage.
Generally with surgeons, the older and more experienced the better, because with good surgeons their physical skill levels are pretty similar, but you want the surgeons with good knowledge. You want the ones that are writing papers, that are teaching surgery. For many cancer surgeries, you want as specialist as possible.
So that’s just an overview of surgery and radiotherapy. Both topics are going to be revisited in future modules, because of making decisions about whether you do surgery first or chemo first, do you risk the surgery or do you try another chemo, if your chemo is not working. These difficult treatment decisions will be covered in future modules as well.
As always, you can watch all previous modules at https://www.makecancerhistory.jp/. Thanks for watching.