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Course: Oncology Nursing�Topic: Surgery in Cancer Treatment Part 1

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the factors influencing the selection of surgery for cancer.
Identify the types of surgery in the prevention, diagnosis, staging, treatment and palliation of cancer.
Identify upcoming surgery alternatives for cancer management.
Explore the nurse’s role in surgical cancer treatment.

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Factors Influencing Use of Surgery in Cancer

Cancer surgery is performed to either completely or partially remove tumors from the body to explore/remove affected tissue¹

Tumor related factors²:

Location
Histology
Growth rate
Invasiveness
Metastatic potential

Individual factors²:

Staging and grading of cancers at presentation
Individual’s health status
Disease trajectory
Treatment history

National Cancer Institute. SEER Training Modules, Cancer Treatment: Surgery.
Cancer Australia (2018).

Contact info: info@nursesinternational.org

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Factors Influencing Use of Surgery in Cancer

Most common causes of death post surgery are:

Bronchopneumonia, Congestive Heart Failure, Myocardial Infarction, Pulmonary embolism, Respiratory failure

Risk factors to consider before deciding surgery are :

Obesity, smoking, cardiac and pulmonary comorbidities

Health service related:

Subspecialization of the team caring for cancer patient before, during and after surgery relate to improved outcome
High volume surgeons/hospital shows improved outcome

Cancer Australia (2018).

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Major Challenge in Cancer Care:

Access to appropriate healthcare team
Well equipped healthcare setting

Cancer Australia (2018).

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Use of Surgery in Cancer Care

Prophylactic Surgery

Diagnostic Surgery

Definitive (or Curative) Surgery

Rehabilitative (or Reconstructive) Surgery

Palliative Surgery

Cancer Australia (2018).

Contact info: info@nursesinternational.org

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Case study:

37 year old Bella was admitted to the cancer hospital with diagnosis of lung cancer. According to her health history she was 5’3” tall, weighed 80 kg, BP 130/85 mmHg, and is a chain smoker.

Describe her health risk factors that could influence decisions regarding surgical interventions in her treatment?

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Diagnostic Surgery

Physically removing all or part of tumor tissue
Also called Biopsy
Performed for the purpose of microscopic examination of tissue samples to-

Detect or confirm presence of cancer
Identify histologic type of cancer
Identify stage of cancer

May involve minor or major surgery while some may not even require local anesthesia

SEER Training Modules, Cancer Treatment: Surgery/Diagnostic Surgery

Contact info: info@nursesinternational.org

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Diagnostic Surgery

Side effects of Biopsy¹:

Slight bleeding or bruising
Tenderness
Pain

Positive biopsy findings indicate presence of Cancer²
Negative biopsy indicates

No cancer²
Or, the specimen was not representative of the tumor ²

In rare cases the needle misses the tumor and removes healthy tissue³
High index of suspicion of cancer requires another biopsy²

Canadian Cancer Society, n.d., Surgical biopsy.
Cancer Australia (2018).
SEER Training Modules,Cancer Treatment: Surgery/Diagnostic Surgery

Infection
Problems with wound healing
Change in the shape (breast surgery)

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Prophylactic Surgery

Removal of tissue that does not yet contain cancer cells but has the probability of becoming cancerous in future¹.
Patients with congenital or genetic trait with high risk of developing cancer ¹.
Does not guarantee that patient will never develop cancer in future¹.
Careful discussion between surgeon and patient is very important before making decision about prophylactic surgery¹.
Regular medical surveillance and counseling is indicated².

SEER Training Modules, Cancer Treatment: Surgery as a Preventive Measure.
Cancer Australia (2018).

Contact info: info@nursesinternational.org

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Definitive/Curative Surgery

Surgical intervention that completely removes tumor/cancerous tissue to treat cancer¹.
Treatment most effective if the cancer is

At an early stage¹-
Only in the place where it started (localized)¹.
Has not spread to other parts of the body¹

A rim of normal tissue surrounding cancerous tissue is also removed during the procedure².

This rim is called Margin.
Minimizes risk of leaving cancer cells behind.

Canadian Cancer Society, n.d., Surgery in Cancer treatment.
SEER Training Modules, Cancer Treatment: Surgery

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Definitive/Curative Surgery

Metastatic disease is also considered for resection if

It is a single site¹
Can be resected without major morbidity¹
Cancer responds poorly to systemic therapy¹

Cytoreductive Surgery²:

Also called debulking surgery
Removes as much cancerous tissue as possible to reduce number of cells
Makes chemotherapy and radiation more therapy effective

Cancer Australia (2018).
Canadian Cancer Society, n.d., Surgery in cancer treatment.

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Definitive/Curative Surgery

Decision for curative surgery is often based on factors such as

Patient’s age
General health condition of the patient
Location of tumor
Stage of tumor
Presence or absence of enlarged nodes
Patient’s desire for preservation

Patient with metastasized cancer may receive chemotherapy along with surgery

Source: SEER Training Modules, Cancer Treatment: Surgery/Curative Surgery

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Methods of Prophylactic/Curative Surgery

Excision with Scalpel
Laser surgery uses powerful beam of light directed to specific sites. Eliminates making large incision
Electrosurgery uses high frequency electrical currents to cut and destroy cancer cells
Cryosurgery uses liquid nitrogen or a very cold probe to freeze and kill cancer cells

SEER Training Modules, Cancer Treatment: Surgery/Curative Surgery

Contact info: info@nursesinternational.org

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Rehabilitative/Reconstructive Surgery

Performed after definitive/curative therapy to improve function and cosmetic appearance¹
Cosmetic surgery is performed to reshape normal structures of the body to improve self-image and self-esteem²
Reconstructive surgery is performed to-

Repair abnormal or damaged body structures after curative surgery²
Improve functions of certain anatomic parts of the body²

Cancer Australia (2018)
SEER Training Modules, Cancer treatment: Surgery/Palliative and Reconstructive Surgery.

Contact info: info@nursesinternational.org

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Rehabilitative/Reconstructive Surgery

Specific reconstructive procedure depends on -

Type of primary surgery performed¹.
Condition of remaining tissue¹.
Need for post-operative adjuvant therapy¹.

Reconstructive surgery may be immediate or delayed depending on circumstances¹.
Multiple stages of reconstruction may be necessary for optimal results when delayed tissue transfer is required².
Considerable psychological support may be required by the patient to address their physical loss before completion of surgical reconstruction restoration¹.

Cancer Australia (2018)
SEER Training Modules, Cancer treatment: Surgery/Palliative and Reconstructive Surgery.

Contact info: info@nursesinternational.org

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Palliative Surgery

Five main purposes have been described for palliative surgical procedures¹:

Evaluation of the extent of the disease
Control of locoregional spread
Control of a fungating tumor, discharge or hemorrhage
Control of pain
Surgical reconstruction or rehabilitation to improve quality of life

May prolong patient’s life in some cases².

Fish & Bruera,eds, 2003, as cited in Cancer Australia, 2018.
SEER Training Modules, Cancer Treatment: Surgery/Palliative and Reconstructive Surgery.

Contact info: info@nursesinternational.org

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Palliative Surgery

Conducted to preserve the quality of life for the longest time possible
Cancer specialists deem it worthwhile when the disease is unresponsive to curative treatments¹
Decision-making process involves²:

Identifying goals
Recognizing values
Acknowledging alternatives
Weighing risks and burdens

Palliative surgeries are not recorded as cancer-directed surgery¹

SEER Training Modules, Cancer Treatment: Surgery/Palliative and Reconstructive Surgery.
Ferrel et al, 2003, as cited in

Cancer Australia 2018.

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Case study:

Bimala, mother of 2 daughters, went to the clinic for general health checkup. From her health history it was identified that she had a strong family history of ovarian cancer. Bimala did not complain of any problem with her health to date and the ultrasonogram of her ovaries showed normal findings.

What surgical intervention would a nurse expect the healthcare team propose to Bimala at this stage?

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Supporting Other Treatments

Surgery might be performed in cancer patient for the following reasons:

Providing direct access to a blood vessel for drug administration
Placing access such, as central venous catheter or pump, for

Taking blood samples
Administering chemotherapy, antibiotics, blood products or IV nutrition

Surgery may be used to help with body functions

Tracheostomy may be done to place breathing tube
Gastrostomy may be performed to administer nutrition/liquids

Canadian Cancer Society, n.d., Surgery in cancer treatment.

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Future Direction in Cancer Surgery

Fast track surgery

Minimally invasive surgery

Robotics

Cancer Australia, 2018

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Fast Track Surgery

Multimodal approach requiring successful organization of multi-disciplinary team
Focus on enhancing recovery and reducing morbidity
Key elements contributing to successful fast track surgery-

Optimal participant selection
Establishing evidence based clinical protocols
Commencing coordination of care pre-operatively
Patients have realistic expectations of their hospital stay
Establishing referral pathways and clinical coordination between acute and primary health sectors to ensure access to specialist services in a timely manner
Maintaining quality clinical care.

Kehlet & Wilmore, 2008, as cited in Cancer Australia, 2018.

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Minimally Invasive Surgery

Less invasive than open surgery¹
Use of laparoscopes and remote control manipulation of instruments with indirect observation of the surgical field through an endoscope¹
Laparoscopy has expanded to diagnosing, staging, treating, monitoring and palliating many malignancies²
Benefit of laparoscopic surgery:²

Reduction of post-operative pain
Decreased healing time
Decreased adhesion formation

1. Newman,2001, as cited in Cancer Australia, 2018.

DeVita et al, 2008, as cited in Cancer Australia, 2018.

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Robotics

Computer controlled device programmed to aid the position and manipulation of surgical instrument
Typically use in laparoscopic surgical approaches
Advantages over conventional laparoscopy:

Superior visualisation
Small movements by surgeon are amplified
Improved ergonomics of the operating surgeon
Mechanical improvements

Hashizume & Tsugawa, 2004, and Herron & Marohn, 2008, as cited in Cancer Australia, 2018.

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Nurse’s Role in Surgical Cancer Treatment

Possess an understanding of surgical cancer treatment and their impact and effects on patient
Identify and respond to untoward symptoms or effects of surgical therapy to ensure safe patient care
Assess patient’s learning needs to provide education to patient pre and post cancer therapy
Identify and reinforce the patient’s support system(family, friends etc.) and health beliefs
Communicate essential information about the patient or patient’s responses to the healthcare team
Ongoing and lifelong commitment to learning

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Red Flags

Fever
Bleeding
Blood clots
Breathing difficulty
Shortness of breath
Chest Pain
Rapid or irregular heart rate
Increased discharge or tenderness or warmth at surgical site

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Cultural Considerations

The degree of family participation in decision making differs across cultures.

It may not be the individual making the treatment decisions.

Patterns of communication differ among ethnicities and good communication must occur when discussing cancer treatment.

Poor communication can impact treatment decision making.

There may be some distrust of healthcare providers and healthcare systems in some cultures.
Religious or cultural beliefs may differ as to the causes of cancer and therefore may affect treatment plans ( Health Belief Models).

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Case study:

During her initial visit to the surgeon’s office, May Blean, 37, shared that her mother died of breast cancer in her 40s and her grandmother died of breast cancer in her 60s. She is concerned that she may develop cancer and is considering bilateral breast removal. She says that she she is afraid that she will no longer feel like a woman if she has both of her breasts removed. She is also worried that her husband will not love her if she she has a bilateral breast removal.

What should the nurse include in response to May?

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Reference:

Cancer Australia. (2018). EdCaN module: Surgery in cancer control. Accessed from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/surgery/surgery-in-cancer-control

Canadian Cancer Society (n.d). Surgery: Surgery in Cancer treatment. Accessed from: https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/surgery/?region=on#Remove

Canadian Cancer Society ( n.d). Test and Procedure: Surgical biopsy. Accessed from: https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/surgical-biopsy/?region=on

Contact info: info@nursesinternational.org

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Reference:

National Cancer Institute SEER Training Modules (n.d.). Cancer Treatment: Diagnostic Surgery. Retrieved on 29th of March 2021, from: https://training.seer.cancer.gov/treatment/surgery/types/diagnostic.htmlNational Cancer Institute SEER Training Modules (n.d.). Cancer Treatment: Surgery. Retrieved on 29th of March 2021, from https://training.seer.cancer.gov/treatment/surgery/

National Cancer Institute SEER Training Modules (n.d.). Cancer Treatment: Surgery. Retrieved on 29th of March 2021, from https://training.seer.cancer.gov/treatment/surgery/types/preventive.html

National Cancer Institute SEER Training Modules (n.d.). Cancer Registration and Surveillance Module: Curative Surgery. Retrieved on 1st of April 2021, from: https://training.seer.cancer.gov/treatment/surgery/types/curative.html

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Reference:

National Cancer Institute SEER Training Modules (n.d.). Cancer Registration and Surveillance Module: Palliative and reconstructive surgery. Retrieved on 1st of April 2021, from https://training.seer.cancer.gov/treatment/surgery/types/palliative.html

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