Less scalpel, better recovery

The treatmentThe standard approach to cancer used to be surgery to remove the malignant tumour, followed by radiation therapy to kill the remaining cancer cells at the tumour site and chemotherapy to systematically "mop up" any other cancer activity in the body. Now, depending on the type of cancer and when the diagnosis is made, the treatment approach varies.

Up to one-third of patients now benefit from having radiation therapy and chemotherapy before surgery. Others are put directly onto new chemotherapy drugs which, following careful monitoring, may prevent the need for surgery at all.

For others, increased understanding of the type of cancer at diagnosis leads to less-invasive surgery and potentially faster and better recovery. For example, radical mastectomies are now rarely carried out as part of the treatment of breast cancer and new tests which find that lymph glands are not affected by the tumour can prevent the removal of these glands, leaving the patient with a better quality of life.

Techniques in radiotherapy have also improved and diagnostic imagery can pinpoint targets more effectively, allowing therapists to deposit radiation energy more precisely than before.

"This allows the maximum hit on the tumour tissue and minimum hit on the normal tissue," explains Dr Michael Moriarty, radiation oncologist at St Luke's Hospital, Dublin.

Overall, the biggest organisational advance in cancer care is the development of a multidisciplinary approach. Following such an approach, each patient's case is discussed by a medical oncologist, radiation oncologist, cancer surgeon and their teams before a treatment approach is decided upon.

Some cancer centres such as the one in St James's Hospital in Dublin can also draw on expertise from abroad through their link-ups with the National Cancer Institute in the US. The team at St James's Hospital also has the benefit of on-site research laboratories at the Institute of Molecular Medicine where the most up-to-date scientific knowledge can inform clinical practise.

Prof John Reynolds, professor of surgery at Trinity College Dublin and consultant cancer surgeon at St James's Hospital, Dublin, stresses the importance of the multidisciplinary approach to cancer care.

The All Ireland Lung Cancer working group, who published the Lung Cancer guidelines earlier this year, stated that lung cancer surgery (the only curative treatment for lung cancer) would double from 10 per cent to 20 per cent of lung cancer cases by providing rapid access to properly co-ordinated multidisciplinary teams.

Lung cancer currently accounts for 20 per cent of all cancer deaths in Ireland.

Prof Reynolds is also adamant that surgery for complex cancers should be carried out only by surgeons who have adequate experience in dealing with such cancers. In complex cancers, he includes lung, oesophageal, pancreas, head and neck and liver surgery.

"The consequences of poor technique or inadequate expertise may be devastating and the risk of the patient dying in hospital after surgery is much higher if the surgery is carried out in a low volume hospital," he explains.

One American study found that patients with oesophageal cancer had a 20 per cent chance of dying in a low volume hospital as compared with 8 per cent in a high volume hospital.

Commenting on the recently published report, Patterns of Care and Survival from Cancer in Ireland - 1994 to 1998, Dr Harry Comber, director of the National Cancer Registry, said, "On a national level, it does seem clear that we need guidelines on treatment of common cancers."

The report showed variations from hospital to hospital and consultant to consultant in terms of what was considered 'optimal treatment' for different cancers. It also found rates of surgery, chemotherapy and radiotherapy differed from region to region.