What's new in cancer?: The rise of robotic assisted surgery

Housed in the New York Medical society is a 4.5 metre long papyrus believed to date from around 1600BC. It is most likely a copy of an even older manual of medicine and contains, in hieroglyphs, the description of 48 medical cases. One of these is a ‘bulging tumour of the breast’ which is treated with what is described as a ‘firestick’. This may be the first ever, rather grim, description of cancer surgery.

As clinical understanding improved, so too did the surgeries being performed. Galen, the second century Greek physician spoke of surgery for breast cancer, and the development of early anaesthesia in the 19th century significantly advanced surgery. But it wasn’t until the 1890s that radiation was first used for cancer. Chemotherapy followed many decades later. By 1369, surgeons had their own professional guild.

Surgery remains a vital part of cancer treatment today. In the UK each month, thousands of new patients are referred for an operation as their first cancer treatment. A long history and tradition does not prevent surgery from continuing to innovate, though, as anyone who watched the recent and amazing ‘Super Surgeons’ documentary on Channel 4 (in partnership with Macmillan) will testify.

One of the most important innovations in recent years has been the introduction of the surgical robot. Robotic assisted surgery allows remotely operated tools to access smaller cavities than could normally be reached by a surgeon’s hands and tools.

In 1982, Patrick Walsh at Johns Hopkins performed the first operation to remove the prostate and preserve nerves in the area to help reduce side effects of loss of sexual function and/or urinary incontinence. Although those first operations were done ‘open’, by the nineties they were being done laparoscopically (using fibreoptic cameras) and were seen as proving ground for a robot-assisted approach.

Meanwhile in the nineties a group of venture capitalists, engineers and surgeons were establishing the company, Intuitive. Their company manufactured the Da Vinci robot which, in 2000, became the first device authorised by the FDA for robotically assisted surgery. In 2019 the company had over $4 billion in revenue and DaVinci machines have become commonly used for nerve-sparing prostatectomy.

It was a natural evolution for surgeons to explore the use of robot assisted techniques in other diseases and there are now established procedures in gynaecological, colorectal and thoracic surgery. Lung cancer surgery is often particularly difficult because of the risk of damaging precious lung tissue in removal of tumours, especially in people who may have lung capacity already reduced by smoking related diseases.

Minimally invasive techniques, such as using video assistance to remove lung cancers, have now been shown to be superior to traditional ‘open’ techniques in the UK-led VIOLET trial, which published early results this year. Surgeons are now exploring Robotic Assisted Thoracic Surgery (the unhappily named ‘RATS’ technique) to further improve safety.

Teaching surgeons to operate safely in a different way brings with it a learning curve that necessarily slows down implementation. These techniques need to prove themselves and it remains important to perform clinical trials to test the assumptions that new will be better.

One area where robotic surgery showed promise was in the treatment of oropharyngeal cancers (in the tonsil and back of the tongue). These cancers are associated with HPV infection (the same virus that causes cervix cancer) and are occurring more frequently. The cancer can often be treated very successfully with modern radiotherapy, but radiation can cause significant short term and long-term side effects, particularly affecting swallowing.

Transoral Robotic surgery (TORS) appeared to offer the potential to excise these tumours and treat patients more quickly without the side effects of radiotherapy. Long term follow-up of the ORATOR trial, comparing radiotherapy with TORS, sadly appears to show a slight disadvantage in swallowing outcomes with TORS when compared to radiotherapy. There is no clear ‘winner’ here and it shows that both surgeons and radiotherapists need to continue to innovate and test techniques carefully in trials.

There is an old adage that a good surgeon knows when to operate but an excellent surgeon knows when not to. Robots may allow surgeons to do what was not previously possible, but some surgeons are assessing the necessity of procedures previously considered normal.

For example, in breast cancer surgery it has been routine to operate to remove the lymph nodes in the armpit next to the breast (axilla). Removing these nodes allows the cancer team to fully understand the spread of the cancer and remove those cells. But we know that axillary surgery can cause pain, nerve damage and swelling of the arm (lymphedema). Over the last few decades, there has been a steady shift away from taking all the lymph glands (axillary clearance) to a ‘smart’ sample of a small number of ‘sentinel’ nodes.

A number of surgical initiatives, including the large UK POSNOC study, are looking to safely further reduce the extent of axillary surgery without compromising cure rates. These efforts complement UK research, which has already safely reduced radiotherapy treatments in breast cancer.

Surgery is also a physical stress. Being as fit as possible before surgery can help reduce the impact of this stress. This is why working with people with cancer to optimise fitness pre-operatively is at the heart of prehabilitation (prehab). Anaesthetists and surgeons have long known that fitter patients have fewer post-operative problems and recover more quickly.

What has become more apparent in the last decade is that it is possible to usefully improve fitness in the relatively short time between deciding an operation is necessary and having the procedure. Macmillan worked with the Royal College of Anaesthetists, the National Institute for Health Research Cancer and Nutrition Collaboration to produce comprehensive guidance for prehabilitation and we continue to work with professionals throughout the UK to implement it.

You will also find excellent education on prehab developed with Macmillan and Health Education England available through the free PRosPer program. A focus from all healthcare professionals on prehab principles mean that whatever surgery a person requires, they can expect better recovery.

Surgery may be the cancer treatment with the longest history, but the specialty continues to look forward. Perhaps we will be able to look forward to a second series of ‘Super Surgeons’?

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