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Treatment Options in Cancer Surgery
review by Irene Alleger

"Making The Right Choice" by Richard A. Evans, M.D.
Avery Publishing Group, Garden City Park, New York
1995, softcover, $14.95, 344 pp.

    Although alternative cancer treatments are being studied and are often effective, when it comes to malignant tumors, it is thought to be imperative to remove the tumor surgically before it begins to metastasize. In the past, surgeons have operated on the premise that removing every last tumor cell, usually involving the lymph nodes and healthy tissue, referred to as radical surgery, was the most effective way to prevent recurrence. Cancer surgeon Richard Evans, MD began to question this rationale early in his career and published, in 1980, an article questioning the necessity of trying to remove all cancer cells by radical removal of breasts, organs, and extremities.

    In the late 1970's, a group called the National Surgical Adjuvant Breast Project (NSABP) published results of studies showing that the microscopic cancer cells left in lymph nodes could remain for months until they became enlarged and had to be removed. But the most important part of the study was the fact that delayed removal of lymph nodes did not impair survival. What was changing was the emergence of the new scientific findings in the field of immunology.

    These new findings involved the immune system's surveillance and ability to kill cancer cells circulating within the bloodstream, proving the "tumor-host" conflict. The patient may have lost the battle in the breast, for instance, but was still capable of defending themselves against the spread of cancer to distant organs. They did this by killing cancer cells circulating within the bloodstream.

    Dr. Evans concluded that a patient who could kill cancer cells circulating from a breast cancer could also kill cells circulating from a cancer in the lymph nodes. Thus, the cancer cells left behind in a lymph node were of no risk to the patient, if they were removed in a timely fashion. Dr. Evans became an advocate of what he calls "conservative" surgery, urging his colleagues to use lumpectomy (in breast cancer) instead of mastectomy inasmuch as studies had proven that lumpectomy was as effective as mastectomy in the treatment of breast cancer. Patients who develop locally recurrent breast cancer following a lumpectomy have a second chance to be cured. A recurrent tumor can be promptly removed without any added risk to the patient's continued survival. Not suprisingly, many of his colleagues still ignore these newer findings, perpetrating unnecessary suffering and disfigurement of their patients.

    In writing Making The Right Choice, the author's stated goal is to ensure that patients faced with cancer surgery be aware of these newer studies, and have the option of discussing them with their oncologist. The book covers conservative surgery in malignant melanoma, the soft tissue sarcomas, rectal cancer, bladder and breast cancer, cancer of the cervix and penis, and prostate cancer. Dr. Evans gives the reader a thorough understanding of the history of cancer surgery, current research in cancer, and in "Principles of Treatment," he discusses types of cancer, how they're graded, their routes of spread, screening procedures for early detection, signs and symptoms, diagnosis and follow-up. Radiation, chemotherapy, and bone marrow transplantation are also discussed in detail. Dr. Evans uses lay language throughout this book, and imparts important information for patients concerning "disease-free survival," response rates," hormonal and biological therapies, and much more.

    Oncology surgeons are under some pressure to recommend aggressive treatment. Making The Right Choice gives the cancer patient a way to participate effectively in deciding treatment options. The author has written a comprehensive book on conservative surgery for cancer, and advises cancer patients to study and prepare until they are confident that the understand the issues: "Don't be satisfied with simple answers."

1983-2002 Townsend Letter for Doctors and Patients
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