# Surgery roadmap: radical operations → less surgery → no surgery when a drug has done the work

Source: https://onco.cc/roadmaps/surgery-roadmap/  
OnCo record `surgery-roadmap` (Roadmap). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Surgery cures more cancers than any other treatment. Its story for a century has been learning how much can safely be left in, and now whether the operation is needed at all once drugs and radiation have cleared the tumour.

## Summary

The radical era removed as much as possible; the trial era showed, one operation at a time, that less was as good: breast conservation instead of mastectomy, sentinel node biopsy instead of clearing every node, and no completion lymphadenectomy after a positive sentinel node (MSLT-II). Minimally invasive and robotic approaches shrank incisions and recovery time, with LACC as the caution that keyhole surgery must be tested rather than assumed.

The present shift is that systemic therapy now arrives before the surgeon. Immunotherapy or targeted therapy given before the operation improves survival in lung, melanoma, bladder, stomach and triple-negative breast cancer, and in mismatch-repair-deficient bowel cancer it can remove the need for surgery altogether (NICHE-2, AZUR-1). Interventional oncology treats liver, kidney and pancreatic tumours through a needle or a catheter, and margins are becoming visible in the operating theatre through fluorescent dyes and rapid intraoperative sequencing.

What decides the pace is not technique but evidence and capacity: surgical trials attract a fraction of drug-trial funding, prehabilitation and geriatric co-management are proven but unevenly delivered, and most of the world lacks safe, timely cancer surgery at all.

## Fields

- Kind: Roadmap
- Last checked: 2026-09-10

## Sources

- MSLT-II (NEJM 2017): https://www.nejm.org/doi/full/10.1056/NEJMoa1613210
- NICHE-2 (NEJM 2024): https://www.nejm.org/doi/full/10.1056/NEJMoa2400634
- Lancet Oncology Commission on global cancer surgery: https://www.thelancet.com/commissions/global-cancer-surgery

## Connected records

- ideas: [A short pre-surgery drug window as the default early test of new agents](https://onco.cc/ideas/idea-tr1-window-of-opportunity-default/), [Chemotherapy before surgery for every resectable pancreatic cancer, settled by the two perioperative trials rather than assumed](https://onco.cc/ideas/idea-pdac-neoadjuvant-chemotherapy-for-all-resectable-disease/), [Find peritoneal spread while it is still small, and run complete cytoreduction through networks rather than adding heated chemotherapy](https://onco.cc/ideas/idea-crc-peritoneal-disease-found-early-and-treated-in-networks/), [Four weeks of training and nutrition before major cancer surgery, as standard](https://onco.cc/ideas/idea-bio2-prehabilitation-standard/), [Geriatrician co-management for older patients having cancer surgery](https://onco.cc/ideas/idea-acc-geriatric-co-management-surgery/), [Multimodal prehabilitation for older patients before major cancer surgery](https://onco.cc/ideas/idea-acc-prehabilitation-older-surgery/), [Pre-surgery platform trials that test combinations on pathological response in months](https://onco.cc/ideas/idea-tr2-neoadjuvant-combo-platform/), [Randomise organ preservation against surgery in mismatch repair-proficient rectal cancer, with bowel function as a co-primary endpoint](https://onco.cc/ideas/idea-crc-organ-preservation-randomised-in-pmmr-rectal/), [Remove the fallopian tubes during any pelvic surgery once childbearing is finished](https://onco.cc/ideas/idea-prev-opportunistic-salpingectomy-default/), [Use pre-surgery immunotherapy windows as the field's biomarker engine](https://onco.cc/ideas/idea-bio2-neoadjuvant-biomarker-engine/), [Watch small kidney tumours rather than remove them, with a national registry](https://onco.cc/ideas/idea-prev-small-renal-mass-surveillance/)
- companies: [HistoSonics](https://onco.cc/companies/histosonics/), [Oxford Nanopore Technologies](https://onco.cc/companies/oxford-nanopore/)
- roadmaps: [Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation](https://onco.cc/roadmaps/colorectal-roadmap/), [Devices and physical therapies roadmap: heat and light → electric fields and focused sound → drug-releasing implants](https://onco.cc/roadmaps/devices-roadmap/), [Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials](https://onco.cc/roadmaps/gallbladder-cancer-roadmap/), [Pancreatic cancer roadmap: from Whipple's operation to gemcitabine, FOLFIRINOX, adjuvant chemotherapy, PARP inhibition, KRAS inhibition, vaccines and the surveillance question](https://onco.cc/roadmaps/pancreatic-roadmap/), [Paths to cures: interception, eradication, control](https://onco.cc/roadmaps/cure-paths/), [Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch](https://onco.cc/roadmaps/prostate-roadmap/)
- fronts: [Surgery & Interventional](https://onco.cc/fronts/surgery/)
- technologies: [Active surveillance of papillary microcarcinoma](https://onco.cc/technologies/active-surveillance-thyroid/), [Endoscopic resection (EMR / ESD)](https://onco.cc/technologies/endoscopic-resection/), [Enhanced recovery (ERAS) and perioperative nutrition](https://onco.cc/technologies/eras-perioperative-nutrition/), [Fluorescence-guided surgery](https://onco.cc/technologies/fluorescence-guided-surgery/), [Focused ultrasound & histotripsy](https://onco.cc/technologies/hifu-histotripsy/), [HIPEC / PIPAC (intraperitoneal chemotherapy)](https://onco.cc/technologies/hipec/), [Intraoperative radiotherapy (IORT)](https://onco.cc/technologies/intraoperative-radiotherapy/), [Irreversible electroporation (NanoKnife)](https://onco.cc/technologies/irreversible-electroporation/), [Limb-salvage surgery and endoprosthetic reconstruction](https://onco.cc/technologies/limb-salvage-surgery/), [Liver transplantation for cancer (Milan criteria and beyond)](https://onco.cc/technologies/liver-transplant-oncology/), [MRD / molecular residual disease testing](https://onco.cc/technologies/mrd-testing/), [Optical & fluorescence imaging](https://onco.cc/technologies/optical-imaging/), [Partial nephrectomy, ablation & active surveillance of small renal masses](https://onco.cc/technologies/partial-nephrectomy-active-surveillance/), [Prehabilitation before cancer surgery](https://onco.cc/technologies/prehabilitation/), [Radioembolisation (TARE / SIRT, yttrium-90)](https://onco.cc/technologies/radioembolisation-tare/), [Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [Robotic and navigational bronchoscopy](https://onco.cc/technologies/robotic-bronchoscopy/), [Sentinel lymph node biopsy](https://onco.cc/technologies/sentinel-node/), [Thermal ablation (RFA, microwave, cryo)](https://onco.cc/technologies/thermal-ablation/), [Transarterial chemoembolisation (TACE)](https://onco.cc/technologies/tace/), [Transoral robotic surgery (TORS)](https://onco.cc/technologies/tors/)
- trials: [AZUR-1](https://onco.cc/trials/azur-1/), [CheckMate 816](https://onco.cc/trials/checkmate-816/), [DESTINY-Breast11](https://onco.cc/trials/destiny-breast11/), [Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial)](https://onco.cc/trials/elective-neck-dissection-tmh/), [EMERALD-1](https://onco.cc/trials/emerald-1/), [ESTIMABL2](https://onco.cc/trials/estimabl2/), [FIRES & SENTOR (sentinel node mapping)](https://onco.cc/trials/fires-sentor/), [KEYNOTE-522](https://onco.cc/trials/keynote-522/), [KEYNOTE-671](https://onco.cc/trials/keynote-671/), [LACC (Laparoscopic Approach to Cervical Cancer)](https://onco.cc/trials/lacc/), [MARS 2](https://onco.cc/trials/mars-2/), [MATTERHORN](https://onco.cc/trials/matterhorn/), [MSLT-II](https://onco.cc/trials/mslt-ii/), [NADINA](https://onco.cc/trials/nadina/), [NIAGARA](https://onco.cc/trials/niagara/), [NICHE-2](https://onco.cc/trials/niche-2/), [OVHIPEC-1](https://onco.cc/trials/ovhipec-1/), [PREHAB: multimodal prehabilitation before colorectal cancer surgery](https://onco.cc/trials/prehab-trial/), [PREOPANC-1](https://onco.cc/trials/preopanc/), [SANO](https://onco.cc/trials/sano/), [SENTICOL III](https://onco.cc/trials/senticol-iii/), [SWOG S1801](https://onco.cc/trials/swog-s1801/)
- bottlenecks: [Most of the world has almost no cancer care](https://onco.cc/bottlenecks/b-global-access/), [Not enough oncologists, nurses, pathologists, physicists](https://onco.cc/bottlenecks/b-workforce/), [Older and multimorbid patients are excluded and undertreated](https://onco.cc/bottlenecks/b-aging-comorbidity/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/)
- key papers: [SPCG-4: radical prostatectomy or watchful waiting in prostate cancer, 29-year follow-up](https://onco.cc/key-papers/paper-bill-axelson-spcg-4-29-year-nejm-2018/), [The mesorectum in rectal cancer surgery: the clue to pelvic recurrence?](https://onco.cc/key-papers/paper-heald-mesorectum-rectal-cancer-surgery-br-j-surg-1982/), [Treatment of carcinoma of the ampulla of Vater](https://onco.cc/key-papers/paper-whipple-carcinoma-ampulla-of-vater-ann-surg-1935/)

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JSON: https://onco.cc/api/v1/entities/surgery-roadmap.json