{"entity":{"id":"surgery-roadmap","kind":"roadmap","name":"Surgery roadmap: radical operations → less surgery → no surgery when a drug has done the work","aka":[],"tldr":"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.\n\nThe 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.\n\nWhat 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.","asOf":"2026-09-10","links":[{"label":"MSLT-II (NEJM 2017)","url":"https://www.nejm.org/doi/full/10.1056/NEJMoa1613210"},{"label":"NICHE-2 (NEJM 2024)","url":"https://www.nejm.org/doi/full/10.1056/NEJMoa2400634"},{"label":"Lancet Oncology Commission on global cancer surgery","url":"https://www.thelancet.com/commissions/global-cancer-surgery"}],"tags":[],"related":["idea-bio2-prehabilitation-standard","idea-acc-geriatric-co-management-surgery","idea-acc-prehabilitation-older-surgery","idea-tr1-window-of-opportunity-default","idea-tr2-neoadjuvant-combo-platform","idea-prev-opportunistic-salpingectomy-default","idea-prev-small-renal-mass-surveillance","idea-bio2-neoadjuvant-biomarker-engine","oxford-nanopore","histosonics","cure-paths","devices-roadmap","prostate-roadmap"],"cancers":[],"sections":["surgery"],"technologies":["robotic-surgery","sentinel-node","fluorescence-guided-surgery","optical-imaging","thermal-ablation","irreversible-electroporation","hifu-histotripsy","tace","radioembolisation-tare","hipec","endoscopic-resection","tors","robotic-bronchoscopy","liver-transplant-oncology","partial-nephrectomy-active-surveillance","prehabilitation","eras-perioperative-nutrition","mrd-testing","limb-salvage-surgery","intraoperative-radiotherapy"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":["mslt-ii","lacc","fires-sentor","senticol-iii","checkmate-816","keynote-671","nadina","swog-s1801","matterhorn","niagara","keynote-522","destiny-breast11","niche-2","azur-1","sano","mars-2","estimabl2","ovhipec-1","emerald-1","prehab-trial","elective-neck-dissection-tmh","preopanc"],"people":[],"bottlenecks":["b-surgery-radiation-innovation","b-workforce","b-global-access","b-aging-comorbidity"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"steps":[{"era":"1890s-1990s","title":"From radical to conservative, one trial at a time","description":"Halsted's radical mastectomy set the template that more tissue meant more cure. Randomised trials dismantled it: breast conservation with radiation matched mastectomy, and sentinel lymph node biopsy replaced clearing every node in breast cancer and melanoma. The lesson that survives is that the extent of surgery must be tested, not inferred from anatomy.","refs":["sentinel-node","mslt-ii","fires-sentor","limb-salvage-surgery"],"status":"historic"},{"era":"2000s-2018","title":"Smaller incisions, robots and a warning","description":"Laparoscopic and robotic surgery cut blood loss and recovery time across prostate, kidney, colon and gynaecological cancers, and transoral robotic surgery let throat tumours be removed without splitting the jaw. LACC (2018) showed that keyhole surgery for cervical cancer had more recurrences than open surgery, a reminder that a smaller scar is not automatically the same operation. Endoscopic resection now removes the earliest oesophageal and stomach cancers from the inside.","refs":["robotic-surgery","tors","endoscopic-resection","lacc","robotic-bronchoscopy","elective-neck-dissection-tmh"],"status":"historic"},{"era":"2018-2026","title":"The drug arrives before the surgeon","description":"Giving immunotherapy or targeted therapy before the operation, when the immune system can still see the whole tumour, improved event-free and overall survival in lung cancer (CheckMate 816, KEYNOTE-671), melanoma (SWOG S1801, NADINA), bladder cancer (NIAGARA), stomach cancer (MATTERHORN) and triple-negative breast cancer (KEYNOTE-522). The pathological response at surgery now tells the team how much treatment is needed afterwards, and pre-surgery windows have become the fastest way to test new combinations.","refs":["checkmate-816","keynote-671","swog-s1801","nadina","niagara","matterhorn","keynote-522","destiny-breast11","preopanc","idea-bio2-neoadjuvant-biomarker-engine","idea-tr1-window-of-opportunity-default"],"status":"current"},{"era":"2022-2028","title":"Organ preservation and no surgery at all","description":"In mismatch-repair-deficient bowel cancer, a few weeks of immunotherapy clears most tumours completely (NICHE-2), and AZUR-1 is the registrational test of skipping surgery, radiation and chemotherapy entirely. SANO showed that watching closely after chemoradiation for oesophageal cancer, operating only if the tumour returns, is safe for the third of patients whose tumour has vanished. ESTIMABL2 let most low-risk thyroid cancers skip radioactive iodine; small kidney tumours and papillary microcarcinomas are increasingly watched rather than removed. MARS 2 showed that a major mesothelioma operation did not help, and practice changed.","refs":["niche-2","azur-1","sano","estimabl2","mars-2","partial-nephrectomy-active-surveillance","active-surveillance-thyroid","idea-prev-small-renal-mass-surveillance"],"status":"current"},{"era":"2010s-2026","title":"Treating through a needle or a catheter","description":"Interventional oncology destroys tumours with heat, cold, electric pulses or focused sound, and delivers chemotherapy or radioactive beads through the artery that feeds a liver tumour. EMERALD-1 added immunotherapy to chemoembolisation; OVHIPEC-1 showed that washing the abdomen with heated chemotherapy during ovarian surgery extends survival; liver transplantation cures selected liver cancers and the disease underneath them. Histotripsy, which destroys tissue mechanically with sound, gained approval in the liver and is now being tested as an immune primer.","refs":["thermal-ablation","irreversible-electroporation","hifu-histotripsy","tace","radioembolisation-tare","emerald-1","hipec","ovhipec-1","liver-transplant-oncology","histosonics"],"status":"current"},{"era":"2026-2030","title":"Seeing the margin and preparing the patient","description":"Fluorescent dyes that light up tumour and nerves, and portable sequencers that classify a brain tumour's methylation during the operation, aim to make the margin visible rather than guessed. After surgery, ctDNA testing says whether anything was left. Before it, four weeks of exercise, nutrition and psychological preparation (PREHAB) cut complications, and geriatric co-management does the same for older patients; both are proven and both are rarely funded. Sentinel node mapping is extending to cervical (SENTICOL III) and endometrial cancer to spare women lymphoedema.","refs":["fluorescence-guided-surgery","optical-imaging","oxford-nanopore","mrd-testing","prehabilitation","prehab-trial","eras-perioperative-nutrition","idea-bio2-prehabilitation-standard","idea-acc-geriatric-co-management-surgery","idea-acc-prehabilitation-older-surgery","senticol-iii","intraoperative-radiotherapy"],"status":"emerging"},{"era":"What sets the pace","title":"Funding, workforce and access","description":"Surgery and radiotherapy cure more people than drugs but attract a small share of trial funding, so questions like how much to remove, when to operate and whether to operate at all wait years for an answer. Most of the world lacks timely, safe cancer surgery, and the surgeons and anaesthetists to provide it. Standing pre-surgery platform trials, default prehabilitation, and opportunistic salpingectomy during any pelvic operation are among the answers already on the table.","refs":["b-surgery-radiation-innovation","b-workforce","b-global-access","b-aging-comorbidity","idea-tr2-neoadjuvant-combo-platform","idea-prev-opportunistic-salpingectomy-default"],"status":"current"}],"watch":[]},"route":"/roadmaps/surgery-roadmap/","neighbours":{"idea":[{"id":"idea-tr1-window-of-opportunity-default","kind":"idea","name":"A short pre-surgery drug window as the default early test of new agents","route":"/ideas/idea-tr1-window-of-opportunity-default/"},{"id":"idea-pdac-neoadjuvant-chemotherapy-for-all-resectable-disease","kind":"idea","name":"Chemotherapy before surgery for every resectable pancreatic cancer, settled by the two perioperative trials rather than assumed","route":"/ideas/idea-pdac-neoadjuvant-chemotherapy-for-all-resectable-disease/"},{"id":"idea-crc-peritoneal-disease-found-early-and-treated-in-networks","kind":"idea","name":"Find peritoneal spread while it is still small, and run complete cytoreduction through networks rather than adding heated chemotherapy","route":"/ideas/idea-crc-peritoneal-disease-found-early-and-treated-in-networks/"},{"id":"idea-bio2-prehabilitation-standard","kind":"idea","name":"Four weeks of training and nutrition before major cancer surgery, as standard","route":"/ideas/idea-bio2-prehabilitation-standard/"},{"id":"idea-acc-geriatric-co-management-surgery","kind":"idea","name":"Geriatrician co-management for older patients having cancer surgery","route":"/ideas/idea-acc-geriatric-co-management-surgery/"},{"id":"idea-acc-prehabilitation-older-surgery","kind":"idea","name":"Multimodal prehabilitation for older patients before major cancer surgery","route":"/ideas/idea-acc-prehabilitation-older-surgery/"},{"id":"idea-tr2-neoadjuvant-combo-platform","kind":"idea","name":"Pre-surgery platform trials that test combinations on pathological response in months","route":"/ideas/idea-tr2-neoadjuvant-combo-platform/"},{"id":"idea-crc-organ-preservation-randomised-in-pmmr-rectal","kind":"idea","name":"Randomise organ preservation against surgery in mismatch repair-proficient rectal cancer, with bowel function as a co-primary endpoint","route":"/ideas/idea-crc-organ-preservation-randomised-in-pmmr-rectal/"},{"id":"idea-prev-opportunistic-salpingectomy-default","kind":"idea","name":"Remove the fallopian tubes during any pelvic surgery once childbearing is finished","route":"/ideas/idea-prev-opportunistic-salpingectomy-default/"},{"id":"idea-bio2-neoadjuvant-biomarker-engine","kind":"idea","name":"Use pre-surgery immunotherapy windows as the field's biomarker engine","route":"/ideas/idea-bio2-neoadjuvant-biomarker-engine/"},{"id":"idea-prev-small-renal-mass-surveillance","kind":"idea","name":"Watch small kidney tumours rather than remove them, with a national registry","route":"/ideas/idea-prev-small-renal-mass-surveillance/"}],"company":[{"id":"histosonics","kind":"company","name":"HistoSonics","route":"/companies/histosonics/"},{"id":"oxford-nanopore","kind":"company","name":"Oxford Nanopore Technologies","route":"/companies/oxford-nanopore/"}],"roadmap":[{"id":"colorectal-roadmap","kind":"roadmap","name":"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","route":"/roadmaps/colorectal-roadmap/"},{"id":"devices-roadmap","kind":"roadmap","name":"Devices and physical therapies roadmap: heat and light → electric fields and focused sound → drug-releasing implants","route":"/roadmaps/devices-roadmap/"},{"id":"gallbladder-cancer-roadmap","kind":"roadmap","name":"Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials","route":"/roadmaps/gallbladder-cancer-roadmap/"},{"id":"pancreatic-roadmap","kind":"roadmap","name":"Pancreatic cancer roadmap: from Whipple's operation to gemcitabine, FOLFIRINOX, adjuvant chemotherapy, PARP inhibition, KRAS inhibition, vaccines and the surveillance question","route":"/roadmaps/pancreatic-roadmap/"},{"id":"cure-paths","kind":"roadmap","name":"Paths to cures: interception, eradication, control","route":"/roadmaps/cure-paths/"},{"id":"prostate-roadmap","kind":"roadmap","name":"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","route":"/roadmaps/prostate-roadmap/"}],"section":[{"id":"surgery","kind":"section","name":"Surgery & Interventional","route":"/fronts/surgery/"}],"technology":[{"id":"active-surveillance-thyroid","kind":"technology","name":"Active surveillance of papillary microcarcinoma","route":"/technologies/active-surveillance-thyroid/"},{"id":"endoscopic-resection","kind":"technology","name":"Endoscopic resection (EMR / ESD)","route":"/technologies/endoscopic-resection/"},{"id":"eras-perioperative-nutrition","kind":"technology","name":"Enhanced recovery (ERAS) and perioperative nutrition","route":"/technologies/eras-perioperative-nutrition/"},{"id":"fluorescence-guided-surgery","kind":"technology","name":"Fluorescence-guided surgery","route":"/technologies/fluorescence-guided-surgery/"},{"id":"hifu-histotripsy","kind":"technology","name":"Focused ultrasound & histotripsy","route":"/technologies/hifu-histotripsy/"},{"id":"hipec","kind":"technology","name":"HIPEC / PIPAC (intraperitoneal chemotherapy)","route":"/technologies/hipec/"},{"id":"intraoperative-radiotherapy","kind":"technology","name":"Intraoperative radiotherapy (IORT)","route":"/technologies/intraoperative-radiotherapy/"},{"id":"irreversible-electroporation","kind":"technology","name":"Irreversible electroporation (NanoKnife)","route":"/technologies/irreversible-electroporation/"},{"id":"limb-salvage-surgery","kind":"technology","name":"Limb-salvage surgery and endoprosthetic reconstruction","route":"/technologies/limb-salvage-surgery/"},{"id":"liver-transplant-oncology","kind":"technology","name":"Liver transplantation for cancer (Milan criteria and beyond)","route":"/technologies/liver-transplant-oncology/"},{"id":"mrd-testing","kind":"technology","name":"MRD / molecular residual disease testing","route":"/technologies/mrd-testing/"},{"id":"optical-imaging","kind":"technology","name":"Optical & fluorescence imaging","route":"/technologies/optical-imaging/"},{"id":"partial-nephrectomy-active-surveillance","kind":"technology","name":"Partial nephrectomy, ablation & active surveillance of small renal masses","route":"/technologies/partial-nephrectomy-active-surveillance/"},{"id":"prehabilitation","kind":"technology","name":"Prehabilitation before cancer surgery","route":"/technologies/prehabilitation/"},{"id":"radioembolisation-tare","kind":"technology","name":"Radioembolisation (TARE / SIRT, yttrium-90)","route":"/technologies/radioembolisation-tare/"},{"id":"robotic-surgery","kind":"technology","name":"Robotic & minimally invasive surgery","route":"/technologies/robotic-surgery/"},{"id":"robotic-bronchoscopy","kind":"technology","name":"Robotic and navigational bronchoscopy","route":"/technologies/robotic-bronchoscopy/"},{"id":"sentinel-node","kind":"technology","name":"Sentinel lymph node biopsy","route":"/technologies/sentinel-node/"},{"id":"thermal-ablation","kind":"technology","name":"Thermal ablation (RFA, microwave, cryo)","route":"/technologies/thermal-ablation/"},{"id":"tace","kind":"technology","name":"Transarterial chemoembolisation (TACE)","route":"/technologies/tace/"},{"id":"tors","kind":"technology","name":"Transoral robotic surgery (TORS)","route":"/technologies/tors/"}],"trial":[{"id":"azur-1","kind":"trial","name":"AZUR-1","route":"/trials/azur-1/"},{"id":"checkmate-816","kind":"trial","name":"CheckMate 816","route":"/trials/checkmate-816/"},{"id":"destiny-breast11","kind":"trial","name":"DESTINY-Breast11","route":"/trials/destiny-breast11/"},{"id":"elective-neck-dissection-tmh","kind":"trial","name":"Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial)","route":"/trials/elective-neck-dissection-tmh/"},{"id":"emerald-1","kind":"trial","name":"EMERALD-1","route":"/trials/emerald-1/"},{"id":"estimabl2","kind":"trial","name":"ESTIMABL2","route":"/trials/estimabl2/"},{"id":"fires-sentor","kind":"trial","name":"FIRES & SENTOR (sentinel node mapping)","route":"/trials/fires-sentor/"},{"id":"keynote-522","kind":"trial","name":"KEYNOTE-522","route":"/trials/keynote-522/"},{"id":"keynote-671","kind":"trial","name":"KEYNOTE-671","route":"/trials/keynote-671/"},{"id":"lacc","kind":"trial","name":"LACC (Laparoscopic Approach to Cervical Cancer)","route":"/trials/lacc/"},{"id":"mars-2","kind":"trial","name":"MARS 2","route":"/trials/mars-2/"},{"id":"matterhorn","kind":"trial","name":"MATTERHORN","route":"/trials/matterhorn/"},{"id":"mslt-ii","kind":"trial","name":"MSLT-II","route":"/trials/mslt-ii/"},{"id":"nadina","kind":"trial","name":"NADINA","route":"/trials/nadina/"},{"id":"niagara","kind":"trial","name":"NIAGARA","route":"/trials/niagara/"},{"id":"niche-2","kind":"trial","name":"NICHE-2","route":"/trials/niche-2/"},{"id":"ovhipec-1","kind":"trial","name":"OVHIPEC-1","route":"/trials/ovhipec-1/"},{"id":"prehab-trial","kind":"trial","name":"PREHAB: multimodal prehabilitation before colorectal cancer surgery","route":"/trials/prehab-trial/"},{"id":"preopanc","kind":"trial","name":"PREOPANC-1","route":"/trials/preopanc/"},{"id":"sano","kind":"trial","name":"SANO","route":"/trials/sano/"},{"id":"senticol-iii","kind":"trial","name":"SENTICOL III","route":"/trials/senticol-iii/"},{"id":"swog-s1801","kind":"trial","name":"SWOG S1801","route":"/trials/swog-s1801/"}],"bottleneck":[{"id":"b-global-access","kind":"bottleneck","name":"Most of the world has almost no cancer care","route":"/bottlenecks/b-global-access/"},{"id":"b-workforce","kind":"bottleneck","name":"Not enough oncologists, nurses, pathologists, physicists","route":"/bottlenecks/b-workforce/"},{"id":"b-aging-comorbidity","kind":"bottleneck","name":"Older and multimorbid patients are excluded and undertreated","route":"/bottlenecks/b-aging-comorbidity/"},{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"}],"paper":[{"id":"paper-bill-axelson-spcg-4-29-year-nejm-2018","kind":"paper","name":"SPCG-4: radical prostatectomy or watchful waiting in prostate cancer, 29-year follow-up","route":"/key-papers/paper-bill-axelson-spcg-4-29-year-nejm-2018/"},{"id":"paper-heald-mesorectum-rectal-cancer-surgery-br-j-surg-1982","kind":"paper","name":"The mesorectum in rectal cancer surgery: the clue to pelvic recurrence?","route":"/key-papers/paper-heald-mesorectum-rectal-cancer-surgery-br-j-surg-1982/"},{"id":"paper-whipple-carcinoma-ampulla-of-vater-ann-surg-1935","kind":"paper","name":"Treatment of carcinoma of the ampulla of Vater","route":"/key-papers/paper-whipple-carcinoma-ampulla-of-vater-ann-surg-1935/"}]}}