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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.
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.
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.
Numbers are from the trial as recorded here; see the source links in the table below. This is orientation, not medical advice: ask your team how closely the trial population matches you.
Numbers are from the trial as recorded here; see the source links in the table below. This is orientation, not medical advice: ask your team how closely the trial population matches you.
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.
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.
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.
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.
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.
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.
Every era's records, trial outcomes and papers, and every watch item, as JSON.
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The clearest evidence that radical treatment of localised prostate cancer saves lives when the cancer was found clinically rather than by a blood test, and the clearest single statement of what grade does: a Gleason score above 7 carried ten times the risk of death of a score of 6 or lower in the same trial.
The single largest improvement in rectal cancer outcomes came from a change in surgical technique, not a drug. Every radiotherapy trial since has had to show it adds something on top of a properly performed total mesorectal excision.
Every treatment on this roadmap is either a way to reach this operation, a way to make it work better, or a substitute for patients who cannot have it.
Shares Multimodal prehabilitation for older patients before major cancer surgery, Four weeks of training and nutrition before major cancer surgery, as standard, PREHAB: multimodal prehabilitation before colorectal cancer surgery, Enhanced recovery (ERAS) and perioperative nutrition.
Shares HistoSonics, Irreversible electroporation (NanoKnife), Focused ultrasound & histotripsy, Thermal ablation (RFA, microwave, cryo).
Shares NIAGARA, SWOG S1801, A short pre-surgery drug window as the default early test of new agents, MATTERHORN.
Shares Multimodal prehabilitation for older patients before major cancer surgery, Four weeks of training and nutrition before major cancer surgery, as standard, PREHAB: multimodal prehabilitation before colorectal cancer surgery, Enhanced recovery (ERAS) and perioperative nutrition.
Shares HistoSonics, Irreversible electroporation (NanoKnife), Focused ultrasound & histotripsy, Thermal ablation (RFA, microwave, cryo).
Shares Multimodal prehabilitation for older patients before major cancer surgery, Four weeks of training and nutrition before major cancer surgery, as standard, PREHAB: multimodal prehabilitation before colorectal cancer surgery, Enhanced recovery (ERAS) and perioperative nutrition.
Shares MSLT-II, Fluorescence-guided surgery, HIPEC / PIPAC (intraperitoneal chemotherapy), Sentinel lymph node biopsy.
Shares SWOG S1801, Pre-surgery platform trials that test combinations on pathological response in months, NADINA, Sentinel lymph node biopsy.