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Colon Cancer - Why Your Surgeon and Surgery Matter

Colorectal cancers - cancers of the colon and rectum - are among the most common cancers diagnosed in the United States. Colon cancer - as opposed to rectal cancer - involves the abdominal portion of the large intestine. In the absence of spread to other organs, colon cancer is usually treated with surgery first, followed by chemotherapy if necessary. The treatment of rectal cancer is vastly different and this will be addressed in a different post. 

Many surgeons (general, oncologic, colorectal, etc.) offer surgery for colon cancer and most think they do it perfectly well, which is sadly not always the case. The operation for colon cancer is often presented simply as the removal of the portion of colon that contains the cancer with some surrounding lymph nodes. The details and nuances of the operation are treated as an afterthought - with the surgeon more often focusing on the instruments to be used and the approach - will the operation be performed with a big cut, small cut, a laparoscope, a robot, a single small incision perhaps, etc.

While the approach is important in determining your immediate recovery, you won't be surprised to know that the actual details of the cancer operation inside have a far greater bearing on your chance of being cured. Treating colon and rectal cancers properly requires extensive subspecialty training or a career dedicated to studying and understanding the disease, preferably both.

There are two general parts of a colon cancer operation, 1) the removal of the right amount of colon and 2) the removal of the right number of lymphs from the right locations. The second part of the operation actually is a much bigger determinant of how well your cancer is treated and this where there is the most variability among surgeons.

A number of academic societies have defined the minimum number of lymph nodes to be removed as 12 in order for the operation to be considered appropriate. Nuances such as location, distance from the tumor and other factors are not specified because these are too difficult to standardize. The goal of defining a number is not to define a good or great operation, but rather to define the bare minimum performance standard. 

Many surgeons will treat the number 12 as the gold standard. It is not. It is instead the BARE MINIMUM. Just as important is where these lymph nodes are taken from. Will your surgeon remove colon and lymph nodes 2cm away from the tumor? 5cm? 10cm away? Does he/she know the difference and why and when the distinctions are important? Will your surgeon remove the lymph nodes at the root of the colon where the disease tends to spread and recur? Will he/she do this consistent or reliably even when the going gets tough? Or will your operation be just good enough? Do you ask your mechanic to fill your car with the bare minimum amount of oil to allow your car to run? Do you ask your AC repairman to do just good enough?

The medical device industry has nudged surgeons to focus more on instruments and approaches - the laparoscope, the robot, the single incision port - rather than the appropriate treatment of disease. Minimally invasive approaches are important. However, many surgeons modify the cancer operation to accomodate an approach, rather than modifying the approach to allow for the best colon cancer operation. This is why expertise in your particular cancer is important. Colon cancer is a life threatening disease after all, and there is often no going back after bad treatment. This is why your surgeon and the details of your colon cancer surgery matter. 



Avo Artinyan, MD, MS, FACS Dr. Artinyan is a nationally recognized expert in the treatment of colon, rectal, gastric and other gastrointestinal cancers. Prior to starting his own private practice in Los Angeles, he served as Chief of Colon and Rectal Surgery in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine in Houston, Texas, one of the preeminent medical schools and surgery departments in the world.