Volume 2 of Operative Standards for Cancer Surgery focuses on a different group of cancers—thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma, and recommends steps that need to occur in the operating room from skin incision to skin closure that assure the best oncological outcomes for patients. 

The second volume is a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. The first volume was published in 2015. However, it shares the same goal. Recommendations from these first two volumes are serving as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise their accreditation manual and requirements later this year. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.

Similar to the first volume, the second volume is not meant to be a surgical atlas. Instead, the recommendations it offers are part of a shift in the way surgeons are performing cancer operations to ensure the procedures are guided by the strongest-available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both manuals. Until recent years, little critical effort has been made to define standards for the technical conduct of cancer operations.

“Unfortunately, we’ve found that some of the things that surgeons accept as gospel don’t necessarily have the best evidence behind them,” said Nirmal Veeramachaneni, MD, FACS, Committee Vice-Chair. “This project has exposed that deficiency, and has offered avenues for investigation moving forward. It makes us rethink and question everything,” he said.

The history of breast cancer treatment provides an example of a lack of evidence-based treatment strategies. In the late 19th century, surgeons performed radical mastectomies, which entailed removing the patient’s entire breast as well as the underlying chest muscle, Dr. Veeramachaneni explained. This was a rather aggressive procedure, but “we used to think that doing more led to better outcomes,” he said. By the 1970s, however, surgeons were performing less extensive operations, which represented a dramatic change of course.

Committee Chair Matthew H. G. Katz, MD, FACS, agreed that the way surgeons are taught to perform certain procedures is not always based on evidence. However, the goal of this manual is to define standards for how these procedures should be conducted to maximize survival and quality of life after the operations.

Similar to the first volume of the manual (covering breast, colon, lung, and pancreas cancer), this volume breaks down the major cancer operations for each of the five disease sites into critical steps. These critical steps were perceived by teams of experts and stakeholders around the country to have the most significant influence on outcomes, Dr. Katz said.

Then, the teams determined how each step should be performed based on a review of available literature and expert opinion. The teams also identified key questions (areas of controversy) for each site related to the technical aspects of how the operations should be performed. Dr. Katz said these questions could be used as the basis for future clinical trials.

Drs. Katz and Veeramachaneni believe the publication of this volume is just the beginning, and their committee has more work to do in the ongoing process of improving cancer operations and outcomes. The CoC is currently working on rewriting its standards this year, and the technical recommendations in this manual will likely be part of discussions as they do so, Dr. Katz said. Within the next few years, a third volume of the manual focusing on seven additional disease sites will be released.