Jury’s still out on minimally invasive cancer surgeries
Is doing major surgery through small incisions better for the patient than more traditional methods?
The answer is surprisingly complicated, especially for patients who have cancer — or don’t realize they have cancer. Minimally invasive technology might fragment a tumor before extracting it, leaving unseen malignant cells behind to grow and spread.
Now, robot-assisted surgery — the most high-tech, high-cost version of minimally invasive technology — is being introduced for breast cancer treatment. But rigorous clinical trials have not been done to compare the safety of robotic approaches with conventional methods.
Last month, the University of Pennsylvania touted “the world’s first” robotic double breast reconstruction using a flap of tissue from the woman’s abdomen. But the robot was employed only after the patient had a conventional mastectomy, sidestepping the risk of spreading tumor cells.
Last spring, the American Society of Plastic Surgeons hailed Long Island surgeons for doing the nation’s “first robot-assisted, nipple-sparing double mastectomy” and implant reconstruction — in a patient who did not have cancer. She has the BRCA gene and removed her healthy breasts to prevent cancer.
Another use of the robot, trumpeted in October by the Asbury Park Press, was suspended in December pending a review by Monmouth Medical Center, according to the newspaper. Stephen Chagares, a Tinton Falls, N.J., breast surgeon, performed a robotic mastectomy on a patient with breast cancer, followed by reconstruction with an implant. (Chagares did not respond to requests for comment.)
The hospital launched its inquiry after Hooman Noorchashm, a Philadelphia-area cardiothoracic surgeon turned patient advocate, sounded an alarm. He pointed out that oncologists strive to remove tumors in one piece to avoid leaving residual cancer. His wife, Amy Reed, an anesthesiologist and mother of their six children, died at age 44 in 2017 of a hidden uterine cancer that was spread during a hysterectomy performed with a minimally invasive tissue-slicing device called an electric morcellator.
“If you want to create a new standard of care and advertise it, at the very least you need to do a randomized controlled trial to demonstrate safety and effectiveness,” Noorchashm said. “You shouldn’t just advertise ‘small incisions, faster recovery.’ ”
In Europe, a clinical trial is underway to compare a robotic and conventional mastectomy after cancer diagnosis, including five-year survival. But a separate French study of robotic mastectomy has no comparison group — considered vital for a definitive study — and aims to assess complications and cosmetic results, not recurrence rates or survival.
If history is any guide, clinical trials can disprove assumptions about the benefits of “laparoscopy” — using instruments and lighted scopes inserted through keyhole incisions — or the da Vinci robot, a system made by Intuitive Surgical that costs as much as $2 million.
Just last month, trial results showed that laparoscopic hysterectomies to treat cervical cancer reduced survival when compared with traditional abdominal hysterectomies. That unexpected finding came a decade after the less-invasive approach was embraced as a way to speed recovery and reduce complications.
Neil Tanna, the plastic surgeon who led just such a robotic surgery at Long Island Jewish Medical Center, sees cancer prevention as a clear-cut indication.
“There’s going to be some controversy, but no one can fault us for doing robotic surgery for prophylactic (preventive) reasons,” he said.
But Tanna said the role of the robot in removing cancerous breasts does warrant a high-quality trial to assess safety and effectiveness. Northwell Health, a network that includes Long Island Jewish Medical Center, has been working with Intuitive Surgical and the U.S. Food and Drug Administration to design such a trial, Tanna said.
“We owe it to science, to our patients and to ourselves,” he said.