Beyond the Blade

The sharpest tool the surgical oncologist has on hand at the operating table is information

If Terry Fox were diagnosed today, not only would he probably survive the cancer but he might be running without a prosthetic, too.

That’s according to one of Canada’s leading surgical oncologists, Dr. Walley Temple, who came to Calgary’s Tom Baker Cancer Centre in 1983 and has been a major player in the field’s rapid evolution. In those three decades, he watched the centre go from three surgeons dealing with tumours – two gynecologists and himself – to approximately 30. And he’s witnessed treatments and cure rates of specific cancers improve at a similar pace.

Meeting of Minds: Dr. Walley Temple, in the glasses, attends a multidisciniplary team meeting aimed at treating the whole patient.
Photo by Ewan Nicholson

In the case of the Canadian hero who died at 22 of osteosarcoma, a malignant bone tumour that most commonly affects adolescents, systemic chemotherapy could have reduced the size of the leg tumour and the disease might not have spread to his lungs. Not only could it have greatly limited the required surgery, but artificial parts could have rebuilt his leg from the inside so that a prosthetic wasn’t necessary.

Temple is the director of Cancer Surgery Alberta. And despite a reputation as a jokester, he is serious in his desire to limit the number of times surgeons reach for the scalpel. “Surgical oncology,” says Temple, “is looking at how you can do less surgery with better results.” So today, a young man diagnosed with osteosarcoma has an 85 per cent chance of recovery – almost double what it was at the time of Fox’s diagnoses – and only a two per cent chance of requiring amputation, when in the 1980s it was 20 per cent.

“Surgical oncology,” says Dr. Walley Temple, “is looking at how you can do less surgery with better results.”

Other technological advancements to roll into the Tom Baker Centre and Edmonton’s Cross Cancer Institute include robotic surgery tools that allow for precision in constrained areas; tools that cauterize blood vessels automatically; surgical simulation hand sensors used in training to measure the amount of force used by a resident surgeon; and hot (40˚C) chemotherapy treatments that bathe the abdominal cavity after a tumour is removed multiply the drug’s strength as a cancer killer by 50 to 100 times – a method that Temple and his University of Calgary team pioneered.

At Cancer Surgery Alberta, a body to create and standardize surgical cancer care, Temple helped found a web-based network of surgeons to compare results for improved future outcomes and knowledge translation.

But most of the “phenomenal progress” Temple has witnessed is not the result of anything turbo charged, nor any great leap by a genius scientist working solo in a lab. The great innovation – cancer surgery’s big leap is “a multidisciplinary approach, where we no longer work in silos.” To that end, the greatest advancement he’s seen in cancer medicine is the holistic weaving of all the three modes of cancer treatments – radiation, chemotherapy and surgery. He says, “Surgery is very challenging, technical and requires the utmost of the entire team.”

Dr. Todd McMullen, a Cross Cancer Institute surgical oncologist specializing in endocrine cancers, says Temple was instrumental in pushing the field in this multidisciplinary direction, and he reserves high praise for him. “He’s one of the key figures who established surgical oncology to Canada and pushed it forward as a specialty where it wasn’t just about the surgery but understanding the nature of oncology, tumours, their natural history, their behaviour, and a multidisciplinary approach.”

McMullen is the director and adjunct professor of the department of oncology at the University of Alberta. Like Temple and many other doctors at Alberta’s leading cancer clinics, he holds cross-appointments across institutions. “Surgical oncology is not just the surgery, it’s knowing when to operate so that you integrate what you plan to do with the radiation oncologists and the medical oncologists,” McMullen says. “So the plan is made by a group of physicians instead of just a surgeon saying, ‘OK. You’ve got something that we’re going to try to take out.’ ”

Every week at Alberta’s two major cancer centres, 30-plus oncologists, as well as pathologists, specialized nurses and sometimes psychosocial professionals sit on a tumour board.

Light Hearted: Dr. Walley Temple makes humour a part of his stressful job of surgical oncology.
Photo by Ewan Nicholson

At the roundtable meeting, the group closely examines the condition of every newly registered patient so that each expert with something to contribute, does. From beginning to end, the roundtable will abruptly switch gears as many as a dozen times, from a patient with an abdominal tumour to one with a tumour of the limb to another with gastrointestinal tumours or sarcoma of the lungs. “We go everywhere in the body,” says Temple. “It’s become a very intense ‘lookup’ of each patient to make sure we deliver the best possible treatment.”

He adds, “That’s our role: To keep interpreting the new possibilities of other modalities to provide a totally different solution.”

Traditionally, McMullen says, professionals simply presented patients with the numbers – the statistics of survival based on a whole population. “Now we’re tailoring our therapy,” he says. “It’s very nice to give patients detail and say, ‘We’ve done an in-depth analysis and for you we think this is the best treatment,’ instead of, ‘Well this is what works for everyone else.’”

Esther Harris, an 87-year-old writer and retired academic, knows the story all too well.

The tumour group examines the condition of every newly registered patient so that each expert with something to contribute, does.

In 2003, she was living in Vancouver when her gynecologist referred her to a hematologist after finding an alarmingly high white blood cell count. “I walked into his office and 10 seconds later he told me I was going to die,” she recalls. The diagnosis was non-Hodgkin’s lymphoma, which can attack any tissue in the immune system. “He said, ‘I don’t think we can give you any of the chemotherapies because, at your age, they will probably kill you.’ ”

This was not the first time she’d been diagnosed with cancer. Fifteen years prior, she developed a tumour close to her eye and had to have her eyelid surgically removed and replaced with a skin graph from behind her ear. Throughout it all, she ploughed through her work, got more articles published, earned another degree and continued teaching. Few things can slow her down but the diagnosis of non-Hodgkin’s lymphoma stopped her in her tracks. She accepted the death sentence and moved to Calgary to be closer to her daughter. There, she registered at the Tom Baker Centre and, to her surprise, got a different story: The oncologists assured her they’d find the right chemo dosage for her situation.

That was just the beginning for Harris. In less than a decade, she has endured three chemotherapies to overcome non-Hodgkin’s lymphoma, plus treatments for two more cancers that she developed and beat.

When she was diagnosed with colorectal cancer in 2008, the oncologist took one look at her medical profile and agreed that, given her age, predisposition to cancer and non-Hodgkin’s lymphoma, he should attend to her right away. Within weeks, surgeons removed the tumour and resectioned her bowel using new robotic technology that allows for precision in very small areas.

Then, three years later, she developed what she says looked like horns on her forehead, the result of squamous-cell carcinoma, a non-fatal skin cancer that causes protrusions. It took 10 months of radiation to shrink the tumours and surgery to excise the ones dangerously near her eye. On the plus side, Harris says jokingly, “They drew a line of stitches across my hairline and pulled skin over my forehead, so I don’t have an old woman’s forehead. No wrinkles or lines, it’s like a facelift.”

Needless to say, the Calgary cancer centre has come to know her well. “I don’t think I would have survived without them. I’m madly in love with all my doctors, men and women.”

Dr. Temple is pleased, but not surprised, to hear her praises. “In Alberta, our patients identify that we have a wonderful system,” he says. “Alberta is just way ahead in terms of what we can offer our patients.” Most Albertans, unfortunately, don’t find this out until they’re diagnosed with cancer.
But there’s much that’s still unknown about surgical oncology, says Temple. “It’s a bit like asking how much do we know about the solar system.” As oncologists better understand tumour behaviour, unique genetic receptors and mutations, they’ll better understand the individual and therefore the particular patient’s disease.

“We’re at the very beginning of this phase of personalized medicine,” says McMullen, who is helping the Cross Cancer Institute lead a trial to determine why, if at all, presence of a newly discovered gene mutation requires more aggressive thyroid cancer surgery.

When it comes to surgical technology, McMullen says there’s always going to be incremental innovations – better devices, more advanced robotics that become cheaper and more common. But, if you were to touch base with him on the topic in 2022, “I still think personalized therapy and tailoring my surgical technique to a given patient, and the oncologist being able to pick the right therapy – those changes are where we’d have the most to discuss.”

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