Reviews & Analysis

Surgery is the oldest oncological discipline and remains the cornerstone of treatment for most patients with cancer. However, the way surgery is used to treat cancer has evolved and outcomes continue to improve as a result of greater biological understanding, relentless technical innovation and a paradigm shift towards multimodal treatment. In this Perspectives, the authors discuss the developments in cancer surgery that have occurred over time and provide an overview of the key uses of surgery in the current era of multidisciplinary cancer care.

Numerous calls for improvement in the quality of follow-up care provided to cancer survivors, particularly survivors of childhood cancer have been issued by key health organizations in the USA; the Passport for Care (PFC) is a web-based support system for survivor care that was developed in response. In this Perspectives, key individuals involved in the development of this support tool for clinical decision making outline the programme, describe how it compares with similar guidance tools, and discuss the potential implications of the PFC for survivorship care. The challenges encountered and the lessons learned during development and deployment of the PFC are also highlighted.

Many cancers, particularly those that arise in childhood, have a hereditary component. In this Perspectives article, the authors provide their views on how the increased adoption of high-throughput DNA sequencing technologies, which produce vast genetic data that is not necessarily limited to known cancer-susceptibility loci, and cancer surveillance strategies are influencing the clinical management of familial cancer. Important ethical issues relating to genetic counselling and disclosure of genetic information on disease susceptibility are discussed, and strategies for approaching these ethical dilemmas are proposed.

Recent advances in multimodality imaging in cancer have involved the integration of multiple quantitative, functional measurements that provide a more-comprehensive characterization of tumours. In this Review, Yankeelov and colleagues discuss how, although some of these approaches still need some adjusting, they can already be applied informatively in clinical trials of cancer therapeutics using existing tools.

Patients with oligometastases who develop a small number of metastatic lesions might achieve long-term survival with the use of ablative surgery or stereotactic radiotherapy. More patients are receiving aggressive treatment for oligometastatic disease, yet long-term survival might not be due to the treatments themselves, but rather to the selection of patients with slow-growing indolent disease. The authors examine the key evidence supporting or refuting the existence of an oligometastatic state and its appropriate treatment.

Gene mutations and genomic aberrations are the basis of tumour development. Over the past decade, single-gene mutations and genomic profiling have been increasingly used in multidisciplinary consultations for risk-assessment and treatment planning for patients with cancer. In this Perspective, the authors discuss the direct and indirect influences of genomic profiling on surgical decision making, and analyse the limitations and unresolved issues of a genotypic-approach to the surgical management of cancer.

The current drug development procedures are far from optimal, owing to the continuous development of the health systems and the clinical research landscape. The European Organisation for Research and Treatment of Cancer proposes in this Perspective the use of collaborative molecular screening platforms (CMSPs) as a new approach for drug development. These CMSPs have the advantage of optimizing expertise of several partners and combining efforts alongside with cost-sharing models for efficient patient selection.

Tissue-preserving focal therapies that target individual cancer lesions rather than the whole prostate have emerged as potential interventions for localized prostate cancer. In this article, the Prostate Cancer RCT Consensus Group recommends the development of a cohort-embedded randomized controlled trial methodology to evaluate focal therapy use in men with clinically significant localized disease. The importance for a randomized controlled trial design to provide cost-efficient practice-changing data is highlighted.

A key challenge in oncology is obtaining drugs predicted to be beneficial based on the patient's tumour profile. One solution is creation of a national facilitated access programme and registry for off-label use of targeted anti-cancer drugs. Schilsky discusses several key elements of implementing personalized cancer care services in an oncology practice setting and offers solutions to some of the obstacles of making personalized medicine available to many patients.