Surgery roadmap: radical operations → less surgery → no surgery when a drug has done the work

Removing just the first lymph node a tumour drains to, instead of all of them, to check for spread.

Showed that removing all the remaining lymph nodes after a positive sentinel node does not help patients live longer, ending a routine operation.

Mapping and removing only the first draining lymph nodes finds spread as reliably as removing all of them, with far less lymphoedema.

Removing a bone or soft-tissue sarcoma while keeping the arm or leg, rebuilding with metal implants, bone grafts or growing prostheses in children.

Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.

Removing throat tumours through the mouth with a robot instead of splitting the jaw, allowing many patients to avoid or reduce radiation.

Removing very early cancers of the oesophagus or stomach from the inside with an endoscope, so the organ is kept intact.

Keyhole surgery, assumed equivalent, turned out to be worse: more recurrences and more deaths than open surgery, reversing practice overnight.

A robot-guided flexible scope that reaches small lung nodules through the airways to biopsy them without a needle through the chest wall.

A Tata Memorial trial ended a 50-year debate by showing that removing the neck lymph nodes at the first operation for early mouth cancer raises three-year survival from about two-thirds to four-fifths.

CheckMate 816 was the first trial to show that immunotherapy before lung cancer surgery improves survival.

Showed that immunotherapy given both before and after lung cancer surgery lengthens survival.

Simply moving three doses of the same drug to before surgery improved outcomes, a result that changed how the field thinks about timing.

Giving the immunotherapy doublet before surgery, instead of nivolumab after, cut the risk of recurrence by about two thirds and let most patients skip further treatment.

The first immunotherapy shown to improve survival when given around bladder-removal surgery.

Adding immunotherapy before and after surgery cut deaths in early stomach cancer; nearly seven in ten patients were alive at three years.

The trial that added immunotherapy to pre-surgery chemotherapy for triple-negative breast cancer and, uniquely, improved survival.

DESTINY-Breast11 brought Enhertu into pre-surgery treatment of HER2-positive breast cancer, replacing anthracyclines.

Dutch trials testing whether treating before surgery beats operating first. Chemoradiation first helped in the long run; FOLFIRINOX first did not clearly beat surgery-first with adjuvant chemotherapy.

Giving immunotherapy for a few weeks before surgery produces a tumour sample that shows exactly what the drug did. That is the fastest way to learn who responds.

Between diagnosis and surgery there are usually a few weeks. Giving a new drug in that window and comparing the tumour before and after surgery shows whether it hits its target in real people, quickly and cheaply.

In NICHE-2, four weeks of immunotherapy before surgery wiped out most mismatch-repair-deficient colon cancers, and nobody had relapsed three years later.

AZUR-1 is the registrational trial of the 'no surgery, no radiation, no chemo' approach for mismatch-repair-deficient rectal cancer, built on the MSK study where every patient had a complete response.

For the third of patients whose tumour vanishes after chemoradiation, watching closely and operating only if it comes back gave the same survival as immediate surgery.

Proved that most people with small, low-risk thyroid cancers can skip radioactive iodine after surgery without any increase in recurrence.

MARS 2 is the trial that overturned decades of surgical practice: removing the lining of the lung did not help patients live longer and left them worse off.

Most small kidney tumours found on scans grow slowly. Options range from watching them, to freezing or heating them, to removing just the tumour and keeping the kidney.

Watching very small papillary thyroid cancers with ultrasound instead of operating, because most never grow and almost none cause harm.

Most kidney tumours under 3 cm found by chance grow slowly and a fifth are benign. Watching them, with surgery only if they grow, could spare many operations.

Thermal ablation kills a tumour with heat or cold delivered through a needle, with no incision required.

Irreversible electroporation uses short high-voltage pulses that punch permanent holes in tumour cells while sparing nearby vessels and ducts.

Destroying tumours from outside the body with tightly focused sound waves, using either heat or microscopic bubbles.

A catheter threaded into the artery feeding a liver tumour delivers chemotherapy and then blocks the vessel, starving the tumour from inside.

Millions of tiny radioactive glass or resin beads are injected into the liver artery, lodging in the tumour and irradiating it from within.

The first trial to show that adding immunotherapy and an anti-VEGF drug to TACE delays progression in intermediate-stage liver cancer.

Washing the abdominal cavity with heated chemotherapy during surgery to kill microscopic peritoneal deposits.

Washing the abdomen with heated chemotherapy during interval surgery extended survival by about a year.

Replacing the whole diseased liver cures both the cancer and the cirrhosis underneath it, for patients whose tumours are small enough.

Inventor of histotripsy, non-invasive tumour destruction with focused ultrasound bubbles; acquired for $2.25B in 2025.

Injecting a dye that makes tumour glow so the surgeon can see exactly where to cut.

Dyes that glow under special light, so surgeons can see tumour edges and nerves in the operating theatre.

Portable and high-throughput nanopore sequencing, used for rapid intraoperative brain-tumour classification and structural variant detection.

An ultra-sensitive blood test after surgery that detects leftover cancer months before a scan would.

Prehabilitation is a few weeks of structured exercise, nutrition and psychological preparation between diagnosis and surgery to make patients fitter for the operation and speed recovery.

PREHAB showed that four weeks of supervised training, protein and support before bowel cancer surgery cut severe complications and sped recovery, in an international randomised trial of 251 patients.

Instead of starving patients before and after an operation, modern surgical pathways feed them early, give carbohydrate drinks the night before, and get them walking the next day. Complications and hospital stays fall.

Getting fitter and better nourished before an operation reduces complications and speeds recovery. It is cheap, but only a few hospitals do it.

When a geriatrician helps manage older patients around the time of a cancer operation, complications, delirium and hospital stays fall. This should be standard for anyone over 75 having major cancer surgery.

A few weeks of exercise, nutrition and mental preparation before a big operation helps older patients recover faster and with fewer complications. It costs little and should be routine.

Tests whether removing only the first draining lymph nodes is safe enough to spare women the lymphoedema of full node removal.

Giving a single large dose of radiation directly to the tumour bed during surgery, with normal organs moved out of the way; used mainly in breast cancer as an alternative to weeks of external radiotherapy.

Surgery and radiotherapy cure more people than drugs do, but attract a fraction of the research investment.

The number of people with cancer is rising faster than the workforce trained to treat them.

Seven in ten cancer deaths happen in low- and middle-income countries, where radiotherapy, pathology, surgery and drugs are scarce.

Most people with cancer are over 65 but most trial patients are younger and fitter. We guess how to treat the majority.

Give combinations before surgery and look at how much tumour is left when it is removed. That answer comes in months, so many pairs can be tested quickly.

Most ovarian cancers start in the fallopian tubes. Removing the tubes at hysterectomy, or instead of tying them, as British Columbia has done, appears to prevent ovarian cancer.