Hillary: Rob’s advice is experience-based and consistent with my understanding. I would like to add what might be a useful data point. The question of surgery at the margins of cancer treatment comes up frequently. It is usually seen as associated with curative treatment—as it often is—with systemic therapy disfavored by patients as palliative-only. Some folks see physician resistance to surgical approaches in given cases as based solely on the view that “it won’t help because there is too much systemic disease.” Understandably, patients often feel differently, wanting to roll the dice on what might be a very small chance that that view is wrong. The true picture is, I think, more nuanced.
Surgery in the context of metastatic disease has to be weighed carefully because it is not without the possibility of significant *negative* consequences beyond the obvious and usual risks of the surgery itself. In other words, it isn’t just that it might not help. It may make things worse. The linked article below is IMO important reading for anyone considering a surgical approach to metastatic disease.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380551/Of course, I’m not saying it’s never appropriate in those circumstances. My signature shows a VATS. The literature shows a clear trend to more and more surgical intervention against metastatic disease (e.g., Rob’s reference to resections of CRC mets in the liver and lungs), and the relatively recent acceptance of the concept of oligometastatic disease is a big part of that. Non-surgical options (e.g. SBRT, cryoablation, radio-frequency ablation, and certain cutting edge technologies current in trials) are also improving and becoming more widely available, as Rob mentioned, and often do not come with the same risks as surgery. The main thing to remember IMO is that the *whole* picture should be carefully processed: pre-and post-surgery systemic treatments, performance and immune status, timing, patient goals, substance and extent of knowledge of disease, etc. it is certainly an area where second and third opinions are helpful. But I would be sure that my team (and any second opinion docs) are aware of the broad range of options and can discuss risk-benefit in a comprehensive, objective way.