Comment on: Author response to: Effect of bariatric surgery on cancer risk: results from an emulated target trial using population-based data

By embracing innovation, addressing research gaps, and fostering collaboration between surgery, endoscopic therapy, and pharmacotherapy, we can revolutionize how we treat this chronic condition, which continues to affect millions of people.

By embracing innovation, addressing research gaps, and fostering collaboration between surgery, endoscopic therapy, and pharmacotherapy, we can revolutionize how we treat this chronic condition, which continues to affect millions of people.

By embracing innovation, addressing research gaps, and fostering collaboration between surgery, endoscopic therapy, and pharmacotherapy, we can revolutionize how we treat this chronic condition, which continues to affect millions of people.

Oesophageal (gullet) and gastric (stomach) cancers are exceptionally hard to treat1. Unfortunately, the United Kingdom has the highest incidence of  oesophageal adenocarcinoma in the world2, meaning that more than 9000 patients every year are faced with this diagnosis. For most patients, by the time their cancer produces symptoms, it will have already spread, meaning curative treatment cannot be considered. For the minority (about 1/3)3 who have cancer confined to the oesophagus or stomach and local lymph nodes, a gruelling multi-pronged course of treatment is usually necessary, incorporating multiple rounds of chemotherapy and a highly invasive operation to remove the oesophagus and/or stomach. This takes a number of months to complete and recovery can take well over a year.

Multiple clinical studies have proven the benefit of chemotherapy and surgery over surgery alone 4–7, but only about 20% of patients derive a survival benefit from the chemotherapy and we cannot predict before the start of treatment who they will be8,9. Perioperative chemotherapy (a course of chemotherapy, followed by surgery, followed by a further course of chemotherapy) is currently the treatment of choice for these patients, but because recovery from surgery takes many months, even in the best clinical trials, with highly controlled and sanitised conditions, less than half of patients actually received chemotherapy after their surgery5,7. Consequently, we don’t know if giving additional chemotherapy after surgery actually makes any difference to survival.

This leaves a fundamental unanswered question that clinicians and patients wrestle when considering treatment options:

Individual surgeon decision-making plays an important role, especially for conditions without a standard treatment.

Choice of anastomosis in colorectal surgery can be really complex. Each decision has specific short and long term implications for both the surgeon and patient. Quality of life, bowel function, and surgery-specific complications are affected by this choice.

A recent article by Bisset et al.1 shows that certain traits of surgeon personality could be associated with decision-making in specific scenarios.