Improving surgery through research
Surgery is the most common treatment for bowel cancer and surgical research is key to developing new surgical treatments and techniques and driving improvements. The UK’s first Surgical Speciality Lead in Colorectal Liver Metastases, Surgical Oncologist Mr Robert Jones, explains more about what surgical research is and why it’s so important.
What is surgical research?
Surgical research focuses on trying to find out more about the way we treat patients with surgery. Most solid cancers (like bowel cancer) are treated with some form of surgery, and this is a very active and exciting research area. A lot of what we do as surgeons is based on dogma and historical practice (“I was always trained to do it this way”), rather than clear evidence that what we do is actually best for patients. Surgical research aims to address this by providing the evidence.
How do surgeons come up with research ideas?
The questions we face every day in our clinics and operating theatres are what drives research ideas. When you have to tell a patient “We don’t know which is the best option” or “We don’t know what impact this will have on the length or quality of your life”, you want to be able to give an answer next time! And so you start Googling and reading journals, talk to other people, and if the answer doesn’t seem to be out there you start thinking about how you could find out the answer to that question.
How does an initial idea become a research study?
I spend a lot of time speaking to colleagues and patients. Brainstorming ideas is so important, and different perspectives often bring the greatest insights. It’s also important to involve patients very early on. Doctors might think it sounds like a great idea, but if patients wouldn’t consider taking part it’s never going to happen.
Collaboration is also critical. We treat bowel cancer in big teams, with different types of surgeons, oncologists, radiologists, palliative care physicians and specialist nurses. This is reflected more and more in research teams. We also think nationally and internationally about how to build collaborations, rather than just who is on your doorstep. You need the best group of people possible working on these projects to have the best chance of success, and they don’t necessarily have to be local.
Historically, patients were the last to be told about trial designs and ideas. We now recognise it is essential to have patients involved in the design and development of research from the very beginning. Patients now sit on study design groups, funding committees, trial management groups and of course taking part in the research as subjects! It is also patients who tell us what matters to them, and what questions our research and trials should be answering.
How are new surgical techniques tested?
Trialling new surgical techniques and technologies is slightly different to drugs. Initially, doctors will have discussions amongst themselves within units and surgical societies about potential risks and benefits. This is then discussed with and approved by the hospital where the procedure will take place.
For completely new techniques, ethics committees (who look after the rights, safety, dignity and wellbeing of people who take part in research) look at the evidence that the procedure is safe before allowing us to proceed. If the technique has been used somewhere else before, surgeons will often visit that unit to see how it works and then have a mentor from that unit come and support them as they start their first few cases. It’s important that we are open and transparent about this process with patients, and offer them the option to have alternative treatments.
Finally, it’s crucial that we collect good high-quality data on what happens with these new techniques and technologies to see if they are actually safe in the real world. These data may eventually lead to trials comparing different techniques to see which is best. For example, in some centres liver surgery has been performed safely for several years as a keyhole procedure, but we don’t know whether it offers any benefits over a traditional open operation. We are running a trial at the moment to help us answer this question.
What kind of surgical research are you involved in?
My research interests are mainly in advanced bowel cancer. We operate on more and more patients with bowel cancer that has spread to other organs, such as the liver and lungs. We know this helps some people live longer, but equally we know that it may offer some patients no benefit at all.
Trying to identify which patients will benefit is important, so I work with laboratory scientists to try and unpick the biology of individual patients’ tumours and see how they behave. This will lead to better personalisation of treatments in the future.
I am involved in a number of clinical trials that aim to compare different surgical treatments to see which is most effective. However, the usual way of running a trial where patients are randomly allocated to treatment A vs. treatment B is difficult in advanced bowel cancer, because the number and type of treatment patients can receive (chemotherapy, colorectal surgery, radiotherapy, ablations etc.) can vary based on each individual patient’s needs. This means finding a population of patients who are similar enough to do an A vs. B trial is exceptionally difficult.
To address this, I am working with a team of colorectal surgeons, trial designers, patients and oncologists to develop a new kind of clinical trial. Using this new design we will learn something from all the treatments that we currently give to patients across the UK, monitoring their effects over time. We will learn not only what is the best way of treating the cancer, but also what impact these treatments have on patient’s lives.