Local and systemic recurrence is the Achilles heel of cancer surgery.

This year approximately 569,490 Americans, more than 1,500 people per day, are expected to die of cancer. Cancer has supplanted heart disease as the leading cause of death in the United States in men and women younger than age 85 years (American Cancer Society, Facts and Figures 2010). Cancer also has a major economic impact on the U.S. economy, with 2010 estimates of cancer associated costs of $263.8 billion (American Cancer Society, Facts and Figures 2010). The four most common cancers (lung, colorectal, prostate, and breast cancer) account for more than half of all cancer incidences in the United States. Surgery, chemotherapy, and radiotherapy are the most established therapies for patients with these malignancies (American Cancer Society, Facts and Figures 2010). Surgery continues to be the most effective therapy for cancer in the United States. It is several-fold more effective than chemotherapy and radiation in curing patients with cancer. Unfortunately, many people are not surgical candidates due to advanced stage disease or comorbid conditions. During the past two decades, both mortality and observed cancer survival statistics have improved dramatically both in patients who do and do not undergo surgery. This likely reflects an improvement in cancer care in the United States. Since 1973, the Survival Epidemiology and End Results (SEER) Program sponsored by the National Cancer Institute has kept a publicly accessible database that has catalogued the outcome of cancer patients (Surveillance, Epidemiology, and End Results Program. Bethesda, SEER Stat Database). These data include information regarding incidence and mortality, as well as the initial surgical and adjuvant therapy provided for the treatment of cancer. This improvement in survival and mortality in this database during the past 20 years is likely due to better screening and detection, biologically targeted systemic therapies, improved surveillance, improved surgical methods, improved patient selection, and more effective adjuvant therapies. Cancer surveillance also has improved dramatically with the improvement in preoperative imaging and minimally invasive and noninvasive staging techniques, such as mammography, colonoscopy, endobronchial ultrasound, and prostate-specific antigen testing. The goal of this short discussion is to highlight some of the trends that have been observed in cancer and surgery during the past 20 years and the role that surgery continues to play in the oncologic community. We found that surgery remains an effective therapy for solid tumors in the United States and dramatically improves survival rates for patients with solid tumors. The proportion of cancer patients who undergo surgery has declined during the past 20 years for all major cancer types. Additionally, we found that local and systemic recurrences continue to be the Achilles heel of Surgical Oncology; although surgery does improve survival, almost one-third of surgical patients will ultimately recur locally and/or systemically. This is an important reminder to surgeons that we must work diligently to improve cancer care for our patients preoperatively, intraoperatively, and postoperatively to prevent these recurrences. Research and clinical trials should be focused on this major objective in the coming decades. Louis A. Aliperti and Jarrod D. Predina contributed equally to this work.