The Globe & Mail
August 10, 2009
By Andre Picard
Imagine for a moment that you have a cancerous tumour eating away at the bone and muscle in your leg. You can choose to amputate the leg or undergo surgery that removes the cancer and leaves the limb intact.
It seems like a no-brainer.
But surprising new Canadian research, published in the medical journal Cancer, says that amputees often have better outcomes.
Patients with a group of cancers known as bone and soft tissue sarcomas who opt to have a limb removed report better movement, less emotional trauma, better sexual functioning and fewer side effects than those who undergo limb-sparing surgery.
"Amputation is often seen as the failure option by surgeons," said Ronald Barr, a professor in the departments of pediatrics, pathology and medicine at McMaster University in Hamilton, and co-author of the study.
"But patients don't always see outcomes the same way as providers," he said. "What matters to them is quality of life."
Dr. Barr said the research — which is a compilation and analysis of a number of small studies — is not an indictment of the work of surgical oncologists but rather a reminder that "they don't need to undertake these operations just because they can — the needs of the patient have to come first."
Soft tissue sarcomas are cancers that develop from cells in the soft, supporting tissues of the body. Almost half occur in limbs – especially the legs.
Amputation is pretty straightforward solution: The part of the limb where there is cancerous tumour is removed.
Limb-sparing surgery is more complex: It involves cutting away the bone affected by the tumour and replacing it with another, either taken from a cadaver or from the patient themselves.
The study found that patients undergoing limb-saving surgery suffer far more postoperative infections, they take longer to recover and rehabilitate and often have more limitations in their movements than amputees.
Adela Janczak, a 24-year-old from Binbrook, Ont., knows these issues all too well.
At 6, she was diagnosed with Ewing's sarcoma, a rare form of cancer, in her right leg. Surgeons removed her right femur and replaced it with a bone from a donor, but her body rejected it.
A second limb-saving surgery was performed. Surgeons removed the fibula from her healthy left leg and used it to construct a femur for her right leg, a complex 16-hour operation.
Ms. Janczak spent months in a body cast and several more months with her right leg encased in a metal contraption that stretched the bone to lengthen it. She also suffered a number of severe postoperative infections, often requiring surgery.
There were 22 surgeries in all but she has been in remission from cancer since 1991.
She said that amputation was definitely considered as an option but "personally, I didn't want to do the prosthesis thing."
"I'm covered in scars and pinholes but it's my leg and it's beautiful."
Ms. Janczak said she recognizes that limb-sparing surgery is not perfect. Her right leg is shorter than her left and she cannot bend her leg at the knee, which means she has mobility limitations. "With a fake leg, I might be able to run or play hockey."
But the key is that the pros and cons of amputation and limb-sparing surgery were always explained to her and "all the decisions were up to me," Ms. Janczak said.
Dr. Barr said that is the essential message he hopes practitioners will take from the research, that patients have a right to make choices that are right for them.
Dr. Jay Wunder, a surgical oncologist at Mount Sinai Hospital in Toronto and co-author of the paper, said there is also more research to be done in the area to understand how these complex decisions are made.
"Future studies that include function, health-related quality of life, economics, and stratification of patients by age will be useful contributions to decision-making … by patients, health care providers and administrators," Dr. Wunder said.