Cancer Center Amsterdam

Scientific research can be seen as an art form in which new creations are conceived and tested in research. Then the care performed is an art. These two concepts, art and skill are linked by education, for only with education comes implementation of research. This is the simple truth of the circle of care-research and education."

Prof. dr. Jurriaan Tuynman

Art and Surgery

Aspects of art such as; skill, artistic expression, freedom, innovation, individuality and above all aesthetics are also present in surgery. An artist has qualities that the surgeon likes to mirror. However, a surgeon is not an artist because in the process of creating art, many things go new, wrong and different. No, the surgeon should not be an artist but a performer of a composition, in other words, a perfect surgical procedure on a patient.

Art is closely related to science. From the very beginning, art has driven driven but also served science. Man marvels at the world around him. It is incredibly beautiful. But, we do not fully understand it yet. Artists and scientists are challenged by the mysterious universe, the forces of nature, time, light, water and fire, and evolutionary life with its balance. This life in particular is the subject of art and science.

_{Source: Ruud de Wild, Instagram}

Life, what is it anyway? It seems to be a tight nexus of organic molecular structures. Chemical reactions degenerate into signals that are regulated and give genetic imprints. Thus, proteins are expressed that ultimately determine our anatomy, the cohesion of organs, our physical appearance and behaviors. Understanding the human being inspired many artists. Human Creation is one of the first artistic expressions involving an unlikely surgical procedure; Woman was brought into existence and life with a rib transplant. This metaphor must have inspired many surgeons.

The relationship between art and science and surgery was particularly beautifully linked by Renaissance pioneer Michelangelo. He meticulously studied human bodies, often through dissections, to increase anatomical precision in his sculptures and paintings. These anatomical studies not only laid the foundation for realistic art, but brought scientific advances.

Surgery and science

Surgery has been practiced for centuries with one of the first procedures being trepanation in which stones were used to make a hole in the skull for various conditions; skull studies of humans from 10,000 years ago showed that this procedure was survived by demonstrating bone growth and healing tissue.

After the Middle Ages, surgery slowly developed from a craft of barbers to stone cutters (incidentally quite a complicated partly colorectal procedure) and still later, it developed into a professional association, a guild. Within these guilds, surgical education was held in high regard with annual mandatory educational sessions. Rembrandt's painting “De Anatomische Les” is an example of education in which anatomical knowledge was disseminated annually to surgeons. In this speech, I will argue that this practice of ongoing education should be revived.

_{Source: Adobe Stock "De anatomische les van Dr. Nicolaes Tulp, Rembrandt van Rijn"}

Surgery, science and art have grown up together. What makes surgery so special is that in addition to the medical side, there is also a very practical side which requires a lot of understanding of organogenesis and pathogenesis. Abdominal surgery has undergone and continues to undergo many developments. The area where a lot of innovation is taking place is where it is most needed. The rectum, with its difficult anatomy in the small pelvis seemed to be not easily accessible to the surgeon. There are also many structures that can be damaged such as nerves for the bladder, defecation and sexual function. This makes this a still a challenging area today and much research is ongoing to improve the results of surgery.

Since much of my research deals with rectal carcinoma, I will take you through the development of this. The first famous publication of a series of rectal surgeries for rectal cancer is that of Sir Ernst Miles; He described in 1908 in the Lancet, a cohort of 12 patients with rectal carcinoma that he approached from both the abdomen and from perineum. His theory was that the spread of cancer also occurred beyond the mesorectum was occurring and thus required wide excision. He found this to be successful although mortality was 41%

Cancer and colon cancer

In ancient times, people did not often die from cancer, rather from infection or an accident. Now cancer is the leading cause of death followed by cardiovascular disease, respiratory disease and old age.

Cancer has a huge impact that is increasing in modern countries. The incidence continues to go up, and so does cancer mortality. Every year 150,000 people die in the Netherlands of which 55,000 of cancer.

Cancer is terrible. From a biological point of view, however, it is a very special disease. The malignant degeneration is an ingenious process in which within an organ through mutations, new formation occurs with uncontrollable growth. Many characteristics of these cancer cells are quite fascinating; For example, they are less subject to mortality and they fool our immune system.

A lot of research efforts including my earlier work as a doctoral student 16 years ago attempt to find leads to stop this process. This can be done by intervening with vaccinations, medication and immune system activation. However, no curative medication for colon cancer has been found, although a small fraction can been treated with immunotherapy or a combination of radiation and chemotherapy to be reduced. Surgery remains the core of an intentionally curative treatment.

Locoregional cancer expansion follows organogenesis in reverse order. This is the process by which primary organs develop from the three germ layers during embryonic development. The digestive system arises from the endoderm and develops in close relationship with the mesoderm, which contains the nourishing
blood vessels, lymphatic pathways and supporting tissues. Cancer growth and spread occurs within these embryological envelopes. Therefore, the locoregional treatment for cancer occurs within these anatomical surfaces. This must be performed without leaving residual blood vessels and lymphatic vessels with any cancer cells and without causing collateral damage to the patient.

Bowel cancer is the most common cancer of our digestive tract. Within the Netherlands, lung cancer ranks first in cancer-related mortality. 80 % of this is due to tobacco intoxication. Bowel cancer ranks second in terms of cancer-related mortality. With smoking cessation, lung cancer is largely preventable. That makes colon cancer the biggest problem because a preventable cause is not there. On the contrary, we see an increase in incidence in young patients and we don't know why. This is a plea for relentless support to improve survival in this disease.

Colon cancer challenges

Innovation is therefore highly necessary for colorectal cancer. I see the following real challenges.

1. Understanding etiology and genetic backgrounds, an example is to understand why the incidence rises in young people.
2. Increased participation and expansion of Population Screening so that mortality decreases and more early stages of colorectal cancer are found.
3. Early detection also requires different treatment where quality of life should be paramount.
4. Colorectal carcinoma requires multidisciplinary treatment in which undertreatment and overtreatment must be avoided. For complex colorectal cancer requires chain care and echelonization.
5. Education is at least as important as research. Implementation of best evidence within surgery; more recurrent education and training and ultimatum quality monitoring. Centralization is not the only solution.

Read the full oration [in Dutch] here:

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