• Increased knowledge of the natural history of cancer biology and an understanding of how cancers develop and behave.

• The development of diagnostic techniques: this has increased the accuracy of staging and grading, ensuring that surgery is used appropriately and improves surgical outcomes. For instance, it may be inappropriate for a patient with advanced secondary disease to undergo surgery which will not eradicate the disease or offer benefit. More detailed diagnosis often reduces the need for radical surgery, reducing the physical and psychological impact as well as improving the overall outcome. A good example of this is the introduction of sentinel node biopsy (Farrant 2004). Previously, when a woman underwent a mastectomy for breast cancer, the surgeon would routinely remove some or all of the lymph nodes from her armpit. This often meant that women experienced long-term lymphoedema (swelling) and weakness in the affected arm. Now during surgery, the surgeon injects a blue dye (sometimes with a radioactive tracer) into the tissue close to the cancer. The dye drains into a number of the lymph nodes; these are then known as the sentinel nodes and are removed to see if they contain cancer. If they are positive then the patient will most likely have a second operation to remove most of the lymph nodes under the arm.

• New microsurgical techniques such as laparoscopic and endoscopic procedures: these allow more conservative treatment, having less of an impact on physical functioning and appearance as well as a shorter postoperative stay.

• Since the Calman Hine report (DH 1995), surgical teams are dedicated to specific types of cancers. Surgeons must undertake a number of specific procedures a year to ensure competence, and all procedures are monitored locally, regional and nationally to ensure quality standards and equity.

• Recovery time in hospital has reduced as a result of the introduction of enhanced recovery programmes. These involve extra pre-, peri- and postoperative hydration and nutrition; regular analgesia; early removal of catheters/drains; and increased exercise soon after surgery (Slater 2010).

• The introduction of ‘rapid discharge programmes’ following surgery has improved physical and psychological recovery, such as the introduction of discharge after 23 hours from returning to the ward following breast surgery (DH 2007).