Advanced Care Planning

In the United States, cancer treatments utilize an exorbitant amount of resources, particularly during advanced stage disease with little-to-no chance for cure, and often at the expense of offering meaningful QoL that meets patient’s wishes. This is also true during end-of-life care, with increasing hospitalization rates, intensive care unit stays, several emergency department visits in the last month of life, and consistently high rates of terminal hospitalizations. Approximately 25% to 30% of terminally ill cancer patients will die in hospital. Additionally, terminally ill patients often receive more intensive care regimens than their stated preferences for treatment.

Unlike noncancer conditions, functional decline is an innate characteristic of cancer’s trajectory and thus is a distinct period in which patients can benefit from ACP and early introduction palliative care principles for symptom management and psychosocial behavior management. ^, Professional oncologic organizations such as the National Comprehensive Care Network (NCCN) and the American Society of Clinical Oncology (ASCO) have long emphasized the importance of ACP in providing optimal palliative care. ^, ACP should therefore be routinely discussed in all phases of cancer care plans, including surgery. Cognitive screening and frailty assessment in high-risk patients and the elderly cancer patient population is gaining momentum. In fact, Shahrokni et al. demonstrated that in oncogeriatric patients (age ≥75 years), the comprehensive geriatric assessment (CGA) deficits were strongly associated with 6-month mortality, whereas the ASA (American Society of Anaesthesiologists) classification was not. Additionally, measuring frailty in older cancer patients can potentially identify those with increased risk of treatment-related complications. Data from 20 studies with over 2900 older cancer patients reported a prevalence rate of frailty as 42% (range 6%–86%). Frailty was independently associated with increased postoperative mortality (hazard ratio [HR], 2.67; 95% confidence interval [CI], 1.08–6.62) and increased treatment complications (odds ratio [OR], 4.86; 95%, CI 2.19–10.78). Accurate evaluation of risk for perioperative complications, options available for treatment planning, and the prognosis after surgery with particular reference to QoL form the mainstay of informed choice, shared decision-making, and ACP, fulfilling patient’s choices, expectations, and goals for care.

Education

A well-designed preoperative education program sets the stage for patient empowerment and improved outcomes through the oncologic perioperative journey. Usually, preoperative education begins in the surgical office, is continued through the preadmission clinic and testing, and emphasized at the preadmission phase when these patients and family come into the hospital. Understanding the risks and benefits of effective preoperative and psychologic preparation is the benefit of effective preoperative education. Additionally, it is important to provide patients and family with a detailed understanding of their surgical procedure so there are clear expectations of, and anticipation for, potential events that could happen in the perioperative period. Setting patient expectations in terms of pain management, ambulation, and resuming oral intake can pave the way for accelerated recovery. It has been demonstrated that perioperative education has been associated with decreased anxiety, better postoperative outcomes, and improved patient and family satisfaction. While patient education is important during the perioperative process, physicians must familiarize themselves with the health literacy of their patients for effective engagement of patients and care givers. Providing patients with appropriate educational materials that they can read and instructions that are written in clear, simple language can also facilitate learning. Pereira et al. showed in 104 patients that an empathic patient-centered approach can reduce preoperative anxiety, and increase surgical recovery and patient satisfaction.

Prehabilitation

In addition to optimizing the nutritional status of the cancer patient, prehabilitation strategies should be implemented during the preoperative period to decrease the psychologic and physiologic stress associated with surgery. Defining cancer prehabilitation is “a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient’s health to reduce the incidence and the severity of current and future impairments.” Maintaining a high level of physical activity, in particular, can attenuate the perioperative risks associated with surgery. Those that implement an exercise regimen prior to surgery have a faster return to baseline. Preoperative exercise capacity serves as a strong marker for health status and is also related to decreased postoperative complications and mortality. Because delays in cancer treatment can lead to poor outcomes, the timing of prehabilitation implementation as it relates to the anticipated date of surgery is critical to take into account when building an exercise regimen. As little as 3 weeks prior to surgery may be sufficient time to build up a physiologic reserve, which can further improve surgical outcomes. Additionally, the integration of neoadjuvant radiation therapy and chemotherapy expands the window in which exercise prehabilitation can be implemented. ^, Prehabilitation also provides psychologic benefit to cancer patients, as it gives them a sense of control over their state of health and thereby decreases anxiety. Psychologic interventions should also be implemented in the prehabilitation landscape to address any psychiatric disturbances (i.e., depression, anxiety, etc.) and provide psychosocial support, as a cancer diagnosis can be particularly burdensome both mentally and emotionally.

Cancer patients who undergo neoadjuvant chemotherapy often have a decline in overall physical fitness, which has been associated with worse outcome after surgery. Preoperative exercise training may have an important benefit for surgical outcome and recovery after surgery in cancer patients. For those awaiting oncologic surgery, a preoperative exercise training program is a feasible option with regard to participation and adherence. Licker et al. demonstrated that high-intensity interval training (HIIT) resulted in “significant improvement in aerobic performances, but failed to reduce early complications after lung cancer resection.” Objective measures of physical fitness, such as cardiopulmonary exercise testing (CPET), have been used to determine the association between postoperative morbidity and decreased exercise capacity. The effect of exercise on cancer patients was evaluated by Loughney et al. with acceptable feasibility adherence rates and safety in patients scheduled for neoadjuvant chemotherapy and surgery. The concept of the “dual hit” of neoadjuvant chemotherapy and surgery was explored in the context of preoperative exercise training. Larger randomized controlled trials are necessary to truly evaluate the effect of preoperative exercise programs in the different cancer populations. Wijeysundera et al. performed an elegant multicenter international prospective trial comparing preoperative subjective assessment with alternative markers of fitness, such as cardiopulmonary exercise testing, serum N-terminal pro-B-type natriuretic peptide (NT pro-BNP), and Duke Activity Status Index (DASI) questionnaire scores, for predicting death or complications after major elective noncardiac surgery. They included 1404 patients in the study, with 28 (2%) having died or suffering a myocardial infarction within 30 days of surgery. Subjective assessment of preoperative functional capacity consistently performed poorly and did not predict postoperative myocardial complications, while the simple DASI questionnaire scores were associated with improved prediction.

Anemia Management

Optimization of an anemia management protocol is crucial to adapt and sustain best practices in enhanced recovery for the cancer patient. Preoperative anemia in cancer patients is prevalent and associated with higher perioperative morbidity and a transfusion risk factor. The pathophysiology of anemia in the cancer patient who has nutritional deficiencies, chronic anemia, and concurrently on chemotherapeutic agents that affect red blood cell production is multifactorial. There is a need to reduce perioperative transfusions and its risks, and lessen the impact of postoperative anemia given the association with preoperative anemia and patient morbidity. Enhanced recovery from surgery in cancer patients can potentially be improved with an opportunity to intervene in the preoperative window in patients with treatable anemia. For example, Munoz et al. describe a patient blood management strategy that involves a multidisciplinary multimodal individualized strategy for addressing perioperative anemia in the colorectal cancer patient. Treating anemia early and aggressively in colorectal patients allows for optimization of preoperative hemoglobin, which transforms transfusion risk from high to low and improves outcomes overall. Iron therapy, erythropoiesis-stimulating agents under appropriate recommendations, restrictive transfusion protocols, and other measures to decrease blood loss should be undertaken. Follow up in these cancer patients is important as they often receive adjuvant chemotherapy and radiotherapy. For successful implementation across services and technology integration, patient and clinician educational programs are critical for both implementation and sustainability.

Nutrition

Nutritional optimization is important to increase anabolism and minimize the catabolic state in the postoperative period. Malnourished surgical patients benefit from perioperative nutrition. Klek et al. aimed to assess the clinical significance of route and type of nutritional support (enteral, parenteral, standard, or immunomodulating) in the perioperative setting of malnourished cancer patients with comparable results. However, another prospective randomized trial that implemented the administration of a supplemented enteral formula during the perioperative period significantly reduced both postoperative infections and length of stay in cancer patients undergoing surgery. Protein supplementation has also been used in prehabilitation programs. A double-blinded randomized controlled trial, which provided a more comprehensive prehabilitation program, with nutritional counseling, whey protein, exercise, and psychologic care, initiated 4 weeks prior for patients undergoing colorectal resection showed a clinical meaningful improvement in functional walking capacity. Optimizing functional capacity and minimizing complications are the cornerstone of most enhanced recovery programs.

Postoperative Nausea and Vomiting Prophylaxis

As stated by Wesmiller et al., postoperative nausea and vomiting (PONV) has a large impact on the overall health of breast cancer patients and is related to significant morbidity (dehydration, wound dehiscence, pain, and immobility). In women with breast cancer, PONV has a significant impact on both the well-being and health of these women. PONV should also be addressed vigilantly in the cancer patient population during the preoperative period to minimize its potential effects. After surgery, as many as 80% of women with early-stage breast cancer will experience PONV. ^, PONV prophylaxis prior to surgery is recommended rather than reactively treating PONV as it occurs. A risk assessment of PONV can be conducted using the Apfel score. The Apfel score evaluates the risk of PONV by using female sex, nonsmoking status, history of PONV, and administration of postoperative opioids as predictive measures. ^, Because prophylaxis for PONV is expensive, it is important to identify those who are at a higher risk and provide them with targeted prophylaxis. Low-risk patients should not receive prophylaxis for PONV unless the surgery in which they are undergoing is emetogenic. However, for those who are moderate- to high-risk for PONV, combination therapy that targets more than one type of receptor and pathway may be more effective than single therapy for prophylaxis.

For surgeries that are associated with a high risk for PONV, such as gynecologic, laparoscopic, HEENT (head, eyes, ears, nose, throat), intraabdominal, breast procedures, as well as those that are of longer duration, PONV prophylaxis should be administered regardless of Apfel score. Preoperative psychologic factors can intensify the severity of PONV in patients with breast cancer. ^, Despite the use of multiple antiemetic agents, approximately 30% of women experience nausea after breast cancer surgery, with 10% having both nausea and vomiting.

Fluid Management and Hemodynamic Optimization

Fluid management of the patient should be optimized throughout the perioperative period with the goal of a euvolemic, hydrated state prior to surgery. For the cancer patient, preoperative radiation and chemotherapy can cause treatment-related diarrhea, which can lead to dehydration and fluid depletion. Radiation can cause increased intestinal motility, while chemotherapy can cause damage to the intestinal mucosa leading to decreased absorption. Prolonged fasting and bowel preparations should be avoided, as they may lead to dehydration prior to surgery. Thus it is of pivotal importance to ensure that the surgical cancer patient is optimized throughout the perioperative period. Perioperative goal-directed fluid therapy (GDFT) is defined as “the concept of using indices of continuous blood flow and/or tissue oxygen saturation to optimize end-organ function.” Monitoring dynamic flow indices can be used to predict the hemodynamic effects of fluid administration to optimize oxygen delivery to tissues. GDFT should be customized on the basis of patients’ surgical risk, vascular access, monitoring needs, and the operating context to optimize hemodynamic stability. ^{, ,} During surgery, fluid administration should be carefully adjusted to reduce perioperative organ dysfunction and to restore tissue perfusion and cellular oxygenation. Intraoperative fluid management should aim to maintain euvolemia and minimize excess salt and water through low-crystalloid therapy and fluid boluses (when necessary) to replace blood/fluid loss and maintain intravascular volume. GDFT may decrease major complications and length of stay, and improve outcomes. ^, However, in a recent meta-analysis in noncardiac surgical patients, GDFT had questionable benefit over standard care as it relates to mortality postoperatively, length of ICU stay, and length of hospital stay overall. However, incidence of all complications including wound infection, abdominal complications, and postoperative hypotension is reduced. There is no evidence of benefit for the use of crystalloid or hydroxyethylstarch (HES) for colorectal cancer surgery for GDFT, despite a lower 24-h fluid balance with HES. ^, In addition, results from a pragmatic international trial showed that among patients at increased risk for complications during major abdominal surgery, a restrictive fluid group was not associated with a high rate of disability-free survival than a liberal fluid regimen but was associated with a higher rate of acute kidney injury (8.6% vs. 5.0%; P < 0.001). In a 2014 randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of cardiac output-guided hemodynamic therapy algorithm compared with usual care did not reduce the composite outcome of complications and 30-day mortality. We must take into consideration the results from both the above trials as we apply optimal fluid management for our cancer patients.

Salmasi et al. showed that mean arterial pressures (MAPs) below absolute thresholds of 65 mmHg or relative thresholds of 20% were progressively related to both myocardial and kidney injury. At any given threshold, prolonged exposure to hypotension was associated with increased odds for both myocardial and kidney injury. Furthermore, there were no clinically important interactions between preoperative blood pressures and the relationship between hypotension and myocardial or kidney injury at intraoperative MAPs less than 65 mmHg. The authors concluded that anesthetic management can thus be based on intraoperative pressures without regard to preoperative pressure. A recent review on preoperative hypertension mentioned that most of the data regarding perioperative blood pressure management are based on epidemiologic data rather than randomized controlled trials; and hence that it may not be appropriate to defer anesthesia and surgery in a patient with mild or moderate hypertension. The anesthesiologist shares the responsibility to ensure that a patient with persistently elevated blood pressure during preassessment is referred for further management before or after surgery as appropriate. In order to minimize oxygen debt, optimal management of fluid therapy, cardiac index (stroke volume), perfusion pressure, and anemia indices have to be considered collectively and not in isolation.

Multimodal Pain Management

Because pain can prolong recovery time and delay discharge, it is important to optimize the management of pain throughout the perioperative period. Multimodal analgesia is a key element of the ERAS pathway that is defined as “the use of more than one modality of pain control to achieve effective analgesia while reducing opioid-related side effects.” The concept of a multimodal analgesic plan allows us to improve postoperative analgesia through different mechanisms and reduce the incidence of any opioid-related effects due to lower dosages. Multimodal pain management consists of the combinatory use of analgesics with different modes of action to minimize side effects and maximize analgesic effects. Multiple agents that act at different receptors within the central and peripheral nervous system to improve pain control should be utilized intraoperatively and postoperatively. Nonopioid analgesics include nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, paracetamol, alpha-2 agonists, ketamine, gabapentin-type drugs, dexamethasone, neuraxial/regional techniques using local anesthetics, hypnosis, and acupuncture. Ultimately, multimodal analgesia serves to minimize postsurgical length of stay, accelerate recovery, and improve outcomes. Pain management strategies should be carefully planned, initiated prior to incision, tailored precisely to patient-specific considerations, and geared towards the surgical procedure in which the patient is undergoing. This careful selection of pain management can allow for the best outcomes for cancer patients. Because pain secondary to cancer is a common occurrence due to both the pathophysiology of cancer and as a result of therapeutic interventions, anesthesiologists must take cancer pain into account when planning an analgesic regimen for their cancer patients. Additionally, surgical interventions for cancer therapies are complex; adequate analgesia should be administered that allows for improved functionality to allow patients to return to chemotherapy and radiation therapy expeditiously. Analgesic plans should aim for early mobilization, decreased perioperative complications, and the improvement of quality care, in addition to lowering pain in the cancer patient. In addition, controversy exists around perioperative opioids and cancer recurrence. Currently, there is no level 1 evidence that opioids influence the perioperative period. A recent meta-analysis showed no conclusive evidence for avoiding the use of opioids with the goal of reducing the risk of recurrence in colorectal cancer. Stress reduction and optimal pain control for our surgical cancer patients should be the goal, with opioids for rescue if needed.

Avoiding Hypothermia

Avoiding hypothermia is also part of the optimal anesthetic plan for cancer patients undergoing an enhanced recovery protocol. Enhanced recovery programs emphasize the need for maintenance of normothermia, as perioperative hypothermia is associated with poor outcomes that could be preventable. Perioperative hypothermia causes impaired pharmacodynamics, surgical site infections, blood loss and coagulopathy, transfusion requirements, thermal discomfort, prolonged recovery, and prolonged duration of hospitalization. Measurement of central core temperature, maintaining normothermia, and consequent warming of patients in the perioperative period are therefore essential. In the National Institute for Health and Clinical Excellence (NICE) guidelines, there is acceptable evidence showing significant dependence of a surgical wound infection and incidence of morbid cardiac events on the incidence of inadvertent perioperative hypothermia (IPH). In addition, complete reversal of neuromuscular blockade and lung protective ventilation strategies are strategies in an optimal anesthesia plan in ERAS for cancer patients.

Pain Management Maintenance

In the realm of postoperative care during the perioperative period, continued effective pain management, complication-free recovery, reduced symptom burden, and enhanced QoL should be emphasized for the cancer patient. Postsurgically, major physiologic changes can occur that can delay recovery. Pain, in particular, can amplify these physiologic changes thereby increasing the time to restoration to baseline function. Similar to intraoperative multimodal pain management strategies, this approach should be also utilized postoperatively. Postoperative analgesia should focus on maximizing the pharmacologic benefits while minimizing side effects to allow for enhanced recovery and functional restoration to ultimately improve outcomes. ^,

Postsurgical Complications and Return to Intended Oncologic Therapies

The concept of return to intended oncologic therapies (RIOT) was introduced by Kim et al. as a novel metric to measure and monitor how perioperative interventions impact functional recovery in cancer patients. RIOT has two components: whether the patient did or did not initiate intended oncologic therapies after surgery and the time between surgery and initiation of these therapies. When RIOT was introduced into the enhanced recovery pathways, the team noted significant practice change management. For example, in colon cancer patients with metastases to the liver the identified RIOT rate was 75%. During the introduction of an enhanced recovery protocol in the liver surgery department, the RIOT rate increased to 95%. Merkow et al. analyzed the American College of Surgeons National Surgical Quality Improvement Program and the National Cancer Database from 2006 to 2009 and showed that 61.8% of the patients who did not experience a complication after pancreatic resection for stages I–III adenocarcinoma received adjuvant chemotherapy. The impact of postoperative complications and RIOT can be seen in the pancreatic surgical population. Patients with no complications had a median time of 52 days to adjuvant chemotherapy, as compared with patients with complications such as deep surgical-site infections, who had a median time of 70 days to adjuvant chemotherapy. Breast cancer overall survival is dependent on both completion and amount of adjuvant chemotherapy. If there is a delay of more than 12 weeks, recurrentce-free survival and overall survival are adversely affected. The rate of survival of cancer patients undergoing surgical procedures is highly dependent on the biology of the tumor, comorbidities associated with the cancer, effects of cancer and cancer therapies on QoL and functionality, and the impact of surgery on recovery. Implementation of an enhanced recovery protocol was associated with receiving on-time adjuvant chemotherapy, defined as at ≤8 weeks postoperatively, in a cohort of 363 colorectal patients. In the non–small cell lung cancer patient, enhanced recovery after thoracic surgery is associated with improved adjuvant chemotherapy completion. Enhanced recovery pathways can potentially allow for a more rapid recovery and shortened time to patient oncologic therapy, which has a meaningful impact on survival ( Fig. 54.2 )

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