In 2018, there were over 18 million cases of cancer worldwide, with the number expected to reach 29 million by the year 2040.1 With the rise in incidence, the number of therapeutic options has also increased over the years, with more patients undergoing multimodality treatment involving chemotherapy, radiotherapy, and surgery. In more recent years, the advent of immunotherapy has the promise of revolutionizing cancer treatment. The perioperative clinician needs to be aware of the unique issues that are involved in the perioperative evaluation and management of the cancer patient facing surgery.
For some cancer patients who have early tumors detected before onset of symptoms, the preoperative evaluation and medical optimization is straightforward, following established criteria and guidelines. For the majority of cancer patients, delaying surgery to optimize medical and functional status is not a viable option due to tumor growth and disease progression. For cancer patients facing a surgical treatment, a variety of comorbid conditions can affect the ability to provide a clear risk assessment. These conditions conspire to further decondition the patient, potentially increasing risk and complications.2 Therefore, it is important for the perioperative clinician to have a comprehensive understanding of the cancer, cancer treatment, and their effects on the patient. In addition to the cancer, the patient’s history and the planned procedure should be considered when evaluating a patient for surgery.
The patient’s history of cancer, including presentation and treatments to date, will inform the perioperative risk assessment. A patient in good health with an incidental finding of a tumor on unrelated imaging will need a straightforward evaluation per current guidelines. However, the patient with a complicated cancer history with multiple prior treatments or history of other prior cancers, requires closer evaluation.
The patient with cancer suffers from the metabolic and physiologic derangements from the disease itself. Fatigue, cachexia, malnutrition, pain, and other symptoms lead to deconditioning and frailty. It is important to assess how much a patient diagnosed with cancer has deviated from their usual state of health prior to diagnosis and treatment.
No cancer treatment is benign; the patient may experience complications from the treatment itself, such as surgery complications or organ dysfunction caused by chemotherapy and radiation therapy. Some side effects are seen immediately but others may take years to manifest.
Unlike elective procedures, cancer surgery usually is urgent and delaying a surgery to optimize a medical condition like diabetes or hypertension may risk tumor and disease progression. Close communication with the surgical and anesthetic team is required in such instances. Having an accurate medication list and medical problem list documented in the preoperative evaluation provides a single source of truth for all medical teams down the line.
Prior treatment with chemotherapy, radiotherapy, or surgery ...