When do you delay surgery?

Cancer BobbieJean Sweitzer, M.D. Director, Anesthesia Perioperative Medicine Clinic Professor of Anesthesia and Critical Care Professor of Medicine University of Chicago I have no disclosures 2 nd leading cause of death in developed world > 500,00 deaths yearly Breast, colon, lung, prostate: >50% of cases & deaths Metastatic burden influences survival Average 5 year survival 68% (>80% for some cancers) Increasing surgical intervention Cancer, other comorbid conditions, chemotherapy and radiation all impact perioperative care Early research suggests possible association between perioperative anesthetic techniques and cancer outcomes When do you delay surgery? Will a delay reduce the chance of cure? Is there an alternative non-surgical treatment? Radiation vs prostatectomy? Can I actually make the patient better/improve their condition? 72 yo male with prostate cancer scheduled for RALP Discovered to have moderate mitral stenosis and pulmonary hypertension during anesthesia preoperative visit Long standing murmur had never been evaluated Cardiology consult: high risk for cardiac complications; high risk for MV replacement After discussion (anesthesiologist, surgeon, cardiologist & patient): Referral to radiation oncologist Preoperative tests are beneficial if: 1) There is a high likelihood abnormalities 2) AND, the abnormality actually increases the risk of anesthesia or surgery 3) AND, the treatment of the abnormality LOWERS the risk 4) AND, waiting to treat the abnormality will not increase risk- especially important for cancer care! 1

Erythropoetin use has been associated with worse outcomes in patients with cancer (some tumors have erythropoetin receptors) Metabolic abnormalities Hypercalcemia 10% of patients Squamous cell lung cancer Bony metastases Hypothyroidism Head and neck radiation Always check TFTs Hyponatremia SIADH (lung, pancreas, breast, colon, prostate cancer) Cancer is a hypercoagulable state Venous thromboembolism prophylaxis is indicated for ALL cancer patients Toxicity of Chemotherapy Adriamycin Cardiomyopathy Thalidomide Severe bradycardia Bleomycin Lung toxicity Methotrexate & L-asparginase: Liver dysfunction Cisplatinum: Nephrotoxicity (1/3 of pts affected by a single 50 mg/m 2 dose) Hypomagnesemia 2

Toxicity of Radiation Therapy Head & neck irradiation Hypothyroidism Difficult airway Carotid stenoses Risk of TIA/CVA 2X higher Mediastinal, chest wall & left breast irradiation Cardiac disease Conduction abnormalities Coronary artery disease Cardiomyopathies Valvular abnormalities HISTORY OF RADIATION Focus on airway, heart, lungs Head & neck irradiation: Prepare for difficult airway Listen for carotid bruits Carotid dopplers Thyroid function tests Mediastinal, chest wall & left breast irradiation: Echocardiography Electrocardiogram Consider stress testing Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery Kertai MD Am J Med 2004;116:8 Auscultation for systolic murmurs should be done in any patient for whom 8.5 fold a complete increased risk CV database is necessary -Etchells JAMA 1997;277:564 3

Cumulative Risks of Death from Ischemic Heart Disease and of at Least One Acute Coronary Event Darby SC. 2013;368:987 QT Prolongation Increased risk of ventricular arrhythmias 16%-36% of cancer patients have baseline ECG abnormalities High rate of comorbid conditions Structural heart disease Hepatic disease Renal disease Electrolyte abnormalities Nausea, vomiting, diarrhea Concomitant use of medications Antiemetics, antifungals, quinolone antibiotics Left ventricular dysfunction Ischemia Hypertension Venous thromboembolism Bradycardia QT prolongation 4

What would you do for this patient? 42 yo lawyer, hx of Hodgkin lymphoma as teenager now with breast cancer Severe restrictive lung disease 2 nd pulmonary fibrosis 2 nd radiation and bleomycin; O2 dependent Patient wants bilateral mastectomy and immediate breast reconstruction Pulmonologist: patient too high risk for surgery Surgeon: Will she survive anesthesia? What we did in our preoperative clinic Discussed realistic options/priorities with the patient and the surgeon Arrived at a plan to do a simple mastectomy and axillary node dissection Promised if she did well we would reconsider reconstruction options Scheduled as 2 nd case of the day High thoracic epidural placed under fluoroscopic guidance in our pain clinic Currently- doing more paravertebral blocks OR anesthesia team pre-arranged experience with pulmonary hypertension patients Arranged for postoperative ICU care Patient had uncomplicated course 2006;144:575-80 Chest x-rays do not predict postop pulmonary complications (useful for acute problems) PFTs and ABGs in non-lung resection surgeries not predictive of complications Risk reduction strategies Lung expansion maneuvers Incentive spirometry, deep breathing exercises PEEP, CPAP Preoperative beta-agonists and steroids Smoking cessation (even short-term) 5

Obstructive Sleep Apnea Increasingly common in all surgical patients Higher risk in patients with head & neck cancers CPAP may be difficult to use after treatments Important to not overlook Nutritional optimization Cancer cachexia (50% of cancer patients) Impaired immune function) Hypoalbuminemia Smoking cessation Pulmonary rehabilitation Pre-habilitation Lung cancer patients-delay of surgery for 2 months improved short-term and long-term outcomes Geriatric patients Frailty ASA alone ASA + frailty RCRI alone RCRI + frailty What should one do? 88 yo rectal bleeding from colon cancer; transfusion dependent Severe aortic stenosis and pulmonary HTN Internist: We have to operate. We can t just let her die What other choice is there? Consider alternative therapies in patients with limited life expectancy Colonic stents Interventional radiology for bleeding Double-balloon enteroscopy for bleeding Hospice care 6

Geriatric patients with cancer Willingness to Undergo Treatment Treatment Intensity Health Outcome Desires Treatment Low burden High burden Return to current health Return to current health 98.7% 88.9% Low burden High burden Functional impairment Functional impairment 25.6% 11.2% When do you delay/cancel surgery? Only after discussion with surgeon, patient, oncologist Are there other nonsurgical treatment options? 77 yo with prostate cancer and end-stage COPD referred to urologist who planned prostate resection After discussion with anesthesiologist all agreed to cancel surgery and refer patient for radiation therapy Thoracic surgery patients had much better outcomes than matched cohort for abdominal surgery- Thoracic patients had routine postoperative ICU care Does anesthesia affect long-term outcome of cancer? Tumor surgery is usually associated with release of tumor cells into lymphatic and blood streams Local and metastatic recurrence depends on efficacy of host defenses- natural killer (NK) cells Surgery: Depresses cell mediated immunity (cytotoxic T- cell and NK cell functions Reduces tumor related antiangiogenic factors Increases proangiogenic factors (vascular endothelial growth factor) Anesthesia: Impairs numerous immune functions (neutrophil, macrophage, T-cell and NK cell functions) Opioids: Inhibit cellular and humoral immune function Morphine is proangiogenic (shown to promote breast cancer tumor growth) 7

Why might regional anesthesia be better? Attenuates neuroendocrine stress response Reduces endogenous opioid release Reduces amount of exogenous opioid use In rodent model NK cell function better preserved and metastatic load to lungs reduced Summary Comorbidity assessment Cardiac function (less emphasis on ischemic disease) Pulmonary status Renal & liver function Cancer therapy implications Patient and provider discussions regarding goals of therapy Postoperative management ICU care Advance Directive Living will Resuscitation status Discharge planning 8