Enhanced Surgical Recovery and Cancer

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.