A presentation done to Celebrate World Anaesthesia day 2023

1. CANCER CARE : THE ROLE
OF THE ANAESTHETISTS
A PRESENTATION TO CELEBRATE THE WORLD ANAESTHESIA DAY
2023
18TH OCTOBER, 2023
BY
DR OSHUNPIDAN AO, DR OGBOGHALU.

3. OUTLINE
• INTRODUCTION
• EPIDERMIOLOGY
• ROLE PLAY OF ANAESTHETIST
• RECOMMENDATIONS
• CONCLUSIONS
• REFERENCES

4. INTRODUCTION
• Cancer is the uncontrolled growth of abnormal cells in the body, cancerous
cells are also called malignant cells. Cancer can develop in almost any organ
or tissue.
• Cancer is a label that cuts across specialties and encompasses many disease
types and treatment regimes.
• Cancer is a leading cause of death worldwide. Surgery is the
primary and most effective treatment for most solid tumors.

5. Introduction
• Greater than 80% of patients with cancer will require anaesthesia for either
curative or supportive therapy. (surgical care for treatment or palliation),,
• In adults, common cancers requiring surgical care include breast, bowel and
protrate cancer. Surgery is not possible in these patients except there is
access to safe anaesthesia.
• In children, anaesthesia is essential for diagnostic procedures such as CT,
MRI and haematological procedures such as intrathecal chemotherapy,
radiotherapy and surgery.

6. Pathogenesis
• Cancer results from the proliferation of a clonal population of cells : a
multistage process termed carcinogenesis.
• A single cell undergoes a mutation in critical genes responsible for the
control of cell division, cell death, and the maintenance of genetic integrity
thereby rendering the cell susceptible to the acquisition of further mutations.
• The tumor cell becomes refractory to regulatory biochemical cell signaling
pathways, which results in the progressive loss of differentiation and in turn,
uncontrolled cellular proliferation ensues.

7. EPIDERMIOLOGY
• The burden of affects all countries either low or middle- or high-income
countries.
• WHO estimates 8.8 million people died worldwide in 2018 because of
cancer, this is one-sixth of the global deaths. This number could rise to
13.2 million by 2030.
• Approximately 19 million people worldwide experience cancer pain every
year, of these 40 – 80% suffer moderate to severe pain.
• Cancer pain can be somatic, visceral or neuropathic. The effects of this
pain can be physiological or psychological

8. Role of Anaesthetists
• Pain management :Nerve blocks, epidural analgesics, intrathecal pain pumps,
lidocaine infusion.
• Peri-operative management ( Onco-anaesthesia )
• Sedation for diagnostic procedures, radiotherapy.
• Enhanced recovery (ERAS)
• Palliative care

9. Oncoanaesthesia
• Onco-anaesthesiology is the practice and study of perioperative management
that can help facilitate early return to intended oncological treatment (RIOT),
reduce length of hospital stay, imbibe multimodal interdisciplinary analgesia,
integrate supportive care, potentially minimize cancer recurrence and
improve oncological outcomes.

10. Oncoanaesthesia
• Gold standard oncoanaesthesia is aimed at minimizing perioperative
morbidity and post-surgical persistent cancer pain so that patients can start
planned post operative chemotherapy or radiotherapy -return to intended
oncological treatment (RIOT) on time to lower metastasis and recurrence .
• Surgery stimulates a stress response which releases factors that increase the
proliferation of blood vessels that support tumor cell growth while
suppressing natural killer (NK)cells and T lymphocytes

11. Choice of anaesthesia
• Perioperative interventions,especially regional anesthesia, during
cancer surgery can alter oncological outcome increasing disease
free survival.
• Combining nerve blocks with total intravenous anesthesia (TIVA)
brings down the requirement of opioids and volatile anesthetic
agents implicated in cancer recurrence.
• Long lasting but reversible epigenetic changes can occur due to
surgical stress and perioperative anesthetic medications. The exact
relationship between these factors and tumor biology is being
studied further. A popular topic under research now is the influence
of regional anesthesia on cancer recurrence. Combining nerve

12. Effects of Inahalational Anaesthetics on
Cancer
• Surgery, anesthetic agents, analgesic drugs, all may decrease immunity and
increase tumor metastasis. Immunosuppression at the onset of surgery
persists postoperatively and hence even if the tumor is completely resected
the cells spilt during surgery may cause metastasis. General anesthetics do
not seem to directly enhance tumor growth.
• Volatile agents decrease natural killer (NK)-cell activity, lymphocyte antigen
activity, and induce of apoptosis in T and B lymphocytes. The hypoxia
inducible factor-1α (HIF-1α) aids tumor cell survival and is stimulated by the
volatile agents. Sevoflurane promotes the increase in HIF-1α and has been
found to cause a recurrence of breast cancer.

13. Effects of local anaesthetics on Cancer
cells
• Local anesthetics are found to have anti-proliferative and cytotoxic outcomes on most cancer cells.
• Research has shown that lignocaine and bupivacaine directly stimulate natural killer cell (NK-cell)
activity and decrease mesenchymal stem-cell proliferation thereby inhibiting transcription pathways
associated with the metastasis of cancer.
• Invitro studies have shown that both bupivacaine and levobupivacaine inhibit colorectal
adenocarcinoma cell proliferation and migration.
• Ropivacaine has been found to have inhibitory effects in breast cancer by deranging mitochondrial
function.
• Administration of intravenous lignocaine infusion is indicated as an adjunctive intervention in patients
with intense acute cancer pain flares or neuropathic.
• Preemptive local anesthesia infiltration, lidocaine patches and EMLA (eutectic mixture of local
anesthetic) have been used to reduce post operative pain.

14. Regional Anaesthesia and cancer occurence
• Combining neuraxial, truncal and peripheral nerve blocks with total
intravenous anesthesia can bring down the requirement of opioids and
volatile anesthetic agents which have been implicated in cancer recurrence.
• Ziconotide is an intrathecal non opioid peptide drug and that has shown to
relieve severe chronic pain. The main advantage being prolonged
administration of ziconotide does not lead to the development of addiction
or tolerance.

15. GA versus RA in Cancer Surgery
GA
• Advantages
Can be used for both short and long
surgeries.
RA
• Advantages
Positive effect on cancer prognosis
LA inhibits tumor growth
Reduce opioid consumption
Reduces acute pain, chronic pain,
PONV and pulmonary complications
Reduces length of stay and pollution

16. GA vs RA in Cancer Surgery
GA
• Disadvantages
Risk of cancer due to
immunomodulation
Opioid reduce cell mediated immunity
RA
• Disadvantages
Difficult to carry out in anxious
patients
Benefits are short term and not
sustained

17. Enhanced Recovery after Surgery
• Enhanced Recovery After Surgery (ERAS) shortens preoperative fasting,
recommends unrestricted fluid therapy, laparoscopic surgery, short acting
anesthetic agents, non-opioid pain management, early oral feeding and
mobilization.
• ERAS implementation has allowed patients undergoing oncosurgery to
mobilize without pain in first postoperative day, tolerate oral diet early and
decrease hospital stay post-operatively.
• It is strongly recommended for colorectal surgery.

18. Hyperthermic Intra-Peritoneal
Chemotherapy (HIPEC)
• Primary peritoneal neoplasm and metastasis to peritoneum from gynecologic or gastrointestinal cancer
were considered an incurable palliative condition for long until Dr Paul Sugarbaker showed that
HIPEC surgery (the process of heating chemotherapy drugs and delivering them into the abdominal
cavity combined with cytoreductive surgery) improved quality of life and survival of patients .
• Perioperative management is complex and is associated with massive fluid shift, blood loss,
temperature imbalance and hemodynamic alterations.
• Prior to initiation of treatment with heated chemotherapeutic agents the patient is cooled with forced
air warmers, and ice packs to approximately to decrease the risks of hyperthermia. During treatment
there are large fluctuations in the heart rate and oxygen consumption increases while systemic vascular
resistance and mean arterial pressure decreases.
• The chemotherapeutic agents (oxaliplatin, cisplatin, mitomycin C, and doxorubicin) are delivered mixed
in isotonic saline or dextrose-containing fluid to the intraperitoneal space.

19. Isolated Limb Perfusion
• Isolated limb perfusion (ILP) is a limb-salvage technique used to treat
melanoma that has spread to the lymph nodes by delivery of high dose of
chemotherapeutic drugs to the circulation of the affected limb through a
cardiopulmonary bypass circuit into axillary or external iliac vessel.
• The patient is given heparin before the vessels are cannulated. The limb is
heated to 38◦–40C.
• Anesthetists deal with problems that result like acidosis from ischemia due to
tourniquet to isolate the limb and accidental leakage of chemotherapy drugs
into the circulation.

20. Intraoperative Radiotherapy
• Intra operative radiotherapy (IORT) is an established treatment for many
types of cancer with the advent of Mobile accelerators.
• IORT delivers an optimal dose of radiation to a targeted location of tissue.
• All staff should go out of the OT just before the radiation is delivered,
therefore the patient is unattended for a few minutes.
• Anaesthetists must be positioned in such a way that immediate intervention
can be given to the patient if required.

21. Photodynamic therapy
• Photodynamic therapy (PDT) is used for palliation of head and neck cancers.
• Photodynamic therapy (PDT) is done by intravenous administration of a
photosensitizing agent which concentrates in the tumor and is activated by
the presence of oxygen by non-thermal light of a specific wavelength leading
to tissue death.

22. Remote Anaesthesia
• Anesthesia given outside the OT carries a high risk of mortality and
morbidity.
• Radiotherapy and brachytherapy are now done at remote locations under
monitored anesthesia care as a day care procedure.
• The plan of anesthesia is to maintain spontaneous ventilation and immobility
without requiring airway intubation or haemodynamic instability.
Remifentanil and propofol infusion is a popular combination.
• Remote monitoring is essential while these patients are sedated and cannot
be over-emphasized.

23. Post Surgical Chronic Cancer Pain
• Post-surgical chronic cancer pain, (PSCCP) occurs in approximately 10–30%
of patients who have had surgery, and usually begins as acute postoperative
pain, described as that pain lasts longer than two months after surgery.
Inadequate treatment of acute pain results in chronic pain.
• Postsurgical pain syndromes occur commonly after mastectomy,
amputations, thoracotomy and head and neck surgery.
• Anesthesiologists should ensure proper treatment of acute pain to prevent it
from progressing to chronic pain.

24. Pain management
• Spinal cord stimulation – uses electrical pulses to prevent pain signals from
being received by the brain. Used for neuropathic pain
• Intrathecal pump implant – relieves chronic pain, uses small amounts of
medicine applied directly to the intrathecal space to prevent pain signals from
being perceived by the brain.
• Nerve block - this is a one -time injection to the source of the pain.

25. RECOMMENDATIONS
• Multidisciplinary approach must not be under-emphasized in the
management of cancer patients.
• Everyone’s role is important therefore no one should see themselves as the
hero rather we all should be team players to improve the outcome in these
patients.
• Further local research should be made on the peri-operative management of
these patients especially in our environment to give improve the quality of
life specifically for the patients we manage.

26. Conclusion
• Management of cancer patients requires well coordinated multidisciplinary
care and anaesthesia must be seen as a core component of this and
resourced appropriately
• As the burden of cancer keeps increasing, many novel researches keep going
on daily to decrease the morbidity and mortality of these patients and
increase the quality of life of those that survive. Our role as managers
cannot be over-emphasized because either or daily or at least weekly basis, a
cancer patient has to be anaethesized. Therefore, we need to give them our
best so we can give them a chance to ‘live their present best’.

27. References
• Mary T. Cancer txt and Rsh Com. 29,2021.100491.
• Bernhard R. Onco-anaesthesia:Improving long term cancer outcomes.
• Raghu ST, Rakesh G, Seshadri R, Jigeeshu VD. Indian J Anaesth. 2020 Jan;
64 (1): 69-71.