Onco-anaesthesiology as an emerging sub-speciality domain: Need of the hour!

INTRODUCTION

The domain of anaesthesiology has advanced extensively and is branching into focussed sub-specialities. There is a need for specialised perioperative care of cancer patients. As a sub-speciality, onco-anaesthesiology provides the anaesthesiologist with an opportunity to positively influence the surgical outcome. Cancer is the second leading cause of death globally, and the World Health Organisation (WHO) predicts 22 million annual new cancer diagnosis globally by 2030.[1] Around 60–80% of cancer patients are likely to require surgery for various indications ranging from diagnostic, therapeutic or palliative procedures. Advances in surgery and anaesthesiology have resulted in the greatly improved perioperative care of cancer patients, which have given birth to the unique subspecialty of onco-anaesthesiology.[2]

WHY ONCO-ANAESTHESIOLOGY?

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 minimise cancer recurrence and improve oncological outcomes. The goals of onco-anaesthesiology would be to strive for:

1. Pre-habilitation: It is a proactive approach of involving patients actively in their care. It has four components: Medical optimisation, physical exercise, nutritional and psychological support.[3] It includes exercise (strength and cardiovascular training), physiological conditioning regimes, physical, psychological and cognitive-behavioural therapies. Physical capacity is an important preoperative factor to assess before major tumour resection because it has been strongly associated with postoperative complications, prolonged hospital length of stay and mortality. Pre-habilitation must be achieved over a relatively short time-window given the time-sensitivity of cancer surgery. A structured, individualised exercise regime improves cardio-respiratory fitness and muscular conditioning, early return of functional status and improves oncological outcomes[3]

2. Multi-disciplinary cancer care aiming for timely access to cancer treatment and to attain the goal of timely RIOT (e.g., post-operative radiation, chemotherapy, immunotherapy, hormone therapy).[4,5] RIOT has two components: binary outcome (whether the patient did or did not initiate intended oncologic therapies after surgery) and the time between surgery and the initiation of the therapies.[5] Perioperative care techniques have the potential to impact cancer-specific survivals by aiding early RIOT

3. Biological perturbations due to perioperative stress response and different anaesthetic techniques may impact cancer recurrence. Animal studies and retrospective data suggest that inhaled anaesthetics and opioids may be associated with increased cancer progression and metastases, while regional anaesthesia and total intra-venous anaesthesia (TIVA) may be protective.[6] The choice of opioids, non-opioid adjuncts, regional anaesthesia techniques, volatile anaesthetics and propofol based TIVA derived from in vitro experimental studies yielding conflicting results cannot be considered as evidence towards cancer causation, recurrence, spread and outcome.[7] Thus, currently there are no studies with robust evidence to support the superiority of an anaesthetic technique over the other.[4] To optimally care for the cancer surgery population, we need evidence-based protocols to evaluate whether these strategies are indeed efficacious in improving long-term cancer outcomes. Active clinical research in onco-anaesthesiology and evidence-based treatment strategies validated by prospective randomised control trials conducted across specialised cancer centres are essential

4. Multimodal interdisciplinary analgesia which incorporates various anti-inflammatory agents, anti-adrenergic adjuncts, locoregional techniques and TIVA-based approaches with a unified goal to prevent chronic post-surgical pain (CPSP).[8] Effective perioperative analgesia combined with enhanced recovery protocols contribute to the early recommencement of clear fluids as well as facilitates early ambulation[8]

5. Institution of continued palliative care as well as integrated rehabilitation support system.[9] The Lancet Oncology Commission proposes the use of standardised care pathways and multidisciplinary teams to promote the integration of oncology and supportive care, with the overall goal of improving patient care. This integrated model must be reflected in international and national cancer plans and is followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated

6. Enhanced recovery after surgery (ERAS) is a multi-dimensional approach to reduce the length of hospital stay involving a rational set of perioperative goals to optimise early patient recovery. Cancer-specific ERAS protocols specific to the subtype of cancer surgery will be major avenues for onco-anaesthesiology research.[10]

Many of these interventions are specific to the perioperative care of cancer patients. The focus on these domains will improve the overall outcome, justifying the need for a dedicated branch in teaching and training extensively on these aspects.

CONCLUSION

With the advancement in cancer surgeries and specific concerns related to perioperative care and cancer outcome, the emergence of onco-anaesthesiology is need of the hour. The core foundation of onco-anaesthesiology sub-speciality will include better understanding related to advanced clinical aptitude, evidence-based clinical practice and research, along with patient advocacy, optimising patient-centred outcomes and maximising comfort.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.