Typically, a hospitalist conducting a preoperative assessment might recommend delaying the procedure if the patient had poor diabetes control, due to the risk of infectious wound healing and other complications. But postponement may not be an option if a patient is scheduled for urgent surgery due to cancer.
“Normally, we would work hard to make sure diabetes control was optimized before surgery but with cancer patients, we may not be able to make the control much better and still be able to operate for a cure,” said Kurt J. Pfeifer, MD, FACP, a hospitalist and associate professor of medicine at the Medical College of Wisconsin in Milwaukee. “Instead, I would discuss with the surgeon how much delay the patient could afford without altering their prognosis.”
Hospitalists working in perioperative settings increasingly are involved in these types of decisions as more cancer patients undergo surgery as part of their treatment. As a result, it's becoming necessary to know about the effects of cancer treatments on organ systems and the potential risks of surgery unique to cancer patients.
In addition, hospitalists need to be familiar with the long-term effects of cancer treatments as people who survive their illnesses return for elective surgeries.
“As internists, we may not be up to date on the intricacies of cancer treatment, but we know about cancer's effect on the body,” said Sunil K. Sahai, MD, FACP, associate professor of medicine and medical director of the Internal Medicine Perioperative Assessment Center at the University of Texas MD Anderson Cancer Center in Houston. “Our group has become very good at knowing which chemotherapy treatment causes which reaction and how we address it in specific patients.”
Preparing patients for surgery
Hospitalists play a critical role in making sure the surgical team is aware of any medical issues that could interfere with a successful procedure or lead to complications, said Dr. Sahai.
“The key to a successful postoperative discharge is a thorough preoperative history and physical so there are no surprises,” said Dr. Sahai. “You need to know the patient has diabetes or hypertension or heart failure, so there are no issues postop. That sometimes gets lost in the cancer care—patients forget that these diseases make a difference in their recovery from cancer.”
But while experts agree careful preoperative assessment can mitigate the risks of surgery, there are no hard and fast rules to follow.
“What is challenging is the lack of evidence-based guidelines on the preoperative workup strategies in this patient population,” said Vijaya N.R. Gottumukkala, MD, professor, vice-chair and medical director of MD Anderson's department of anesthesiology and perioperative medicine. “For the most part, timing of surgery and coordination of preoperative care is dictated by tumor biology, patient logistics and the ability to coordinate care amongst the various perioperative specialists involved in the care of a patient.”
With non-cancer patients, the general rule of thumb regarding preoperative diagnostic testing is “don't order it if it won't alter your decision to go to the operating room,” said Dr. Sahai. However, cancer patients should undergo a complete battery of tests due to their higher risk of abnormalities.
“Lab testing is much more relevant in the cancer population, due to the higher probability of finding an abnormality,” said Marina Rozenberg, MD, ACP Member, a physician on the medical consult service at Memorial Sloan-Kettering Cancer Center in New York City, who provides perioperative care to surgical patients.
“A lot of tests not indicated in the non-cancer population would be indicated in the cancer population, based on the kind of cancer and the type of treatment they had,” she said.
For example, a patient previously treated with the chemotherapy drug cisplatin is at risk for renal dysfunction and wasting of magnesium and therefore should undergo testing of electrolytes, blood urea nitrogen/creatinine, and magnesium.
A preoperative assessment should include a thyroid function panel for any patient who has been treated with radiation therapy to the head and neck, which can cause hypothyroidism, and supplementation can be prescribed before surgery, Dr. Rozenberg added.
Electrocardiography (ECG) and chest X-ray also should be part of the preoperative assessment in selected cases, said Dr. Rozenberg, as many cancer treatments affect the heart and lungs. For example, anthracyclines can cause dilated cardiomyopathy; radiation therapy to the chest can cause conduction abnormalities and premature coronary disease; and some chemotherapy drugs can cause lung disease.
“A patient treated with anthracyclines who complains of progressive exertional dyspnea would warrant an echocardiogram to rule out cardiomyopathy, and if present, could be optimized with a beta-blocker or angiotensin-converting enzyme inhibitor before surgery,” she said. “A patient treated with chest radiation or bleomycin who complains of dyspnea and a cough would require a chest X-ray and pulmonary function tests to evaluate for interstitial lung disease.”
Patients who receive chemotherapy to treat a tumor before surgery should be assessed carefully for their readiness to undergo a procedure, as low functional status can interfere with recovery, noted Dr. Pfeifer. “It depends on the type of chemotherapy given. If a patient is still neutropenic and very fatigued and anemic, taking them to surgery wouldn't be a good idea.”
One of the biggest risks for cancer patients following surgery is venous thromboembolism (VTE), said Dr. Sahai. MD Anderson and other hospitals now have additional protocols for VTE prophylaxis and both the American Society of Clinical Oncology and the American College of Chest Physicians recommend extended postoperative prophylaxis for up to one month following major cancer surgery in patients with high-risk features, such as a previous history of VTE.
Hospitalists who don't work at a cancer center may not have been told about the need for extended prophylaxis, but it is important for the hospitalist to advocate strongly for aggressive action, said Dr. Pfeifer.
“Too often hospitalists have been afraid to even broach the subject of anticoagulation if the patient has had surgery because we're afraid the surgeon won't want to do it,” he said. “VTE risk is particularly high in patients undergoing surgery for malignancy and aggressive prophylaxis is almost always warranted.”
However, that prophylaxis can increase the risk of bleeding, added Dr. Pfeifer. As a result, physicians need to monitor the patient closely for adverse effects in the postoperative setting.
Cancer patients are at overall higher risk than other patients for postoperative complications, such as pneumonia, said Dr. Sahai. Patients undergoing surgery soon after being treated with chemotherapy are at particular risk for poor wound healing and infection.
Hospitalists' growing role
Coordination of care is one of the most important aspects of medicine in the perioperative setting, said Dr. Gottumukkala, especially as cancer surgery techniques advance and surgeons take on increasingly complex cases.
“By virtue of their broad-based training in general internal medicine, hospitalists can play a significant role in coordinating the postoperative care in these patients with increasingly complex medical conditions,” he said. “Up to 35 clinicians may have contact with a surgical patient in a hospital on any given day, so postoperative care can become disjointed and complex if there is not a well-organized and coordinated care process.”
Some hospitals are moving toward models that incorporate hospitalists as part of the perioperative care team. At Memorial Sloan-Kettering, Dr. Rozenberg is part of the medical consult service, seeing patients before surgery as outpatients or as inpatients if they are admitted by the surgical team. Hospitalists coordinate preoperative care for patients admitted to the general medicine service.
“Some centers are moving in the direction of having co-management of surgical patients, with a hospitalist as a member of the postoperative care team,” said Dr. Rozenberg. “Hospitalists will be taking care of more surgical patients, and that will include many cancer patients.”
The perioperative practice at the Medical College of Wisconsin's Froedtert Hospital has grown from one inpatient consultative service to three teams dedicated to providing inpatient co-management for surgical patients with cancer and other conditions, said Dr. Pfeifer. Involving hospitalists makes sense, he said, because they are used to dealing with many of the co-morbidities that surgical patients have, such as diabetes, chronic obstructive pulmonary disease or heart failure.
“These major medical issues have the capacity to severely impact patients' recovery from surgery and, if the reason for surgery is to save their life, we're not doing them any favors if we fail to manage them,” said Dr. Pfeifer. “As the population ages and has more of those comorbidities, we need to have the physicians who are most knowledgeable about these conditions managing them through the whole surgical setting.”