The first comprehensive conference on perioperative care of the cancer patient was held from November 28 to December 2, 2012 at The University of Texas MD Anderson Cancer Center (MDACC) in Houston, Texas. The conference was attended by 145 registered delegates from 15 countries.
JUSTIFICATION OF THE MEETING
Cancer is the leading cause of death worldwide and the second most common cause of death in the United States. It is reported that the aging baby boomer population and longer life expectancies will result in a 45% increase in the incidence of cancer by 2030.1 As the incidence of cancer and cancer survivorship grows, the services of perioperative health care providers will be in demand for the diagnostic and/or interventional needs of this patient population.2 As such, there is a growing and immediate need for anesthesiologists and other perioperative health care providers to be prepared for the special care required by the elderly, cancer patients, and cancer survivors in our practice.
Day 1—Geriatric Anesthesia (Moderator Dr. Alec Rooke)
Dr. Ronald DePinho, President of The University of Texas MDACC, opened the meeting by discussing his vision for MDACC. It is his hope that integrated research and clinical programs will translate new discoveries into clinical successes and improved outcomes for our patients. Dr. Alec Rooke’s presentation outlined the physiologic basis for diminished functional reserve in the elderly. He explained the concepts of frailty and the importance of “prehab.” Prehabilitation is the process of enhancing preoperative nutritional status and functional capacity to promote faster postoperative recovery. The effects of drug dosing on an aging cardiovascular system were presented by Dr. Shamsuddin Akhtar. Dr. Holly Holmes gave an overview of the geriatrician’s role in taking care of the elderly cancer patient. She discussed the American College of Surgeons National Safety Quality Improvement Program/American Geriatrics Society best practice guidelines for optimal preoperative assessment of the geriatric surgical patient. Dr. Zhongcong Xie discussed the differences between delirium and postoperative cognitive dysfunction. Dr. Marc Rozner spoke about cardiac implantable electronic devices. He stressed the importance of this subject, given the exponential increase in the number of patients receiving these devices because of an aging population as well as the expanding indications for the use. Dr. Wei Mei spoke about China’s transformational growth in facilities and research plans to include multidisciplinary and multi-institutional collaborative projects. Dr. Xie’s talk about the past, present, and future of geriatric anesthesia demonstrated that much scientific work is still needed to better take care of this patient population. After the didactic session on day 1, there was a moderated poster session. Thirty-three posters were presented and discussed.
Day 2—Onco-Anesthesiology (Moderator: Dr. Dilip Thakar)
Dr. Raphael Pollock presented his original research on the effects of immune effector system on tumor biology from the 1980s and finished the talk by challenging the group to develop the much-needed corpus of knowledge in this field to improve patient care and also establish onco-anesthesiology as a specialty. Dr. Jean-Bernand Durand reviewed new molecular target therapies in cancer medicine and their significant negative effects on the cardiovascular system as well as the role of cardiac biomarkers and imaging in the early detection and treatment of cardiac injury. Dr. Joseph Nates highlighted the unique challenges of the critically ill cancer patient along with an overview of the oncologic emergencies needing intensive care such as malignant airway obstruction, septic shock, and gastrointestinal bleeding.
Dr. Sebastino Mercadante gave an overview of medical management of cancer pain in the nonacute surgical setting. He discussed basic principles of chronic opioid therapy as well as therapy for intractable and resistant pain conditions using multimodal analgesic adjuvant medications. Dr. Radha Arunkumar led a panel of neuroanesthesiologists, neuroradiologists, neuro-oncologists, and neuropsychologists to discuss brain imaging, neuropsychological testing, intraoperative neuro monitoring, super-selective scalp blocks, and advanced airway management techniques for awake craniotomies.
Day 3—Onco-Anesthesiology (Moderator: Dr. Andrea Kurz)
Dr. Dam Truong highlighted clinically challenging cases involving the difficult airways in head and neck cancer patients. He described a yet to be validated method of airway assessment for patients with tumors invading the airway and/or patients who have received radiation therapy to the head and neck. He also described his strategy for retromolar intubations in patients with trismus. Dr. Vijaya Gottumukkala discussed the current laboratory, animal, and clinical evidence of the effects of anesthetic agents, local anesthetics, and opioids on tumor progression and oncological outcomes. He also outlined the additional oncologic factors (tumor type, stage, and preoperative and postoperative adjuvant therapy) in this patient population, which have significant bearing on outcomes and yet have not been factored into the clinical studies published in the anesthesia literature thus far. Although definitive clinical evidence is lacking, based on laboratory evidence and animal studies, he concluded that by avoiding volatile anesthetics and opiates in favor of propofol, neuraxial and peripheral nerve blockade, and adjuvants (i.e., Cox-2 inhibitors), we can tip the balance away from tumor escape and toward tumor elimination. He stressed that to be successful and have a meaningful impact on outcome, a comprehensive multidisciplinary approach is required that includes not only our surgical colleagues but also cancer biologists and immunologists. Dr. Jonathan Hiller gave an overview of the perioperative factors that affect progression of minimal residual disease to clinical metastasis. He spoke about how lympho-vascular space invasion impacts recurrence and survival. The example given was a metastatic breast carcinoma that secreted the growth hormone vascular endothelial growth factor D. The research showed that Cox-2 inhibition causes vasoconstriction of lymphatic vessels, promoting an anti-metastatic environment by decreasing the pathway for minimal residual disease spread to lymph nodes. He ended his presentation with some thoughts on “personalized medicine” for the future in the perioperative context by proposing that future surgical timeouts should include a discussion about which specific cancer outcome strategies will be used on a case-by-case basis. This discussion would be driven by tissue biopsy results and tumor gene expression. Dr. Adrian Alvarez discussed the physiological basis for and positive results of thoracic epidural analgesia on reducing pulmonary complications and ileus. As evidence, he cited many of the studies that were published promoting the success of enhanced recovery after surgery protocols. Dr. Alvarez pointed out ways that elderly and cancer patients can benefit from enhanced recovery after surgery strategies but cautioned that protocols should be individualized. He finished his presentation by describing his technique for thoracic epidural analgesia in morbidly obese patients. Dr. Juan Cata discussed transfusion-related immunosuppression and the current clinical evidence on the relation between blood transfusion and cancer recurrence. He concluded by suggesting that randomized control studies are needed in noncolorectal patients to get definitive answers. He reiterated the importance of the transfusion trigger in this patient population as an important element in the complex interplay of factors that influence the decision to transfuse surgical patients with blood products. Dr. Peter Slinger discussed the most recent literature and the current understanding of the effects of ventilation and fluid management on outcomes after thoracic surgery. He concluded his talk by discussing the importance of preoperative cardiac risk and functional capacity assessment in the elderly patient undergoing pneumonectomy. He proposed that the American College of Cardiology’s classification of thoracic surgery as intermediate risk is inaccurate with respect to the elderly patient, stating any elderly patient should be classified as high risk. With this suggested escalation of risk, he also proposed an increased usage of transesophageal echocardiography and noninvasive cardiac assessment testing for elderly patients undergoing thoracic surgery to better risk stratify and predict postoperative outcomes.
Day 4—Perioperative Medicine (Moderator: Dr. Girish Joshi)
Dr. Duminda Wijeyasundera discussed the revised cardiac risk index and how it is far superior to the subjective assessment of metabolic equivalents. He elaborated on the poor correlation between metabolic equivalent of task and cardiac complications and concluded by highlighting some of the current research that is investigating the use of serum biomarkers as an even better method for cardiac risk prediction. The biomarkers discussed were brain natriuretic peptide, N-terminal prohormone brain natriuretic peptide, high-sensitivity troponin, and high-sensitivity C-reactive protein. Dr. Geno Merli spoke about the problem of immediate and delayed deep venous thrombosis in patients with cancer and the importance of balancing anticoagulation with the risk of bleeding in our surgical patients. Dr. Joshi emphasized the need for procedure specific pain management strategies and enhanced recovery after surgery protocols to focus our efforts on functional recovery and reduced length of stay to improve outcomes and reduce cost of care.
Day 5—Health Care Challenges (Moderator: Dr. Thomas Rahlfs)
Dr. Don Lighter discussed the health care reform act. He concluded by outlining the opportunities and challenges that will transform health care delivery such as implementation of the Affordable Care Act, International Classification of Diseases-10 codes, bundled payments, and Meaningful Use. He outlined the positive impact of Meaningful Use 1 and outlined what is on the horizon for Meaningful Use 2. He also brought up the issue of public trust and how to bridge the gap between how we as health care providers are perceived and how we would like to be perceived by our patients. Drs. Suresh Reddy and Larry Driver spoke about palliative medicine and medical ethics, respectively, in the care continuum of the cancer patient. They gave examples of situations that arise with determining optimal care, decisions regarding withholding care, hospice care, and end-of-life issues. Dr. Lorenzo Cohen spoke about the impact of modifiable factors (nutrition, tobacco, sedentary lifestyle, obesity, stress, and social support) on cancer burden. He emphasized the importance of an integrative clinical model that is a multidisciplinary team approach led by a medical oncologist with specialty training in integrative oncology consultation. This model focuses on defining health not only as a physical construct (via surgery, chemotherapy, radiation) but one that incorporates psychospiritual (meditation, massage, and cognitive therapy) and social (support groups, education, and music therapy) elements as well. Dr. Robert Satcher gave the final presentation of the meeting titled Effective Team Building: An Astronaut’s Perspective. Dr. Satcher is an orthopedic surgeon at MDACC and a former National Aeronautics and Space Association astronaut. He outlined team-building exercises that will be essential in the perioperative practice as patients get older and more complex requiring input from several different specialists for optimal care and improved outcomes.
Each of the international partners has agreed to work with their respective national societies to advance Onco-Anesthesiology through educational sessions. Going forward, MDACC plans to actively engage our partners in the MD Anderson Sister Institution Network in collaborative projects. Future meetings of this conference will alternate between United States and international locations for maximal outreach to practitioners all over the world. The next meeting will be hosted by The Peter MacCallum Cancer Center in Melbourne, Australia, from March 21 to 23, 2014. More information can be found at www.canceranaesthesia2014.org.
1. Kohler BA, Ward EM, McCarthy BJ, Schymura MJ, Ries LA, Eheman C, Jemal A, Anderson RN, Ajani UA, Edwards BK. Annual report to the nation on the status of cancer, 1975–2007, featuring tumors of the brain and other nervous system. J Natl Cancer Inst. 2011;103:123
2. Retooling for an Aging America: Building the Health Care Workforce. 2008 Washington, DC The National Academies Press