Cancer and Anesthesia: In for a Penny, In for a Pound

This article is about things to know if you’re diagnosed with cancer and are contemplating surgery.

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Being told you have cancer is frightening and a common reaction is to want the cancer excised as quickly as possible. Indeed, this is the way most solid tumors are treated. Cancers of the blood like leukemia or lymphoma are different and can’t be “cut out.” But for solid tumors like tumors of the breast, large intestine, or prostate gland, there is often an identifiable mass or organ that can be removed and  —  along with chemotherapy and/or radiation therapy  — lead to cure.

Let’s dig a little deeper into what happens before the surgery. As you strengthen your resolve to “beat this thing,” you listen carefully to your oncologist, your surgeon, and all the other doctors involved in your care. You might get a second opinion (or even a third) and Google as much as you can about your type of cancer. You want to understand everything that’s going on. You might change your diet, you might start exercising more vigorously, you might take some herbal medicines, you might start meditation or do pretty much everything and anything else you can do to win this fight. You’re not in for a penny  — you’re 100% committed, you’re “in for a pound!” But in order to really do that, you need to know some things about your surgery and anesthesia that aren’t commonly mentioned.

A Few Facts About Cancer Surgery

This idea of simply cutting out a cancer to get rid of it has been practiced by surgeons for thousands of years. Examples can be found as far back as 100 BC. The remarkable Pulitzer prize-winning book on cancer by Siddhartha Mukherjee, The Emperor of all Maladies, talks about these ancient practices. And even if a patient didn’t die of infection or bleeding in the era before antibiotics, anesthesia, or sterile techniques, surgery often worsened the cancer and hastened the demise of the patient instead of offering a cure.

A solid cancerous mass may enlarge (like on the breast) and lead to pain, disfigurement, and discomfort. But cancers don’t usually kill unless they spread (in medical terms, metastasize) to other organs in the body.

When you have a solid tumor removed, the surgery often causes tiny tumor particles or seedlings to break off and spread throughout the body. This happens even in the hands of the most meticulous surgeons. And these seedlings might then grow and become full grown tumors in other organs of the body like the liver, the bones, or the brain.

To destroy these seedlings, surgeons and cancer doctors often use chemotherapy or radiation after (and sometimes before) the surgery. Dr. Daniel Sessler, head of Outcomes Research at the Cleveland Clinic, and one of the foremost anesthesiologists in the United States, has discussed this idea in many papers. He notes:

Although not widely appreciated, tumor surgery is usually associated with release of tumor cells into the lymphatic and blood streams; furthermore, a large fraction of patients already harbor micrometastases and scattered tumor cells at the time of surgery.

OK, so why is this important to know? Is there anything you can do about these seedlings and micrometastases before you get your chemo or radiation? You can’t begin chemo or radiation immediately after surgery because the radiation will interfere with wound healing and the chemo will hinder your body’s infection-fighting ability and make a surgical infection more likely. You need to wait a little while (say two weeks).

It’s this vulnerable period  —  from the beginning of anesthesia and surgery until the time chemotherapy or radiation can begin  — that we want to discuss. This is a really important interval: during the vulnerable period, we have to rely exclusively on our body’s inherent immune system to keep the seedlings from putting down roots and growing.

The body’s immune system is pretty darn good at doing this, using things like natural killer cells or NKCs, which are kind of like the body’s Swiffer to constantly keep wiping up and suppressing tumor cells.

But what if the NKCs aren’t working so well? The very act of surgery triggers a huge stress response in the body which significantly weakens the ability of the immune system to function. Therefore, all those seedlings and micrometastases have a better chance of taking root or growing. And to make matters worse, anesthesia also weakens the NKCs as do some of the narcotics that are commonly used after surgery to control pain. That the very acts of anesthesia and surgery interfere with the body’s cancer-fighting ability have been known for a long time. There have been hundreds of papers written about the subject.

What You Can Do When You’re in for a Pound: Anesthesia Matters

There is something that can be done to help you get safely through this vulnerable period. And the answer again lies in a careful talk with your anesthesiologist and surgeon.

There are many laboratory studies and clinical studies that clearly demonstrate that the type of anesthesia matters. In those cases in which an epidural can be placed for surgical pain control (the same type of epidural that laboring mothers use), much of the stress response of surgery can be eliminated.

I’ve done hundreds of anesthetics for patients with major surgeries like colon removal and if the epidural is placed and dosed ahead of time, these patients really have no pain. They wake up on a dime smiling. The type of anesthesia can often blunt the detrimental effects of the surgery itself on the NKCs.

But there are still other issues: anesthetic gases are also known to decrease NKC function; moreover, powerful narcotics (such as morphine, which is commonly used during and after surgery) are other culprits.

Fortunately, there are equally effective anesthetic techniques that don’t use anesthetic gases such as a technique called Total Intravenous Anesthesia or TIVA. And more and more anesthesiologists and surgeons are getting on the “let’s minimize the use of narcotics” bandwagon.

Choose Anti-Cancer Anesthesia

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So the most important thing to remember is that our scientific understanding of how cancer spreads as well as many clinical studies all suggest (but do not conclusively prove) that the best anesthetic technique for cancer surgery is one that avoids anesthetic “ether-like” gases, minimizes narcotic use, and when possible places an epidural or other block before surgery to minimize the stress response to surgery and reduce narcotic requirements during and after surgery.

Since this “anti-cancer” type of anesthesia technique can be administered just as easily and safely as the older techniques which incorporate the liberal use of anesthetic gases and narcotics, why wouldn’t you use it? Even if your anesthesiologist or surgeon argues that there is no conclusive proof that “anti-cancer” anesthesia techniques really help, there are plenty of studies suggesting they do. The science strongly backs up the idea and modern anti-cancer anesthetic protocols are just as safe as the old-fashioned way.