The Role of the Acute Care Surgeon in Caring for Patients with Cancer

Cancer remains the second leading cause of death in the US after heart disease.¹ However, patients with cancer have recently benefited from advancements in both diagnostic tools and therapies, which often extend both disease-free and overall survival. As a result, patients with solid and hematologic malignancies are living longer.

During the course of treatment or survivorship, oncology patients may require general surgical consultation for conditions that arise independent of their malignancy or as a consequence of their disease or therapy. In addition, general surgeons frequently are consulted for tissue diagnosis of suspected malignancies, vascular access, and long-term complications of oncologic surgery. Management of acute general surgery issues in this setting is challenging and often requires complex decision-making, which accounts for patients’ oncologic therapy and prognosis, as well as their surgical condition.

Concerns that are unique to cancer patients include neutropenia, concurrent systemic therapy, concerns about metastatic disease, and overall prognosis that further complicate the management of acute general surgical conditions.^2,3

Gallbladder Disease Secondary to Cancer Care

Approximately 10%−15% of adults in the US will develop gallstones, and 1%−4% will develop symptoms.⁴ In addition to the normal risk factors for acute cholecystitis, cancer patients may develop the condition because of biliary stasis secondary to liver metastases, malnutrition or rapid weight loss, and overall impaired immunity.

In a Danish population-based study, the relative risk for cholecystitis among patients with cancer compared with the general population was 1.38 (95% confidence interval, 1.20–1.58), with the highest risk of cholecystitis in the first 6 months after initial cancer diagnosis. In addition, the risk of cholecystitis was highest in cancer patients younger than 70 years of age and in patients with newly diagnosed pancreatic and colorectal cancers.⁵ Several meta-analyses and randomized trials have recommended early cholecystectomy in low-risk cancer patients.⁶ General surgeons not only provide expertise in these cases, but also offer continuity of care in patients who require percutaneous cholecystostomy tube placement and participate in decision-making about the need for interval cholecystectomy in the context of planned future therapies.⁷

Vascular Access

Adequate vascular access is extremely important in the care of oncology patients during the initial phase of surgical treatment and chemotherapy, as well as in the long-term management of advanced cancer.⁸ Integrating general surgeons in vascular access procedures can allow for more timely initiation of systemic therapy and improved patient satisfaction by minimizing delays in treatment initiation or disruptions in therapy. When deciding on a location for vascular access, the site of malignancy and anticipated operative and radiation fields should be considered and, when possible, avoided.

Biopsy

For a new cancer diagnosis or evaluation for recurrence, biopsies are typically needed for tissue diagnosis and subsequent treatment planning. Malignancy is identified in 4% of patients older than age 40 who present with unexplained lymphadenopathy versus 0.4% of patients younger than 40 years old.⁹ In some cases, the history, physical exam, and imaging will identify the underlying etiology; however, biopsy still is necessary in most patients.

Although fine-needle aspiration and percutaneous image-guided biopsy have more than 85% sensitivity, general surgeons often are consulted for open excisional or incisional biopsies.^10,11 These procedures provide a diagnostic option in patients who have inadequate tissue sampling with a percutaneous approach or who have lymph nodes inaccessible by less invasive techniques.

Other Examples

Other general surgery needs in the oncologic population may include:

• Management of the spleen in hematologic disorders and malignancy
• Peritoneal dialysis catheter placement in patients who develop chronic renal insufficiency secondary to oncologic treatment
• Feeding tube placement
• Assistance with intra-abdominal internalization of ventriculoperitoneal shunts in patients with a hostile abdomen

Communication and coordination of care among general surgeons and the multidisciplinary oncology team is critical to ensure that active issues can be addressed effectively, while also considering the patient’s prognosis, current treatment, and future therapeutic options.

As survival improves for many cancers, the focus of patient care should also include quality of life. Ventral incisional hernias after laparotomy can cause pain and a poor cosmetic appearance, thereby reducing quality of life in cancer survivors. In the general population, 3%−20% of patients who undergo laparotomy develop ventral incisional hernias.¹² The hernia rate increases to more than 40% in patients who undergo abdominal operations for cancer and more than 50% for patients who specifically undergo hepatic resection, pancreatectomy, laparoscopic or open colectomy, and esophagectomy.¹³ General surgeons are often consulted for their expertise in incisional, parastomal, and inguinal hernias during the survivorship period and can offer patients a significant improvement in quality of life in many cases.

Summary

Acute care general surgeons play a unique role in the surgical oncology population by providing a patient-centered and efficient approach to comprehensive cancer care. General surgeons offer continuity of care for nononcologic surgical diseases and provide specific expertise on general surgery conditions, which may help provide safe and effective care for cancer patients. Moreover, general surgeons can help reduce wait times for nononcologic surgical issues such as vascular access.

References

1. American Cancer Society. Cancer Facts & Figures 2018. Available at: https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2018.html. Accessed December 16, 2021.
2. Gorschlüter M, Mey U, Strehl J, et al. Cholecystitis in neutropenic patients: Retrospective study and systematic review. Leuk Res. 2006;30(5):521-528.
3. Jayakrishnan TT, Groeschl RT, George B, Thomas JP, Clark Gamblin T, Turaga KK. Review of the impact of antineoplastic therapies on the risk for cholelithiasis and acute cholecystitis. Ann Surg Oncol. 2014;21(1):240-247.
4. Sanders G, Kingsnorth AN. Gallstones. BMJ. 2007;335(7614):295-299.
5. Thomsen RW, Thomsen HF, Nørgaard M, et al. Risk of cholecystitis in patients with cancer: A population-based cohort study in Denmark. Cancer. 2008;113(12):3410-3419.
6. Rodríguez-Sanjuán JC, Arruabarrena A, Sánchez-Moreno L, González-Sánchez F, Herrera LA, Gómez-Fleitas M. Acute cholecystitis in high surgical risk patients: Percutaneous cholecystostomy or emergency cholecystectomy? Am J Surg. 2012;204(1):54-59.
7. Chung YH, Choi ER, Kim KM, et al. Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis? J Clin Gastroenterol. 2012;46(3):216-219.
8. Gallieni M, Pittiruti M, Biffi R. Vascular access in oncology patients. CA Cancer J Clin. 2008;58(6):323-346.
9. Fijten GH, Blijham GH. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians’ workup. J Fam Pract. 1988;27(4):373-376.
10. Lioe TF, Elliott H, Allen DC, Spence RA. The role of fine needle aspiration cytology (FNAC) in the investigation of superficial lymphadenopathy; uses and limitations of the technique. Cytopathology. 1999;10(5):291-297.
11. Steel BL, Schwartz MR, Ramzy I. Fine needle aspiration biopsy in the diagnosis of lymphadenopathy in 1,103 patients. Role, limitations and analysis of diagnostic pitfalls. Acta Cytol. 1995;39(1):76-81.
12. Itatsu K, Yokoyama Y, Sugawara G, et al. Incidence of and risk factors for incisional hernia after abdominal surgery. Br J Surg. 2014;101(11):1439-1447.
13. Baucom RB, Ousley J, Beveridge GB, et al. Cancer survivorship: Defining the incidence of incisional hernia after resection for intra-abdominal malignancy. Ann Surg Oncol. 2016;23(Suppl 5):764-771.