PERRR (an idea help reduce recurrence)

Fallleaves

Since my mother-in-law had surgery for DCIS last August I've been doing a lot of research into the effects of anesthesia on cancer recurrence. In July, Sas-schatzi started a thread on ketorolac, an NSAID that was shown to drastically reduce short term recurrence in BC patients who took it preoperatively (https://community.breastcancer.org/forum/73/topics... ). 123JustMe also started a thread on NSAIDS and cancer, particularly aspirin ( https://community.breastcancer.org/forum/73/topics... )

I've created threads on paravertebral nerve blocks and propofol (https://community.breastcancer.org/forum/73/topics...) , both of which may help reduce recurrence when used in BC surgery, on opioids (https://community.breastcancer.org/forum/73/topics...), which in some studies have been shown to cause cancer progression, and a thread looking at review articles on how anesthesia affects recurrence (https://community.breastcancer.org/forum/73/topics... ). I also found studies about local anesthesia such as lidocaine and bupivacaine reducing postsurgical pain and the need for opioids (though I haven't created a thread for that yet!).

To summarize what I've learned, surgery creates a lot of stress on the body. It may actually promote metastasis through the unavoidable release of cancer cells into circulation, and production of factors that suppress immunity, increase resistance to apoptosis, and promote angiogenesis. Anesthesia can cause additional suppression of the immune system and enhance tumor development, increasing the likelihood of recurrence, or it can ameliorate the effects of surgery and reduce the chance of recurrence.

In short, inhaled anesthetics and opioids should be avoided because of their immunosuppressive effects. Opioids have also been implicated in increasing angiogenesis. Total intravenous anesthesia (TIVA) with propofol (which may reduce postoperative nausea) seems to suppress the inflammatory response to surgery. COX-2 inhibitors and NSAIDS, in particular preoperative ketorolac, could also reduce recurrence due to their anti-inflammatory properties, and their reduction of the need for opioids. Paravertebral nerve block (frequently with propofol) may be particularly valuable in reducing inflammatory cascades and preserving immune function, and reducing recurrence. It also provides better pain control than general anesthesia, reducing the need for opioids post surgery. Local anesthetics such as lidocaine and bupivicaine have been shown to cause apoptosis in breast cancer cells, and both surgical use of lidocaine and liposomal bupivacaine can provide good postsurgical analgesia and reduce the need for opioids. Preoperative gabapentin and pregabalin are effective in reducing postoperative pain and opioid use, and are preventive for chronic post surgical pain, and tramadol is a good analgesic choice as it enhances the immune system.

During my research I also became aware of the concept of Enhanced Recovery After Surgery pathways (ERAS) or Enhanced Recovery Pathways (ERP). The first ERAS pathway was created by a Danish surgeon in 1997 to enhance recovery in colorectal surgery patients. The goal was to reduce physiological stress on patients, to speed their recovery. Since then, many surgical departments (particularly in the U.K.) have developed such pathways, most commonly for colorectal surgery. But the Mayo Clinic developed one for breast reconstruction surgery (http://newsnetwork.mayoclinic.org/discussion/new-a...). The main elements of that pathway are using preoperative analgesics to prevent pain (typically celecoxib, gabapentin, or acetaminophen), prevention of nausea and vomiting, use of NSAIDS, avoidance of opioids, allowing patients clear fluids up to two hours before surgery, and resumption of food and walking soon after surgery, among other things. A study of 100 patients found that use of these methods significantly reduced the length of stay for patients, and reduced use of opioids by 71%. (http://www.ncbi.nlm.nih.gov/pubmed/25488326)

My thought is, why not take ERP's one step further and make anesthetic choices that not only enhance patients' short term recovery, but could also reduce their chance of recurrence down the road? How about a Pathway to Enhanced Recovery and Recurrence Reduction (PERRR, credit my cats with that acronym, lol) Use all of the strategies to reduce the negative impacts of surgery on patients so they can recover more quickly, but also choose anesthetics with the goal of preventing recurrence. We are talking about a wide range of drugs and techniques that have ALL been tested, approved, and are in wide use. Why not favor those that do not promote the growth of cancer and that might actually inhibit it? Clearly anesthetics need to be tailored to each patient, but the impact on cancer recurrence should be a factor in the equation.

I'd love to hear any feedback anyone might have on this. Since most of us with BC end up having surgery, anesthesia has wide impact. I'm NOT an expert on anesthesia, but I think we should use every tool at our disposal to fight cancer!

JohnSmith

Probably need large RCT's to validate everything you wrote. not sure. The wife had the Michael Jackson drug, propofol.

MelissaDallas

There are so many variables to take into consideration. Example, I must be a rapid metabolizer because I don't get the amnesic effect of Versed. I had a lot of conscious sedation procedures in a few months, including transjugular liver biopsy, IVC filter insertion & removal & colonoscopy. I can quote the conversations in the procedure rooms and I watched my colonoscopy on the screen & it hurt. I suspect most people justdon't remember the discomfort.

Also, the anesthesiologist wanted to use a spinal block before my debulking surgery but couldn't because I had had to be started on blood thinners because of a PE shortly before surgery. They stopped it just long enough to get me operated.

Fallleaves

MelissaDallas, you're right, there are a lot of variables in anesthesia. And of course each patient is different. I just think having a protocol in place where every drug has been thoroughly researched specifically for it's effects on cancer, good and bad, ahead of time, would be helpful. Then of course, immediate needs would outweigh possible long term repercussions. For example, blood transfusions increase risk of recurrence, but if you need one, you need one.

Interesting that you could remember everything despite having Versed. I actually asked NOT to have it, but couldn't remember anything, anyway. Ouch on the colonoscopy! I wouldn't want to remember that either!