Onco-Anesthesiologist : A Silent Companion in Cancer Care

‘Cancer is a disease in which some of the cells become abnormal, grow uncontrollably and spread to other parts of the body through the blood and lymph systems.’ (National Cancer Institute, USA)

Cancer is the second leading cause of death globally, accounting for one in six deaths, with an estimated 9.6 million deaths in 2018. In India, one in nine persons is likely to develop cancer in his / her lifetime.

Some have equated cancer with ‘WAR’ while others call it ‘A JOURNEY’.

On Dec 23, 1971, US President Richard Nixon signed The National Cancer Act and declared ‘A WAR AGAINST CANCER’. He authorized huge federal funding for research and development of more effective treatment of cancer. Half a century later, cancer continues to inflict injury, cause pain, agony and death. The war is still ON and gaps in cancer care still persist.

If cancer is a journey, it’s a tedious long journey on a bumpy road with uncertainties of destination. The journey is often painful, with anxiety and fear.

Be it a WAR or a JOURNEY, the patient needs support from someone to help ‘heal the injuries inflicted ‘ or ‘smoothen the bumpy ride’.

Oncology ‑ a branch of medicine, that deals with the study, diagnosis, treatment, and prevention of cancer. Anesthesiologists are specialists who have specialized training in providing anesthesia to patients for operations and procedures. Anesthetic management of cancer patients can affect the quality and outcome of treatment. With rising incidence of cancer, and better understanding, onco‑anesthesiology has emerged as a separate superspecialty to cater to complex unmet needs of cancer patients, and make it safer and pain‑free.

It’s pertinent to note that from detection of cancer to discharge or death an Onco Anesthesiologist is a ‘Silent Companion’ in the journey of cancer. (Figure꞉ 1)
Journey of Cancer:

Cancer often starts as a symptom depending upon its site ‑ it could be fever or unrelieved pain, lump, ulceration, prolonged cough, unexplained bleeding (vaginal or rectal), jaundice or seizures. Symptoms could be non‑specific like weight loss, easy fatigability or an incidental finding following a routine medical check.

The journey of cancer starts with suspicion of cancer which needs to be confirmed.

Cancer is a tissue diagnosis. A tissue from the suspected part needs to be procured, processed, and examined by a trained pathologist, who finally gives his ‘verdict’꞉ ” Cancer Hai / Cancer ho sakta hai / Cancer Nahin hai” (It’s cancer / Suspicion of cancer / No cancer). Procuring body tissue is an invasive procedure. It could be drawing out the sample from the diseased part with a needle or taking a biopsy with small surgery, “IT’S PAINFUL”. The degree of pain varies from minimal to severe depending upon the site and procedure.

If the tissue is reported as cancer, further steps fall in line꞉ is it localized or spread to other organs? This enables one to choose from available treatment options ‑ surgery, radiotherapy, chemotherapy, or a combination.

Pre‑operatively, an onco‑anesthesiologist ensures optimization for best possible outcome post‑operatively. During surgery, the anesthesiologist makes arrangements for safety and comfort of the patient by monitoring and maintaining the hemodynamic parameters (heart rate, blood pressure), respiration, and pain relief. For smooth recovery and comfortable post‑operative period, the onco‑anesthesiologist provides relief from pain, nausea and vomiting.

An onco‑anesthesiologist must be well‑versed with modalities of chemotherapy, radiotherapy and immunotherapy along with anticipated complications and adverse effects so as to efficiently manage the perioperative phase.

If chemotherapy is planned, one needs to have a route for anti‑cancer drug administration directly into the blood on multiple occasions, spreading over weeks. The patient is often very anxious and apprehensive as his cancer diagnosis is recent and often unexpected. Delivery of chemotherapy requires insertion of a wide bore peripherally inserted central catheter (PICC) line into a large blood vessel or a chemoport into heart chamber. Both of these are invasive procedure and painful. An onco‑anesthesiologist provides sedation and ensures that it’s a pain‑free insertion.

Radiotherapy is yet another modality of cancer treatment wherein radiation is used to kill the cancer cells in the diseased organ. It could be deep in the cervix, or in the oral cavity. The exposure to the radiotherapy beam has to be precise, and confined to the affected organ so as to avoid damage to the healthy tissue. Accessing the site for radiotherapy involves a painful probe and needle insertion. An onco‑anesthesiologist enables safe pain‑free insertion of the devices by providing a quiet, calm, and still patient. In the case of a child, where maintaining a still patient is a challenge every sitting of radiotherapy requires anesthesia.

If cancer is widespread to various organs, intractable pain is a common complaint. In desperate situations, what patient looks forward to is not cancer cure but immediate pain relief. Using his expertise the anesthesiologist provides relief using regional anesthesia techniques ‑ nerve blocks, plexus blocks, or by continuous infusion of pain relieving agents (narcotics, non ‑ narcotics or a combination). A patient requiring prolonged hospital admission for intractable pain can be discharged early following these interventions, thereby, reducing the length of hospital stay and the cost.

When a cancer patient becomes critical by progress of cancer, or lifethreatening side effects of chemotherapy/radiotherapy, or super‑added infections due to immune suppression, the patient requires admission in the ICU. It is the anesthesiologist, who manages the ICU and tries hard to pull the cancer patient out of the crisis.

For the unfortunate ones death becomes imminent despite the best of efforts. The patient has a desire to be at home with his family. “I would prefer to die at home rather than in a hospital.” An onco‑anesthesiologist and his team of palliative care play a major role in fulfilling such wishes and is involved in home care.

Besides pain and death, the recurrence of cancer is yet another common fear in patients and their family. Newer anesthesia techniques (use of regional anesthesia) are reported to reduce the chances of cancer recurrence.

There is clear evidence to vouch for the improved outcome of patients treated in a specialized oncological center by an efficient team comprising the surgeon and anesthesiologist as a perioperative physician. Thus, an onco‑anesthesiologist is a silent companion of a cancer patient right from the detection of cancer to discharge or a comfortable death.

Cancer now is a major health problem in India. Anesthesia for cancer surgery is a specialized field, and onco‑anesthesiology has emerged as a new specialty. Unfortunately, in India with such a huge burden of cancer, there is a scarcity of trained onco‑anesthesiologists. There is an urgent need to bridge this gap by bringing up increasing onco‑anesthesia training facilities. Leading cancer institutes are conducting training programs in onco‑anesthesia ranging from 1 year fellowship program (TMC Mumbai, TMC Kolkata, RGCIRC, Delhi) to 3 years DM programs (Dr. BRA‑IRCH at AIIMS, New Delhi, AIIMS, Rishikesh). The National Board of Examinations of Medical Sciences has recently commenced 2 year Fellowship course in onco‑anesthesiology.

We are optimistic that in the near future India will have an adequate number of trained onco‑anesthesiologists ‑ the silent companion of every cancer patient.

Dr. Rajiv Chawla
Director – Anesthesiology
Rajiv Gandhi Cancer Institute and Research Centre, Delhi