The severity of underlying illnesses and co-morbid conditions needs to be considered during the pre-surgical workup. An individuals' cardiac, pulmonary, haematologic and nutritional status have been implicated in post-operative morbidity.25 The pre-operative evaluation of people with cancer should include an assessment of:25
Nutritional intake can be impaired by pain, nausea, stomatitis, or tumours involving the oropharynx or gastrointestinal tract, and metabolic aberrations may cause anorexia and weight loss. If time permits, malnourished individuals could be treated with parenteral or enteral nutrition before major head and neck surgery.
A general prognostic indicator for surgical outcome and mortality.
Individuals need an opportunity to verbalize fears and discuss their previous experiences with surgery. Providing information on current approaches to symptom management may assist in allaying fears or concerns.
Some individuals are not surgical candidates or face higher peri-and post-operative risks due to underlying cardiac or pulmonary disorders.
There is evidence to suggest that cessation of smoking before surgery can positively impact the individual's cardiac and pulmonary function in the peri-operative period.
General medical issues
All individuals with cancer should be screened with pre-operative serum blood urea nitrogen (BUN), creatinine, sodium, calcium and full blood count. Individuals who are myelosuppressed as a result of chemotherapy or haematologic malignancy are at an increased risk of infection and bleeding, and whenever possible, surgery should be postponed.
Psychosocial, cognitive and educational needs
The psychological impact of surgery may be intensified with the added stress of a cancer diagnosis and the individual's perception of the meaning of cancer. In the pre-operative period, psychological preparation has been linked to shortened hospital stay and a decreased need for analgesia.26 The MDT shares responsibility for pre-operative teaching, including surgeons, anaesthesiologist, pain management teams, pharmacists, social workers and nurses. Referrals to Allied Health Services should be considered at this time.
Decision making processes undertaken by older people with cancer is complex and requires careful assessment of physiological changes related to age, comorbidities and nutritional and functional status. A thorough and detailed assessment enables individualised treatment decisions to be made and development of a relevant education plan.27 Further information on treatment decision making may be found in the module Part 1: Cancer treatment planning.
Access the website Risk prediction in surgery28 and calculate an individual's operative risk. Outline the limitations and benefits of risk prediction tools.
- summarise the anatomic and physiologic effects of cancer chemotherapy which have implications for the peri-operative management of the person affected by cancer.
- appraise the capacity of the pre-operative assessment tool at your facility to effectively assess the person affected by cancer who has received neoadjuvant chemotherapy.
Access the article Tools for assessing elderly cancer patients32 , and discuss how the geriatric assessment tool may facilitate pre-operative assessment of elderly people affected by cancer.
Site specific assessment
Some site specific considerations need to be taken into account before surgery.
Surgery for cancers that occur within the pelvis can significantly affect fertility, either by resection of the reproductive organs or as a result of damage to the autonomic nervous system or vascular changes. Fertility preservation is greatly important to many people diagnosed with cancer. An increased risk of emotional distress has been identified in those who become infertile as a result of treatment.33
With careful assessment and planning, fertility preservation is often possible in people undergoing surgery for cancer. Timely referral to a fertility specialist is important. Early communication about potential threats to fertility is recommended to allow for the widest array of options for fertility preservation. Sperm, oocyte, and embryo cryopreservation are standard practice and widely available.34
Surgery for colorectal cancer may require a stoma and represent a group with special needs. A stomal therapist should see the person before surgery to provide reassurance and information about the stoma/ostomy, its function and care. The stomal therapist can assist the surgeon to identify the best location for the stoma to ensure it can be easily self-managed and away from where clothes and body folds sit.35
Discuss the aspects of an individual's pre-operative assessment which would indicate the need for a referral for fertility preservation.
Identify the sperm and embryo preservation measures available in your health care facility for people affected by cancer before surgery.
Describe the referral processes and procedures the person may experience during sperm and embryo preservation.
Discuss the aspects of an individual's pre-operative assessment which would indicate the need for referral to a stomal therapist.