Cancer Immunotherapies: What the Perioperative Physician Needs to Know

Abstract

Purpose of ReviewFor patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents. Recent Findings The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immunerelated adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth. Summary Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.

Mistletoe Extracts during the Oncological Perioperative Period: A Systematic Review and Meta-Analysis of Human Randomized Controlled Trials

“…Furthermore, all the steps of this SR were duplicated to ensure accuracy. In addition, the inclusion of the non-randomized trials for safety data and information regarding the application of MEs in cancer patients during the perioperative period strengthened the review [ 98 , 99 ]. The main limitation of the methodology was in excluding non-English reports and not searching Asian databases, which introduced a language bias.…”

“…The perioperative period in cancer patients is challenging as it usually includes major surgeries, stressful and lengthy preparations, hospital admission, and prolonged recovery [ 98 ]. Surgically induced stress, the resultant inflammatory response, and a weakened immune response might promote angiogenesis, tumor shedding and metastasis, and proliferation of tumor growth factors [ 100 ].…”

Perioperative Assessment and Optimization in Major Colorectal Surgery: Medication Management

“…These medications can cause cardiopulmonary toxicity; however, routine preoperative assessment is adequate to identify patients at risk for adverse perioperative events. 22 Monoclonal Antibodies (Bevacizumab, Cetuximab, Panitumumab)…”

“…Therefore, electrolytes should be aggressively repleted prior to administration of anesthesia. 22 The current recommendation is to postpone elective surgery for at least 4 weeks after administration of any of these agents. In the setting of emergency abdominal surgery and bevacizumab use, anastomoses should be deferred, and ostomy creation is favored.…”

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“…A common immunotherapeutic approach employs monoclonal antibodies (mAbs), which specifically bind to targets on tumor cells or stroma cells in the tumor microenvironment. Their binding can induce tumor lysis through different mechanisms, including a ligand or receptor blockade and the activation of host immunity [ 90 , 91 ]. Such mAbs can also be conjugated to a cytotoxic compound, such as chemotherapeutic agents, and some mAbs can simultaneously bind more than one target (known as bispecific antibodies) [ 90 , 91 ].…”