Noble Sprayberry

Removing the stage 1 tumor on Kathy Leiser’s lung required only three small incisions in a minimally invasive laparoscopic procedure, one of a range of tools and techniques capable of limiting postoperative complications.

Still, soreness remained nearly nine months after the surgery at Vanderbilt-Ingram Cancer Center in Nashville, Tenn., says Leiser, 63. “Recently, I saw my pulmonologist, and he said it might take as long as a year for everything to heal up,” she says. “It was laparoscopic, but they still went between my ribs.”

Risk of complications exists even with the least invasive surgeries, and efforts to limit postoperative problems begin in the days before surgery, continue during each procedure and extend into each patient’s recovery.

Determining the appropriate type of surgery by balancing risks against potential benefits is a key early step in limiting problems, says Eric Grogan, MD, the thoracic surgeon who treated Leiser.

For example, traditional open surgery generally requires an incision large enough to provide a surgeon direct visual and physical access to a tumor or treatment area.

“The larger the tumor is, and the more invasive the operation is, certainly the more complications that may arise,” Grogan says. “If one can ensure that it’s the correct cancer operation with a less invasive approach, it’s logical the less invasive approach should be chosen.”

Minimally invasive surgeries use tools such as a laparoscope, a telescoping camera system inserted via a small incision. But, there are several forms of these procedures, many with benefits for cancer surgeries. In lung surgery, for example, video-assisted thoracoscopic surgery (VATS) uses a scope to send a small video camera into the patient’s body, while surgical instruments enter through separate incisions. “It uses the camera to assist the lung resection, so you don’t have to crack or spread the ribs,” Grogan says. “Everything should be the same oncologically as a traditional open surgery, but there’s less pain.”

The larger the tumor is, and the more invasive the operation is, certainly the more complications that may arise.

Other forms of minimally invasive surgery include robotic surgery, which relies on a computer or a remote manipulator to guide and control the endoscope and other instruments. Single-incision operations allow surgeons to visualize and work through a lone opening instead of multiple openings. Natural orifice translumenal endoscopic surgery (NOTES) inserts a flexible endoscope into an opening, such as the mouth, and allows instruments to go through that scope to perform procedures.

As attractive as these approaches may be, there is still limited information as to whether patients actually have better outcomes compared with standard surgery. And there may be some disadvantages, as well: The surgeon may not have the same field of vision to properly control a complication, such as excessive bleeding, and may not have the same ability to feel the tissue and avoid structures, such as nerves.

“Minimally invasive procedures now represent about half of all cancer surgeries we do,” Grogan says. “Ten years ago, 95 percent would have been traditional open surgeries. The minimally invasive approaches have changed the risks-benefits ratio a bit because it has slightly reduced the risk of the operation.”

Laparoscopic surgery also represents one of the biggest innovations to prevent surgical scarring in the past 20 years, and it limits a range of other postoperative complications, says Christopher Mantyh, MD, chief of gastrointestinal and colorectal surgery at Duke University Medical Center in Durham, N.C.

“The idea is that you limit the incision length, so you can use very small instruments, and the amount of scar is reduced,” he says. “It has been shown that laparoscopic surgery has a lower site infection rate, a lower post-op hernia rate and improved patient satisfaction.”

While new surgical techniques can improve the odds of limiting postoperative complications, inherent risks exist with any procedure. For many cancer patients who undergo surgery, whether minimally invasive or traditional open, formation of blood clots pose one of the most serious potential problems.

“This is for liver cancer, colon cancers, gastric cancers and across the board,” Mantyh says. “The reason is that these are big operations that last a long time. People with cancer, their blood clots a little more readily than people without cancer.”

The complication, venous thromboembolism, can include deep vein thrombosis (a blood clot in a deep vein, usually in the legs) or pulmonary embolism (a blockage of one or more arteries in the lung). “That is something that hopefully doesn’t happen often, but when it does happen, it can be fatal,” Mantyh says.

A 2012 study considered the instances of venous thromboembolism in 43,808 operations across 11 types of cancer surgeries, including breast resection, prostatectomy, lung resection and cystectomy (removal of the bladder). The results varied somewhat—from 1 in 357 to 1 in 14 among patients with different cancers&mdash;and researchers stated that data suggests both tumor type and resection magnitude impacted a patient’s risk.

Limiting the risk of clots is a priority. For example, Mantyh says one approach, and one he uses, relies on administering heparin, which prevents blood from clotting. “We continue the drug after surgery, once the patient goes home,” he says, “and we may give it to them for up to two weeks.”

Possible postoperative complications extend beyond blood clots, yet tracking those complications can be difficult for many hospitals, according to the American College of Surgeons, which is why the organization created the National Surgical Quality Improvement Program (NSQIP). “This is a program that’s growing by leaps and bounds,” Mantyh says. “It gives you a snapshot of how your hospital is doing, and it gives a national snapshot every six months.”

Hospitals also have a financial incentive to participate and improve performance. In the case of problems considered preventable by the hospital—one example is infection of surgical sites&mdash;insurance programs, such as Medicare, increasingly refuse to reimburse for the treatment.

It has been shown that laparoscopic surgery has a lower site infection rate, a lower post-op hernia rate and improved patient satisfaction.

Unlike previous efforts, which might consider whether a hospital followed recommended procedures, NSQIP focuses on distinct complications, Mantyh says. “It’s a very powerful tool, and you can drill down to specific types of surgery or even to a specific surgeon.” Often a comprehensive strategy, not one technique, is necessary to eliminate possible complications from cancer surgery. For example, the prevention of surgical site infections will not change by one measure, Mantyh says. Instead, surgeons must consider a multifaceted approach, including antibiotics, the careful monitoring of glucose (blood sugar) levels and the controlled warming of a patient’s body after surgery to promote infection-free healing.

Similarly, a procedure requiring anesthesia brings the possibility of pneumonia or extended periods with a patient having to use a ventilator. “In the bad old days, without new techniques, you’d give patients five or six liters of fluid, and that fluid could leak into the lungs and cause pulmonary edema,” he says.

Now, a system known as goal-directed therapy allows the anesthesiologist to carefully monitor heart function to determine the proper amount of fluids a patient receives during surgery, lessening the chance of complications, Mantyh says.

Even the type of surgery can have unique requirements. When operating to treat rectal cancer, a surgeon must take care to spare specific nerves, guarding against the possibility of inhibiting bladder or sexual function, Mantyh says.

For patients with lung cancer, such as Leiser (whose cancer was discovered when she volunteered for a Vanderbilt-Ingram Cancer Center study to evaluate lung cancer screening techniques), potential benefits outweighed any worry about postoperative complications.

Debilitating pain and nausea from medication to control the discomfort made her recovery a challenge, even though she had minimally invasive surgery with no other significant complications.

“The surgery had to be done,” she says. “If they had told me before surgery that I was going to be in pain for two months afterward, it wouldn’t have mattered.”

Articles

New surgical techniques can limit the risk of postoperative complications in patients with cancer.

New Surgical Techniques Are Cutting Edge

How someone prepares in the days before an operation, both physically and mentally, can shape outcomes.

Just a few weeks of regular walking can make a difference, says thoracic surgeon Eric Grogan, MD, of the Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

With a greater physical capacity, a patient increases the odds ofrecovery from surgical complications. "If I do a lung resection andsomeone gets pneumonia afterwards, they may have problems gettingthrough that if they don't have a lot of reserve," Grogan says.

And most important, smokers should kick the habit before surgery."It's not important for just lung function," says ChristopherMantyh, MD, chief of gastrointestinal and colorectal surgery forDuke University Medical Center in Durham, N.C. "Smoking cancause small vessels to constrict, which can hinder wound healingand possibly lead to higher rates of surgical site infections. Smokingis huge—a big, big deal."

Also, nutrition and weight play into surgical success and recovery.Focusing on improved nutrition can help some patients strugglingwith nausea or diarrhea associated with chemotherapy, Mantyh says."The stress of surgery will really take a lot of effort metabolically torecover," he says.

Conversely, obese patients have other challenges. For example,high glucose levels associated with diabetes can slow wound healing,Mantyh says.

While a patient can take steps to prepare physically, other typesof preparation also matter. Mantyh says patients at his hospital oftenreceive nutritional counseling and informative literature.

Helping patients, particularly those coping with the stress of cancer,to understand the scope of a surgery and the steps needed forrecovery, often receives short shrift, Mantyh says.

Building that understanding, however, is vitally important, Mantyhsays. "I think patient education, their understanding of what goeson during an operation and what their expectations are after surgeryare really, really important. So much so, I think it [influences] theiroutcome."

How someone prepares in the days before a cancer operation, both physically and mentally, can shape outcomes.

Preparing for Surgery

Artificial sweeteners promise the taste of sugar without the calories, a trade-off leaving some medical professionals and scientists cautious and others confident in the safety of sugar substitutes.

Weighing the risks and benefits is of growing importance since 86 percent of Americans use low-calorie, reduced-sugar or sugar-free foods and beverages, according to a 2007 survey by the Calorie Control Council.

Concerns, in part, focus on possible connections between artificial sweeteners and cancer. The 

history of saccharin—used first in foods in 1900&mdash;offers an example. In the 1970s, research on rats linked the sugar substitute to urinary bladder cancer, but later studies indicated the risk was limited to rats.

Similarly, the Food and Drug Administration regulates artificial sweeteners, and no studies have found clear evidence tying FDA-approved sweeteners to cancer. The FDA has approved five sugar substitutes: saccharin, aspartame, acesulfame potassium, sucralose and neotame. Rebaudioside A, a purified component of the stevia plant, received a GRAS notice, marking it “Generally Recognized As Safe.”

However, research continues. A 2007 study conducted on rodents points to possible links between aspartame and cancer, including lymphomas and leukemias. Other studies support aspartame’s safety.

For the average consumer, unraveling all of the sometimes conflicting science is difficult, says Linda A. McCauley, dean of Emory University’s Nell Hodgson Woodruff School of Nursing, who co-authored a study evaluating artificial sweeteners.

There are no clear guidelines for evaluating the risks. And most consumers would be shocked by the limited research done before products like sweeteners appear on store shelves, McCauley says. 

Information is often limited because many studies are funded by companies developing the products, and the information is not released to the public, she says. “It’s not exhaustive testing,” she adds. “It’s very select testing, and it only studies the amount that would be a safe dose and not cause acute toxicity in humans.”

When used in moderation, however, sweeteners are likely OK for most people, McCauley says. “We go through our lives making decisions about the level of risk we expose ourselves to—including smoking, artificial sweeteners and using cell phones,” she says. 

With fears about artificial sweeteners often ramping up online, consumers should take a step back, says D. Milton Stokes, MPH, RD, a private-practice nutritionist in Connecticut.

“Despite the urban legends and despite the chain emails that won’t go wherever emails should go to die, I have not seen systematic evidence confirming that non-nutritive sweeteners cause health problems,” he says. “In 20 years, we may have a study that shows a cause-and-effect relationship, but we don’t have that data. The only thing we have now is speculation and anecdote, and it really leads to patient confusion.”

Two servings of non-nutritive sweeteners daily is the recommended limit, about two cans of diet soda or two cups of diet yogurt, Stokes says. Also when faced with losing weight, people should look beyond sugar intake. “We want consumers to have a total-diet approach, meaning we want to see some real whole foods in their diets,” he says.

Particularly for patients receiving treatment for cancer, diet needs typically focus on weight maintenance and not weight loss, Stokes says. “That said, I have zero hesitation saying to someone with cancer that they can have a diet soda or a light yogurt, if that’s what they want.”

Despite the urban legends and despite the chain emails that won’t go wherever emails should go to die, I have not seen systematic evidence confirming that non-nutritive sweeteners cause health problems.

Science weighs in on sugar substitutes and its relationship to cancer.

Sweet but Safe?

With chemotherapy, a breast cancer patient faces a risk responsible for not  only eroding her body image but also of heightening the odds of a chronic  disease: weight gain. Breast cancer treatment and weight gain, however, aren’t a  pairing most people make. 

Researchers first noted weight gain in breast cancer patients in 1978 and  subsequent work expanded the understanding of the relationship between diet,  exercise, weight gain and chemotherapy. Weight gain in breast cancer patients  commonly ranges from about 5.5 pounds to about 13.5 pounds.

“Now, with us winning the war on cancer and fewer people diagnosed at later  stages, people have an opportunity to have a different disease course, and being  overweight is associated with a much poorer prognosis,” says Wendy  Demark-Wahnefried, PhD, a registered dietitian and professor at Duke University  Medical Center School of Nursing and Department of Surgery.

Research from the ongoing Women’s Healthy Eating and Living, or WHEL, study  involving 3,088 breast cancer survivors linked weight gain to chemotherapy.  Sixty-five percent of women receiving chemotherapy gained 5 percent or more of  their pre-diagnosis weight, says Nazmus Saquib, MD, PhD, a post-doctoral fellow  involved in the study at Moores UCSD Cancer Center.

Data show women treated with the hormone therapy tamoxifen showed no  treatment-related weight gain, and the type of chemotherapy, either  anthracycline or non-anthracycline didn’t matter, Dr. Saquib says.

Several factors may play into the added weight, but overeating isn’t  considered a cause. A woman often loses lean body mass during treatment, slowing  metabolism and making it harder for her body to burn calories. Also, treatment  can chemically induce premature menopause, a time when women often gain  weight.

And the problem isn’t always the number of pounds added. “Even if [breast  cancer patients] don’t gain weight and their weight stabilizes, treatment will  cause loss of muscle mass. So, they may have more fat and less muscle,”  Demark-Wahnefried says. “They occupy more space and, even if they’re the same  weight, they won’t fit into the same clothes.” In addition to breast cancer,  studies have found a risk of weight gain during treatment for prostate and  ovarian cancers.

Traditionally, exercise for cancer patients focused on the potential of  aerobic exercise to reduce nausea and fatigue, but combining strength training  and aerobic exercise may have more far-reaching results. Aerobic exercise and  strength training, particularly a regimen emphasizing the leg region and  abdomen, may prove particularly useful since research suggests the greatest loss  of lean tissue occurs in these regions.

A membership to a fitness center, however, isn’t necessary, though some gyms  and cancer centers offer exercise programs for cancer patients. “Resistance  training is very important, as is exercise overall,” Demark-Wahnefried says. A  woman can fight obesity by walking briskly for 30 minutes daily for five days a  week, she says.

Diet is also important, although ongoing research still strives to determine  which foods and what proportions of specific foods make the greatest difference.  Most cancer centers have dietitians on staff to help patients choose the right  foods.

Women who eat a low-fat, plant-heavy diet have greater odds of surviving  cancer, Demark-Wahnefried says. But the research itself is inconsistent on  whether eating vegetables reduces breast cancer risk, and studies on the effect  of fruit continue. The Women’s Intervention Nutrition Study tested whether a  low-fat diet after treatment could reduce recurrence and improve survival in  localized breast cancer patients. Final results indicate a decrease in dietary  fat intake may significantly reduce the risk of recurrence among postmenopausal  breast cancer patients.

Final results from the WHEL study are expected in 2008, but for now, the  American Cancer Society recommends an emphasis on a diet heavy in vegetables and  fruits, as well as with low amounts of saturated fats and high in dietary fiber.  

Why breast cancer patients may gain weight during treatment and how to manage it. 

Noble Sprayberry

New Surgical Techniques Are Cutting Edge

Preparing for Surgery

Sweet but Safe?

The Weight Gain Mystery

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