Deciding on surgery
The topic of whether cancer surgery does more harm than good is a valid issue. Surgery can be a curative treatment by itself or with other treatments such as chemotherapy or radiation. However, in addition to promoting a cure and healing, surgery may also create conditions that may increase your risk of metastasis.1Tohme S, Simmons RL, Tsung A. Surgery for cancer: a trigger for metastases. Cancer Research. 2017 Apr 1;77(7):1548-1552.
Even though surgery is a routine treatment for solid tumors, surgery itself can promote the development of metastasis by releasing tumor cells into circulation, suppressing important immune defenses such as your cellular immune system and promoting the development of blood vessels to supply tumors (angiogenesis).2Kim SY, Kim NK et al. Effects of postoperative pain management on immune function after laparoscopic resection of colorectal cancer: a randomized study. Medicine (Baltimore). 2016 Jun 17;95(24):e4641.
Consider taking this handbook with you to discuss with your surgeon.
Inflammation
Inflammation from surgery is another condition that may increase risk of metastasis. Inflammation is a normal response to tissue being cut and is necessary in the process of healing wounds. However, evidence suggests that inflammation related to tissue trauma from surgery can also inhibit your natural immune response against cancer, leading to cancer growth and spread. The type of anesthesia used and other factors can also impact your anticancer immune response. Surgery is somewhat literally a classic “double-edged sword”, with the potential for both good and harm.
Low body temperature during surgery
Mild low body temperature (hypothermia) also worsens the suppression of your immune response from abdominal surgery.3Khanna AK, Perez ER, Laudanski K, Moraska A, Cummings KC. Perioperative care and cancer recurrence: Is there a connection? World Journal of Anesthesiology. 2014;3(1):31-45; Dang Y, Shi X, Xu W, Zuo M. The effect of anesthesia on the immune system in colorectal cancer patients. Canadian Journal of Gastroenterology & Hepatology. 2018 Apr1;2018:7940603. Hypothermia may impair your immune system’s ability to stop infection and kill cancer cells. Maintaining your body temperature during surgery will reduce your risk of immune suppression.
Blood transfusions
Use of blood transfusion products can cause suppression of your immune response and increase your risk of recurrence.4Dang Y, Shi X, Xu W, Zuo M. The effect of anesthesia on the immune system in colorectal cancer patients. Canadian Journal of Gastroenterology & Hepatology. 2018 Apr 1;2018:7940603; Gelman D, Gelmanas A et al. Role of multimodal analgesia in the evolving enhanced recovery after surgery pathways. Medicina. 2018 May; 54(2): 20. Blood transfusion using your own blood (autologous transfusion) may reduce your risk of recurrence, though this is unclear and may not be recommended if you are anemic.5Khanna AK, Perez ER, Laudanski K, Moraska A, Cummings KC. Perioperative care and cancer recurrence: Is there a connection? World Journal of Anesthesiology. 2014;3(1):31-45.
Your stress response
Your stress level and other characteristics around the time of surgery can affect your immune system and may increase your risk of recurrence:
- Some aspects of the surgical stress response can subdue your immune system’s ability to stop infection and kill cancer cells, increasing the likelihood that cancer cells will travel and lead to metastasis.6Khanna AK, Perez ER, Laudanski K, Moraska A, Cummings KC. Perioperative care and cancer recurrence: Is there a connection? World Journal of Anesthesiology. 2014;3(1):31-45; Hiller JG, Perry NJ, Poulogiannis G, Riedel B, Sloan EK. Perioperative events influence cancer recurrence risk after surgery. Nature Reviews Clinical Oncology. 2018 Apr;15(4):205-218; Dang Y, Shi X, Xu W, Zuo M. The effect of anesthesia on the immune system in colorectal cancer patients. Canadian Journal of Gastroenterology & Hepatology. 2018 Apr 1;2018:7940603.
- Your stress level can act to suppress your immune system separate from your surgical stress response. Higher levels of stress are linked to greater suppression of the immune system after surgery, including natural killer cells and the response of antitumor T cells.7Khanna AK, Perez ER, Laudanski K, Moraska A, Cummings KC. Perioperative care and cancer recurrence: Is there a connection? World Journal of Anesthesiology. 2014;3(1):31-45; Hiller JG, Perry NJ, Poulogiannis G, Riedel B, Sloan EK. Perioperative events influence cancer recurrence risk after surgery. Nature Reviews Clinical Oncology. 2018 Apr;15(4):205-218; Dang Y, Shi X, Xu W, Zuo M. The effect of anesthesia on the immune system in colorectal cancer patients. Canadian Journal of Gastroenterology & Hepatology. 2018 Apr 1;2018:7940603.
- Your physical condition: lower fitness for surgery—such as measured by a high Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)—and a high systemic inflammatory response before surgery predict early disease recurrence after a potentially curative resection for colorectal cancer.8Richards CH, Platt JJ et al. The impact of perioperative risk, tumor pathology and surgical complications on disease recurrence following potentially curative resection of colorectal cancer. Annals of Surgery. 2011 Jul;254(1):83-9.
- Your mood (anxiety and/or depression) can depress your immunity.9Dang Y, Shi X, Xu W, Zuo M. The effect of anesthesia on the immune system in colorectal cancer patients. Canadian Journal of Gastroenterology & Hepatology. 2018 Apr 1;2018:7940603; Gelman D, Gelmanas A et al. Role of multimodal analgesia in the evolving enhanced recovery after surgery pathways. Medicina. 2018 May; 54(2): 20.
Find guidance on managing your stress response in this handbook.
Surgery or not?
Your decision to undergo surgery needs a full, open discussion with your oncology team about both benefits and risks.
Consider an analogy: You’re at home on a cold, snowy day, and suddenly you realize your house is on fire. If you stay in the house, the fire may kill you. If you go outside, you may develop pneumonia, and that may kill you down the road.
The cancer in your body is like the fire. It might kill you pretty quickly if you do nothing, but that depends on how big the cancer (fire) is, how quickly it’s spreading, whether you’ve fireproofed your home, whether you have a fire extinguisher, and more.
The threat of cancer spread or metastasis from surgery is like the risk of pneumonia. It’s a risk, but not a sure thing. And you may be able to take action to reduce that risk. Grabbing some warm clothes or contacting a neighbor could dramatically reduce your risk of pneumonia. Some surgical techniques and options can similarly reduce your risk of cancer spread related to surgery.
This handbook discusses factors that can contribute to inflammation and immune dysfunction, and also measures that you and your surgical team can take to reduce the risk of cancer spread related to surgery. Options are available to reduce the risks of poor cancer outcomes posed by the anesthetic, blood transfusion, low body temperature (hypothermia), and complications after surgery.10Tohme S, Simmons RL, Tsung A. Surgery for cancer: a trigger for metastases. Cancer Research. 2017 Apr 1;77(7):1548-1552.
Before deciding whether surgery is your best option, you need to discuss questions such as these with your oncology team and get clear answers:
- What will likely happen if I don’t have surgery?
- What can I do to prepare myself to improve my immune function and reduce inflammation? (also see Preparing for surgery ›)
- How long can I take to bolster myself before surgery?
- What will the surgery team do to reduce inflammation and minimize the risk of cancer spread?
- What can I do after surgery to reduce my risks of cancer spread and metastasis? (also see In remission ›)
Reducing risks from surgery
You or your surgery team may be able to modify many of the risk factors linked to increased risk of cancer spread. See specific steps to reduce risks of recurrence and metastasis in Preparing for surgery › and On your surgery day ›
Chronic use of opioids decreases immune response. Minimizing use of opioids, while still maintaining the level of pain control you need, may also lead to better immune function and cancer outcomes. See Pain › for details.
A health professional who is trained in integrative approaches may have more tools to help you reduce inflammation, improve immune function, and improve your resilience before and after surgery. If your team doesn’t include someone with this expertise, consider adding an integrative oncologist, naturopathic oncologist, or functional medicine physician to your team if possible.
Helpful links
References