The third most common cancer in women around the globe, cervical cancer kills approximately 300,000 women per year [1, 2]. Typically caused by persistent infection of human papillomaviruses (HPVs), the pathology originates when cancerous cells grow from the surface of the cervix to the deeper tissues [3]. Without treatment, the cancer can spread to nearby organs, such as the uterus, lymph nodes, and bladder [3]. If detected at an early stage — before the cancer spreads to the deeper layers of the cervix — treatment typically includes minimally invasive procedures to remove the cancerous cells, such as cryosurgery, conization, or laser surgery, sometimes followed by chemotherapy or radiation treatment [3]. However, if the cancer has already spread, major surgery is often necessitated and can range from simple hysterectomy to pelvic exenteration. In any case, anesthesia choice and management can impact the outcome of surgery for cervical cancer due to the differential effects on the immune system, surgical stress, and anti-tumor properties [4].
Hysterectomy, a major surgery for cervical cancer in which the uterus is fully removed, can be performed using sev anesthesia options. Minimally invasive techniques, such as laparoscopic or vaginal surgery, are associated with less blood loss, healthier immune responses, and reduced surgical stress compared to the former standard of open abdominal surgery [5, 6]. Additionally, regional anesthesia can be used, which typically decreases the length of hospital stay and postoperative pain [4, 5, 7, 8]. Recent studies have shown that regional anesthesia methods, such as nerve blocks, lidocaine and epidural anesthesia, can provide the patient with comfort and analgesia without suppressing the immune response, an effect commonly caused by general anesthesia and surgical stress that can negatively impact recovery [6, 8, 9]. One study found that, compared to patients who underwent hysterectomy with general anesthesia, those who received regional anesthesia showed a faster return to normal immune function and reduced postoperative pain [8]. Minimally invasive hysterectomy with regional anesthesia is becoming more common as more data emerge on the benefits of this approach [6, 8].
For invasive surgeries, such as pelvic exenteration, pelvic lymph node dissection and trachelectomy, general anesthesia is the standard. The intravenous agent propofol and the inhalational anesthetic sevoflurane are the most commonly used medications, although ketamine, desflurane and isoflurane are utilized in some cases [4, 10, 11]. Currently, as more immunomodulating effects of anesthetics are being discovered, researchers are beginning to understand the effects of different anesthetics on cancer outcomes. Propofol, an anti-inflammatory and anti-oxidative agent, is associated with longer survival after cancer surgery and increased protection of the immune system compared to sevoflurane, specifically in cervical cancer cases [4, 6]. Meanwhile, the pro-inflammatory anesthetic sevoflurane may suppress cervical cancer cell growth and migration [12]. While both anesthetics demonstrate anti-tumor properties, additional comparative studies must be performed to further analyze the advantages and disadvantages associated with each drug [10, 12].
No matter the drug of choice, anesthesia management for cervical cancer surgery should involve preoperative evaluation, perioperative monitoring, and postoperative care [13]. Risk factors, such as obesity and cardiovascular problems, should be considered when determining the surgical technique and the anesthetic choice [14]. After surgery, postoperative nausea and vomiting (PONV) prophylaxis should occur and analgesia should continue [14, 15].
References
1: Lkhagvasuren, N. (2020). Human papillomavirus (HPV) and cervical cancer. World Health Organization. URL: www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer
2: Adegoke, O., Kulasingam, S. and Virnig, B. (2012). Cervical cancer trends in the United States: a 35-year population-based analysis. Journal of Women’s Health, vol. 21. DOI: 10.1089/jwh.2011.3385.
3: Lea, J. and Lin, K. (2012). Cervical cancer. Obstetrics and Gynecology Clinics of North America, vol. 39. DOI: 10.1016/j.ogc.2012.02.008.
4: Plucker, J., Wirsik, N., Ritter, A., Schmidt, T. and Weigand, M. (2021). Anaesthesia as an influence in tumour progression. Lagenbeck’s Archives of Surgery, vol. 406. DOI: 0.1007/s00423-021-02078-z.
5: Rosati, M., Bramante, S., Conti, F., Frattari, A., Rizzi, M. and Roman, R. (2020). Operative gynecological laparoscopy under conscious sedation. Journal of the Society of Laparoscopic & Robotic Surgeons, vol. 24. DOI: 10.4293/JSLS.2020.00020.
6: Liu, S., Gu, X., Zhu, L., Wu, G., Zhou, H., Song, Y. and Wu, C. (2016). Effects of propofol and sevoflurane on perioperative immune response in patients undergoing laparoscopic radical hysterectomy for cervical cancer. Medicine, vol. 95. DOI: 10.1097/MD.0000000000005479.
7: Arain, M. and Buggy, D. (2007). Anaesthesia for cancer patients. Current Opinion in Anesthesiology, vol. 20. DOI: 10.1097/ACO.0b013e32814f1c34.
8: Hong, J. and Lim, K. (2008). Effect of preemptive epidural analgesia on cytokine response and postoperative pain in laparoscopic radical hysterectomy for cervical cancer. Regional Anesthesia and Pain Medicine, vol. 33. DOI: 10.1016/j.rapm.2007.07.010.
9: Ben-Eliyahu, S., Page, G., Yirmiya, R. and Shakhar, G. (1999). Evidence that stress and surgical interventions promote tumor development by suppressing natural killer cell activity. Experimental Cancer, vol. 80. DOI: 10.1002/(SICI)1097-0215(19990315)80:6<880::AID-IJC14>3.0.CO;2-Y.
10: Yuki, K. (2021). The role of general anesthetic drug selection in cancer outcome. Biomedical Research International, vol. 2021. DOI: 10.1155/2021/2563093.
11: Tseng, W., Lee, M., Lin, Y., Lai, H., Yu, M., Wu, K. and Wu, Z. (2021). Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in epithelial ovarian cancer surgery: a retrospective cohort study. Frontiers in Pharmacology, vol. 12. DOI: 10.3389/fphar.2021.685265.
12: Ding, J., Zhang, L., Zeng, S. and Feng, T. (2019). Clinically relevant concentration of sevoflurane suppresses cervical cancer growth and migration through targeting multiple oncogenic pathways. Biochemical and Biophysical Research Communications, vol. 514. DOI: 10.1016/j.bbrc.2019.05.082.
13: American Society of Anesthesiologists (2012). Practice Advisory For Preanesthesia Evaluation: An Updated Report By The American Society Of Anesthesiologists Task Force On Preanesthesia Evaluation. Anesthesiology, vol. 116. DOI: 10.1097/ALN.0b013e31823c1067.
14: Morosan, M. and Popham, P. (2013). Anaesthesia for gynaecological oncological surgery. Continuing Education in Anaesthesia Critical Care & Pain, vol. 14. DOI: 10.1093/bjaceaccp/mkt035
15: Committee on Standards and Practice Parameters. (2019). Standards for postanesthesia care. American Society of Anesthesiologists. URL: www.asahq.org/standards-and-guidelines/standards-for-postanesthesia-care.
