What enhanced recovery means for patients with cancer undergoing surgery

Enhanced recovery after surgery (ERAS) protocols have gained significant traction since the first multimodal perioperative care pathway was described in 1999 by Dr Henrik Kehlet. Dr Kehlet’s article detailed the various factors behind the body’s response to stress induced by surgery and the potential opportunities for intervention, many of which became the foundations for ERAS. The ERAS approach emphasizes early mobilization, optimization of preoperative nutrition and carbohydrate loading, early postoperative enteral nutrition, minimal perioperative hypervolemia, and decreased utilization of opioid pain medications. Since its inception, studies have demonstrated the positive impact of ERAS protocols on clinically relevant perioperative outcome measures in patients across multiple disciplines and diseases. The most highly cited benefit of ERAS protocols is a reduced hospital length of stay (LOS). A meta‐analysis of ERAS protocols across multiple elective abdominal operations demonstrated a significant reduction of 2.5 days in LOS. This was similar to the findings of previous meta‐analyses in the colorectal literature that showed a reduction in LOS of 2.5–2.9 days. The same studies showed a significant improvement in other metrics, including but not limited to times to flatus/defecation and ambulation, and reductions in postoperative morbidities such as pulmonary complications. It is difficult to definitively state significant widespread improvements in all postsurgical outcomes because of the differences among multiple disease sites and the varying complexity of interventions. Nevertheless, there have been more than 1300 publications on ERAS pathways over the past 2 decades that support the overall consensus that these multimodal pathways provide overall value for surgical patients. Although ERAS pathways provide clear and well‐cited advantages for patients, surgeons, and hospitals in the immediate postoperative period, the impact of enhanced recovery programs on patients with cancer and their long‐term oncologic outcomes is less known. In this issue of Cancer, Chakravarthy et al. report the implementation and study of an ERAS protocol for a novel population of patients undergoing surgery for spine metastases. Their study demonstrated a significant reduction in postoperative opioid utilization and hospital LOS as well as improvements in other secondary outcomes such as early mobilization, introduction of an enteral diet, and Foley removal. Their findings echo those of previous ERAS studies conducted for other cancer types such as gastric, breast, and peritoneal malignancies. One key limitation of this article is that Chakravarthy et al. do not address the impact of their ERAS pathway on oncologic outcomes. For oncologists of all disciplines, it is vital to understand how these improvements in what seem to be relatively transient, perioperative metrics translate into cancer‐specific outcomes. A study on the impact of ERAS pathways on patients undergoing surgery for soft tissue sarcoma demonstrated a reduction in wound complications with potentially significant implications for preoperative radiation therapy versus postoperative radiation therapy. There have also been colorectal cancer studies that have reported improved cancer‐ specific mortality associated with adherence to ERAS interventions, although the true cause and effect relationship between the two has not been clearly established. The existing literature on how enhanced recovery can improve cancer‐specific outcomes emphasizes the role of ERAS in restoring patients to their baseline or near‐baseline physiologic status in order to return to intended oncologic treatment (RIOT). RIOT was first described in 2014 as a novel metric for evaluating the quality of oncologic surgery, and it has been shown to be associated with improved oncologic outcomes. For patients undergoing oncologic surgery, postoperative complications can often delay the resumption of adjuvant systemic therapy or impede RIOT, and this can subsequently lead to decreased overall and progression‐free survival. Adjuvant treatments such as radiation can also be delayed; patients undergoing surgery for breast cancer must recover from any and all postoperative complications and have the full range of ipsilateral shoulder motion to commence radiation treatment. The impact of delayed RIOT on oncologic outcomes has been demonstrated at multiple disease sites, including breast, pancreatic, liver, and colorectal cancer. In a validation cohort of patients with metastatic colorectal cancer undergoing hepatectomy, the baseline RIOT rate was defined as 75% with a median time to therapy of 42 days. This is where ERAS pathways can play an important role in the therapeutic care plan for patients with cancer. When studied in the context of an ERAS program for hepatectomy patients at the same institution, RIOT improved to 95%, and this demonstrated the specific value of ERAS protocols for patients with cancer. A secondary analysis of the factors delaying RIOT, including an LOS longer than 5 days, the surgical approach (open vs. minimally invasive), and any postoperative complications, showed the significance of adhering to ERAS programs when available.