Letter to the Editor

A reader responds to ACP Hospitalist's coverage of perioperative cancer care.

Your article on perioperative care of cancer patients (ACP Hospitalist, February 2013) omitted an important point. The angiogenesis inhibitors are an increasingly common class of drugs used to treat cancer. They work by interfering with blood vessel growth. Unfortunately, they also have the same effect on normal tissue. Operating when a patient is on one of these drugs all but assures poor wound healing. The drugs need to be stopped for some period prior to surgery (how long is really just a best guess).

The most common drug in this category is bevacizumab (Avastin). This is from the black box warning on the Avastin package insert:

“The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients. Discontinue Avastin in patients with wound dehiscence. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined. Discontinue at least 28 days prior to elective surgery. Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed.” [See Dosage and Administration (2.4), Warnings and Precautions (5.2), Adverse Reactions (6.1).]

The package insert is available online.

Bottom line: Part of the preop evaluation of cancer patients is to postpone elective surgery for patients on this class of drugs.

Kenneth Mishark, MD, FACP
Scottsdale, Ariz.