A history of cancer in non-cancer surgery: what changes in anaesthetic management

September 7, 2026 · Read 9 min

More than 80% of new cancer cases involve surgery, and treatment leaves sequelae that persist for years after remission. One in 18 adults in the United States lives with a history of cancer, and that proportion continues to rise. The history is asked about at every preanaesthetic assessment and the dates are recorded: the last cycle, the last radiotherapy session, and the last corticosteroid dose decide more than the diagnosis.

1. Why the patient with cancer presents for any type of surgery

Most cancer survivors are older adults, with cardiovascular risk from age and from treatment, and the European guideline on non-cardiac surgery has classed them as a population at increased risk since 2022. The assessment records:

• Tumour type and status: active, in remission, or under follow-up.
• Date of each treatment: chemotherapy and agent, radiotherapy and field, immunotherapy, corticosteroid.

In patients with cancer admitted to intensive care after major surgery, exposure to an immune checkpoint inhibitor (e.g., ipilimumab, nivolumab) in the previous six months did not increase cardiopulmonary instability or organ injury; it increased only prolonged vasopressor dependence. Two management points follow:

• The diagnosis does not justify postponing or escalating the surgery.
• Recent immunotherapy justifies planning for vasopressor support and postoperative haemodynamic monitoring.

On anaesthetic technique and cancer survival there is no consensus; the technique is chosen for the patient and for the procedure.

2. Airway and thyroid after head and neck radiotherapy

Trismus and neck stiffness from radiation fibrosis

After head and neck radiotherapy a difficult airway is common, and in one in ten cases it was not predicted despite a full assessment.

• Difficult facemask ventilation from osteonecrosis, mucositis, missing dentition, and oedema.
• Difficult laryngoscopy from fibrosis and limited mouth opening.
• With any predictor present: consider awake tracheal intubation from the planning stage, with a checklist (Difficult Airway Society, awake tracheal intubation guideline).
• If the difficulty was not predicted: the Difficult Airway Society 2025 algorithm for unanticipated difficult tracheal intubation.
• History of anterior mediastinal mass: reinforced tracheal tube to withstand external compression; in central airway obstruction with cardiac compromise, establish before induction whether extracorporeal membrane oxygenation (ECMO) may be required and whether it is available.
• Subacute radiation pneumonitis (lung inflammation from radiation) between 2 and 6 months; surgery may coincide with that phase, with no evidence of more pulmonary complications attributable to radiotherapy.

Post-radiation hypothyroidism

It is common, rarely symptomatic, and appears between 3 months and 16 years after irradiation.

• Thyroid-stimulating hormone (TSH) at every assessment with that history, with no time limit.
• Subclinical: surgery proceeds with levothyroxine started and TSH below 15 IU/L.
• Moderate or severe clinical hypothyroidism: postpone elective surgery until euthyroid. Correction reduces the risk of intraoperative arrhythmia and does not eliminate it.

Lung cancer: tumour obstruction and superior vena cava

• Obstruction by the tumour: worsens when muscle tone is lost at induction; muscle support keeps an already compromised airway patent.
  • With risk of collapse at induction: awake tracheal intubation, with videolaryngoscope, flexible bronchoscope, supraglottic airway devices, and cricothyroidotomy kit available.
  • CT before induction: tracheobronchial area below 50% and compression of the heart or great vessels change the plan.
  • Establish, with the patient awake, the position in which symptoms do not worsen, record it, and have the table ready to tilt.
• Superior vena cava syndrome: congestion reaches the pharynx and larynx; intubation is expected to be difficult.
  • Drugs given through supradiaphragmatic access do not reach the right atrium reliably: femoral venous access before induction.
  • Postoperative intensive care.
• Pleural effusion: drainage the day before gives the full benefit (complete effect at 24 h); drainage on the same day, a partial one. The gain is modest; pneumothorax 3.4% and haemothorax 1.6%. The evidence is from intensive care and does not set a preoperative threshold.

3. Heart, blood, and thrombosis after chemotherapy

Anthracycline cardiotoxicity

• Anthracyclines (e.g., doxorubicin): ventricular dysfunction even when the maximum cumulative dose is not exceeded.
  • Almost always in the first year after treatment.
  • Cumulative doxorubicin of 400 mg/m2 or more: very high risk.
• Trastuzumab: additional cardiotoxicity.
• Thoracic radiotherapy: premature coronary and valvular disease, also in young patients with no other risk factor.

Management is decided by the last documented cardiovascular evaluation:

• Survivor with a cardiotoxic drug or radiotherapy: electrocardiogram and natriuretic peptides every year, restratification at five years (cardio-oncology guideline).
• Without a recent evaluation, and with a high dose, trastuzumab, or thoracic radiotherapy: electrocardiogram and natriuretic peptide before elective surgery.
• Echocardiogram if either is abnormal or there is pre-existing heart disease.
• Atrial fibrillation: anthracyclines, cisplatin, and melphalan induce it; 5-fluorouracil produces myocardial ischaemia. The baseline electrocardiogram is compared with the pre-treatment one.

Anaemia and myelosuppression

Preoperative anaemia is common and mostly due to iron deficiency. The international consensus on anaemia in the surgical patient sets a single threshold for both sexes (table).

• Screening for every patient except minor procedures; iron deficiency is corrected before surgery.
• A single intraoperative unit of red cells is already associated with more mortality, stroke, and infarction.
• With a recent cycle, elective surgery proceeds with recovered platelet and neutrophil counts; if either has not recovered, surgery is postponed for two weeks.
• A temperature of 38.5 °C with neutropenia is febrile neutropenia.

Prothrombotic state and extended thromboprophylaxis

The prothrombotic state persists for up to six months.

• Open abdominal or pelvic surgery for cancer: prophylaxis for 4-5 weeks, preferably with low-molecular-weight heparin.
• Already anticoagulated for cancer-associated thrombosis: low-molecular-weight heparin with creatinine clearance of 30 mL/min or more, or a direct oral anticoagulant; caution in upper gastrointestinal malignancy because of gastrointestinal bleeding. Treatment for at least six months.
• Vena cava filter only if anticoagulation is contraindicated.
• Neuraxial block is planned around that regimen and the timing of its last dose.

Kidney and analgesia according to organ toxicity

• Cisplatin: nephrotoxicity in one third of those treated; chronic damage may appear years later.
• Ifosfamide: renal failure and Fanconi syndrome.
• Analgesia with nephrotoxicity:
  • Paracetamol before a non-steroidal anti-inflammatory drug.
  • No codeine (renal elimination) or morphine (neurotoxic metabolites).
  • Fentanyl with renal adjustment.
• Analgesia with cardiotoxicity: no methadone (prolongs the QT interval) or tricyclic antidepressants.
• Protective ventilation in every case: tidal volume 6-8 mL/kg predicted body weight, plateau pressure below 30 cmH2O, and PEEP titrated to the lowest driving pressure; routine PEEP above 6 cmH2O does not reduce pulmonary complications and increases cardiovascular ones.

Bleomycin: oxygen restriction is inherited doctrine

• The current British Society for Haematology guideline does not require restricting FiO2 and asks for the same management as for any other patient; hypoxaemia from restricting it is the harm that is certain.
• Postoperative acute respiratory distress syndrome is concentrated in the first procedure after exposure and is associated with crystalloid volume and the rate of colloid infusion, not with FiO2. The risk does not fall with the years elapsed.
• What changes the risk is established pulmonary toxicity: new cough or dyspnoea with CT findings; spirometry neither diagnoses nor predicts it. With active toxicity, prednisolone 0.5-1 mg/kg/day and respiratory medicine referral.
• An elective case is not postponed for the history or for the time since the last dose, in the absence of symptoms or CT findings.

4. Adrenal gland and peripheral nerve: what is not seen

Hidden corticosteroid

• Sources of exposure in oncology: corticosteroid given with chemotherapy cycles, oncohaematology regimens containing a corticosteroid, and systemic corticosteroid for immune-related events.
• Threshold of suspicion for suppression: prednisolone 5 mg/day or equivalent for one month or more, by any route (oral, inhaled, topical, intranasal, intra-articular).
• Cover: hydrocortisone 100 mg IV at induction, then 200 mg by infusion over 24 h until double the usual oral dose can be given; taper after 48 h, or after up to one week following major surgery.
• Dexamethasone 8 mg is equivalent to 200 mg of hydrocortisone over 24 h, except in primary adrenal insufficiency (no mineralocorticoid activity).
• When in doubt, it is given: short cover has no long-term consequences.

Immune checkpoint inhibitors

• Windows of immune-related events:
  • Myocarditis: around 17 days.
  • Hypophysitis: around 11 weeks, especially with anti-CTLA-4 (ipilimumab).
  • Primary hypothyroidism: between 5 months and 3 years, more common with combination therapy.
  • Colitis and hepatitis: alter volume status, electrolytes, and drug metabolism.
• Preoperative panel: TSH, free T4, cortisol and adrenocorticotropic hormone (ACTH), glycated haemoglobin, electrocardiogram; troponin and natriuretic peptide from six weeks into treatment.
• Hypothyroidism: the postponement criterion in section 2.
• Intraoperative hypotension unresponsive to anaesthetic depth, fluids, or vasopressor is treated as adrenal crisis: hydrocortisone 100 mg IV, then 50 mg IV every 6 h.

Chemotherapy-induced neuropathy and regional block

• Risk: with pre-existing neuropathy, new deficit or worsening after neuraxial anaesthesia is one to two orders of magnitude more likely than in the general population.
• Mechanism (ASRA): double crush; an already compromised nerve is more vulnerable to a second insult.
  • Mechanical, ischaemic, metabolic, or toxic insult.
  • Neuropathy from platinum agents (e.g., cisplatin) and from vinca alkaloids falls into the toxic category.
  • ASRA itself describes the claim as theoretical.
• The block is not contraindicated by the history.
• Baseline deficit is documented by territory before the block; every new symptom is compared with that baseline.

5. Frailty, surgical timing, and the intensive care bed

Frailty, function, and nutrition

• In high-risk emergency laparotomy, 30-day mortality rises with each ECOG (Eastern Cooperative Oncology Group) step and more than doubles with albumin below 36 g/L. ECOG enters the risk discussion with the patient and the surgeon; the data are from emergency surgery and are not extrapolated to elective surgery.
• Low albumin predicts outcome and does not change the dose: hypoalbuminaemia does not justify reducing highly protein-bound drugs.
• Nutrition from diagnosis: intake, weight, and body mass index; 25-30 kcal/kg/day and more than 1 g/kg/day of protein.
• Up to half of patients with cancer use complementary medicine products: ask for them by name, for interactions with anaesthetics and with haemostasis.
• Frailty: screening in everyone over 70 years or with weight loss above 5% in one year, with the Clinical Frailty Scale; it at least doubles the risk of major complication, death, and readmission.

The cost of postponing

• Between neoadjuvant therapy and resection, 4-6 weeks is the optimal interval; delaying resection worsens survival.
• Starting adjuvant therapy more than 44 days after surgery was associated with higher mortality, and each additional week reduces survival.
• Preoperative preparation — iron, thyroid, frailty, inspiratory muscle training if there is time, which reduces postoperative pulmonary complications — is done within that window. Postponing for moderate or severe hypothyroidism or for active myelosuppression is justified; each additional day has a cost that the oncology team should know.

Criteria for reserving an intensive care bed

Admission to intensive care without indication does not improve outcome and increases cost; omitting an indicated admission increases morbidity and mortality. Criteria from the Italian consensus for major abdominal surgery:

Recent immunotherapy is added to the general criteria, because of the vasopressor dependence described in section 1.