Cancer diagnoses can be devastating, taking an emotional and physical toll on patients and their families, and fraught with tension, fear and anxiety. Once diagnosed, oncologists aim to get patients on the path to remission as quickly as possible. But sticking to the treatment timeline is not always so simple.

For optimal recovery after tumor resection surgery, adjuvant therapies, such as chemotherapy, radiation and immunotherapy, must be administered quickly to eradicate residual disease and lower the risk of recurrence. However, the optimal window for beginning adjuvant chemotherapy administration is narrow, with a recommended time frame of four to eight weeks post-surgery for many cancers, including breast, colorectal, gastric and lung. Adhering to this schedule has shown to considerably increase survival rates. However, all too often we miss this window due to preventable causes.[1]

Despite advancements in surgical care, patients still find themselves exposed to potentially preventable complications—some of which stem from standard of care (SOC) practices—that can postpone their course of treatment. For patients with aggressive cancers, these delays can have severe implications.

The most common of these complications are surgical site infections (SSIs), generally onsetting within 30 days of a procedure. There are three categories of SSIs—superficial incisional SSIs and deep incisional SSIs, which occur at the incision site, and organ/space SSIs, which occur beyond the direct surgical area, in an organ or space between organs—including the tumor resection site.

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Presenting in two to fourteen percent of patients after inpatient cancer resection procedures, SSIs are responsible for over 40 percent of all Healthcare Acquired Infections (HAIs), with an alarming three percent mortality rate. While SSIs are detrimental to all patients, the stakes are that much higher for those undergoing cancer treatment.[2][3][4]

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SSIs and Oncology: A Preventable Risk
 The rate of SSIs after tumor resections varies greatly depending on the site of the procedure among other factors, such as age, body mass index (BMI), and comorbidities, but when a cancer patient does develop an SSI, the results can be devastating. The recovery period for an SSI can take a few weeks—sometimes longer—but even with an excellent recovery, the patient has lost critical time in beginning adjuvant chemotherapy treatments, which can cause impaired cancer treatment outcomes.[5]

While classified as a ‘low risk’ procedure due to the clean surgical area, SSIs present in roughly two percent of breast cancer surgeries. [6] Other studies suggest that the rate of SSI after breast cancer surgery is much higher. Additionally, SSIs after a lumpectomy or mastectomy offer an additional complication with the cosmetic considerations that are common for these types of surgeries. [7] Colorectal surgeries, on the other hand, are classified as ‘clean-contaminated procedures’—especially prone to infection due to exposure to bowel content—increasing the risk of SSI to a concerning 11 percent.[8]

 The high rates of SSI that exist, despite tremendous advancements in general surgical practices, prove that our current prevention methods are insufficient, demanding the need for reform. Most alarmingly, pre-op SOC methods of antibiotic administration directly impact the prevalence of SSIs.

Current infection prevention protocols rely on intravenous (IV) administration of prophylactic antibiotics an hour before surgery begins, systematically circulating through the blood stream before ultimately reaching the surgery site in a limited concentration. Additionally, closing an incision at the completion of surgery does not prevent the risk of exposure to bacteria; the surgical wound is still susceptible to the invasion of bacteria during recovery. Patients may be regaining strength a week after undergoing tumor resection, unaware that bacteria are festering.

Such preventable infections throw cancer treatment off course even before it gets off the ground. By allowing SSIs to develop, we fail our most vulnerable patients.

Location and Duration, a Winning Combination
The importance of location is not unique to real estate. Systemic drug administration requires high doses of antibiotics, exposing patients unnecessarily to increased risk of toxicity and potentially generating antibiotic-resistant strains of bacteria. Unsurprisingly, studies have found that systemic drug administration has several risks and treatment gaps which reduce efficacy and yield side effects.[9]  With the ongoing advancements in cancer care, we cannot ignore preventable complications that can negate these advancements and regress the course of treatment for cancer patients.

To prevent infection and unnecessary risks for cancer patients, antibiotics dispensed directly to the surgical site can have more optimal outcomes and allow for lower drug dosages, reducing risks of toxicity and antibiotic resistance. Cutting-edge solutions are being developed utilizing medication-agnostic, extended-release drug delivery capabilities that are anchored directly to the surgical site and can deliver antibiotics throughout the complete recovery process, thwarting SSIs before they can develop. When antibiotics remain anchored to the surgical site for an extended duration, patients have layers of protection against developing SSIs.

The future for infection prevention is bright. Shifting to local drug administration as the new infection prevention SOC can significantly lessen the occurrence of SSIs and give oncology patients the best chance for optimal health outcomes.

Reference
[1] Petrelli F, Zaniboni A, Ghidini A, Ghidini M, Turati L, Pizzo C, Ratti M, Libertini M, Tomasello G. Timing of Adjuvant Chemotherapy and Survival in Colorectal, Gastric, and Pancreatic Cancer. A Systematic Review and Meta-Analysis. Cancers (Basel). 2019 Apr 17;11(4):550. doi: 10.3390/cancers11040550. PMID: 30999653; PMCID: PMC6520704.
[2] Amri R, Dinaux AM, Kunitake H, Bordeianou LG, Berger DL. Risk Stratification for Surgical Site Infections in Colon Cancer. JAMA Surg. 2017 Jul 1;152(7):686-690. doi: 10.1001/jamasurg.2017.0505. PMID: 28403477; PMCID: PMC5547926.
[3] Weiner-Lastinger LM, Abner S, Edwards JR, Kallen AJ, Karlsson M, Magill SS, Pollock D, See I, Soe MM, Walters MS, Dudeck MA. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol. 2020 Jan;41(1):1-18. doi: 10.1017/ice.2019.296. Epub 2019 Nov 26. PMID: 31767041; PMCID: PMC8276252.
[4] Awad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surg Infect (Larchmt). 2012 Aug;13(4):234-7. doi: 10.1089/sur.2012.131. Epub 2012 Aug 22. PMID: 22913334.
[5] Zhan QH, Fu JQ, Fu FM, Zhang J, Wang C. Survival and time to initiation of adjuvant chemotherapy among breast cancer patients: a systematic review and meta-analysis. Oncotarget. 2017 Dec 7;9(2):2739-2751. doi: 10.18632/oncotarget.23086. PMID: 29416807; PMCID: PMC5788675.
[6] Pastoriza J, McNelis J, Parsikia A, Lewis E, Ward M, Marini CP, Castaldi MT. Predictive Factors for Surgical Site Infections in Patients Undergoing Surgery for Breast Carcinoma. Am Surg. 2021 Jan;87(1):68-76. doi: 10.1177/0003134820949996. Epub 2020 Sep 15. PMID: 32927974.
[7] O’Connor RÍ, Kiely PA, Dunne CP. The relationship between post-surgery infection and breast cancer recurrence. J Hosp Infect. 2020 Nov;106(3):522-535. doi: 10.1016/j.jhin.2020.08.004. Epub 2020 Aug 13. PMID: 32800825.
[8] Kamboj M, Childers T, Sugalski J, Antonelli D, Bingener-Casey J, Cannon J, Cluff K, Davis KA, Dellinger EP, Dowdy SC, Duncan K, Fedderson J, Glasgow R, Hall B, Hirsch M, Hutter M, Kimbro L, Kuvshinoff B, Makary M, Morris M, Nehring S, Ramamoorthy S, Scott R, Sovel M, Strong V, Webster A, Wick E, Aguilar JG, Carlson R, Sepkowitz K. Risk of Surgical Site Infection (SSI) following Colorectal Resection Is Higher in Patients With Disseminated Cancer: An NCCN Member Cohort Study. Infect Control Hosp Epidemiol. 2018 May;39(5):555-562. doi: 10.1017/ice.2018.40. Epub 2018 Mar 19. PMID: 29553001; PMCID: PMC6707075.
[9] Poeran J, Mazumdar M, Rasul R, Meyer J, Sacks HS, Koll BS, Wallach FR, Moskowitz A, Gelijns AC. Antibiotic prophylaxis and risk of Clostridium difficile infection after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2016 Feb;151(2):589-97.e2. doi: 10.1016/j.jtcvs.2015.09.090. Epub 2015 Sep 28. PMID: 26545971; PMCID: PMC5142529. 

Featured image/Photo by JC Gellidon on Unsplash. Used with permission.

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