Extended Timeframe for Cancer Surgeries: Balancing Preoperative Optimisation with Risks of Metastasis

The updated 2024 guidelines on cardiac risk stratification for noncardiac surgery have expanded the timeframe for time-sensitive surgeries from 6 weeks to 3 months,[1] which marks a significant shift in managing oncologic procedures. Cancer surgery is considered time-sensitive,[2] particularly for certain aggressive types of cancer where delays can lead to tumour progression, metastasis and poorer survival outcomes. The timing of surgery plays a crucial role in improving survival rates and reducing the risk of metastasis, especially in cancers like breast, colon, lung and head and neck cancers. Extending the preoperative window to 3 months offers some benefits, such as thorough evaluations, optimising comorbid conditions and implementing lifestyle and nutritional interventions, potentially reducing perioperative risks such as major adverse cardiac events. For complex cancer surgeries, this timeframe enables multidisciplinary teams to collaboratively plan care, incorporate neoadjuvant therapies and enhance surgical outcomes. In addition, hospitals can better manage operating room schedules, alleviate resource bottlenecks and create buffers for urgent cases, ensuring more efficient prioritisation and allocation of surgical slots in resource-constrained settings. Surgical delay risks vary significantly across cancer types, with molecular biomarkers playing a critical role in informing decisions. In breast cancer, tests like MammaPrint, which assesses a 70-gene profile, help identify low-risk patients who can safely delay chemotherapy, supporting more personalised treatment plans.[3] Pancreatic cancer, known for its aggressive nature, benefits from molecular profiling, including biomarkers such as Kirsten Rat Sarcoma viral oncogene homolog, mothers against decapentaplegic homolog 4 and circulating tumour DNA, which aids in detecting minimal residual disease and guiding targeted therapies, potentially adjusting surgical timing.[4] For prostate cancer, genomic tests help determine tumour aggressiveness, enabling decisions on whether immediate surgery or active surveillance is more appropriate. These biomarkers provide a scientific foundation for balancing timely intervention with safe delays, optimising treatment for each patient.[5] On the other hand, delays in cancer treatment, particularly surgical interventions, significantly affect survival and recurrence outcomes, as evidenced by several key studies. A meta-analysis by Hanna et al. demonstrated that each 4-week delay in treatment increases the risk of death by 6%–8% (hazard ratios: 1.06–1.08) across seven cancer types, including bladder, breast, lung and head-and-neck cancers, highlighting the cumulative impact of even short delays.[6] Similarly, a retrospective study by Smith et al. on breast cancer patients revealed a stark difference in 5-year survival rates, with those experiencing a 6-week delay having an 80% survival rate compared to 90% for those treated within 2 weeks.[7] For head and neck squamous cell carcinoma, a retrospective cohort analysis by Liao et al. showed that treatment initiation delays exceeding 60 days significantly worsened overall survival (hazard ratio: 1.69, 95% confidence interval [CI]: 1.32–2.18) and a higher risk of recurrence (odds ratio: 1.77, 95% CI: 1.07–2.93).[8] This necessitates careful evaluation of individual cases to determine if waiting will adversely impact cancer control. For certain cancers, especially aggressive or advanced-stage cancers, delayed surgery could indeed increase the risk of metastasis, affecting long-term outcomes and survival. For cancers with moderate rates of growth or lower metastatic potential (e.g., early-stage breast cancer and colorectal cancer), a delay of up to 3 months might not significantly affect outcomes, provided that there’s no evidence of rapid disease progression. However, oncologists may need to closely monitor these cases, potentially incorporating additional imaging, biomarker monitoring or bridging treatments (e.g., systemic therapies) to control tumour growth and minimise metastasis risk during the waiting period. Delaying cancer surgery, despite potential benefits such as prehabilitation or psychological support, often carries significant risks that can outweigh any perceived advantages. Studies have shown that even short delays can increase mortality rates, with an 8% increased risk of death for each 4-week delay in breast cancer surgery.[6] The potential harm is compounded by the limitations of molecular biomarkers, which, while promising, are still under development and not universally accessible. The ideal biomarker, one that is quantifiable, reliable and consistent across populations, remains a challenge,[9] making it difficult to guide decisions precisely when delaying surgery. Furthermore, the costs and inequities in access to advanced molecular therapies exacerbate the situation, as many patients in under-resourced communities face significant barriers to timely treatment. Healthcare systems are further burdened by these delays, leading to inefficiencies, worsened patient outcomes and heightened psychological distress for patients who face uncertainty or a worsening prognosis due to postponed surgery. To implement an individualised approach to surgical timing in cancer treatment, clinicians should combine tumour-specific factors, patient health and diagnostic tools. Implementing decision-making algorithms based on clinical guidelines ensures that surgery is appropriately timed, balancing patient well-being with the urgency of intervention. By using interdisciplinary pathways, such as early mobilisation and opioid-sparing pain regimens, clinicians can accelerate recovery while minimising risk.[10,11] Although the updated guidelines provide a 3-month window for surgery, high-risk cancers require expedited treatment, while others may benefit from delays in preoperative optimisation. Oncologists, surgeons and anaesthesiologists must collaborate to assess metastatic risks and tailor surgical timing, balancing the need for prompt intervention with the potential benefits of optimisation and patient well-being. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.