Risk stratification of the cancer patient: a narrative review

Major cancer surgery is associated with significant morbidity and, given the several management options that may be available, preoperative assessment should include an estimate of the potential postoperative complications that can significantly affect quality of life and disease progression. That will enable direct patient involvement in decision making and disease management, encourage preoperative optimisation and allow planning of postoperative care and allocation of resources. This review article aims to describe the preoperative tools that may be used to estimate the risk of postoperative complications. Risk stratification includes perioperative risk scoring systems, commonly used ones being the POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) and ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Project) risk calculators. Given the ageing population of the cancer patients, assessment of frailty, fitness and cardiorespiratory reserve are also relevant and particularly important prior to major surgery. Comparison of individual achievements on cardiopulmonary exercise testing (CPET) with specific thresholds allows risk stratification into high, intermediate or low risk categories for the development of postoperative complications. Additionally, biomarkers are increasingly being used as an adjunct to the assessment of postoperative risk, particularly troponin and brain natriuretic peptide (BNP). Postoperative complications are the major determinant of survival following major surgery, more so than preoperative characteristics and intraoperative factors and, therefore, perioperative care should be directed at their prevention. Preoperative risk stratification may assist in this way by personalising patient care and allowing for the best management choice given the patient’s wishes, comorbidities and level of fitness.