By David Sherer
The recent diagnoses of pancreatic cancer in three of my anesthesia colleagues have both saddened me and piqued my interest as to the potential causes of this cluster. All three are (or were) male colleagues in their 50s and early 60s, and all of them have been exposed to the physical environment of anesthesia for more than three decades. Two of the said individuals are in treatment now, and one, sadly, passed away. This unfortunate and tragic state of affairs got me to thinking about the risks we in healthcare in general and in anesthesia specifically must endure when we practice what we do. And unlike other professions, there really is no substantial “hazardous duty pay” when it comes to delivering the care we render.
The COVID-19 pandemic has thrown a particularly bright light on the hazards we face and brought no small degree of stress to our lives. Such risks come in three basic forms: physical, emotional and mental. The emotional and mental are well known to us. They come in the form of substance abuse, depression, stress, anxiety, sleep deprivation, burnout and negatively affected personal relationships. The physical risks are also well known, and exact no less of a toll. Decades ago, the main fears were the contracting of communicable diseases from our patients, be they infectious hepatitis, HIV or tuberculosis. Radiation exposure in the environments where we practice has been a consistent threat, as has the inhalation of vaporized virus particles from procedures where aerosolized viral particles permeate the OR and other procedural environments. Even something as simple and basic as wearing a heavy lead apron for hours on end can do a number on your neck and back.
These physical, emotional and mental risks to our well-being, brought on as part and parcel of what we do every day, are well known but not frequently discussed. And that’s too bad. It’s unfortunate because it furthers the misunderstanding both by the general public and even our colleagues as to the tremendous price each of us who practices anesthesiology pays while helping our fellow human beings. And while I am not looking for sympathy here, I am looking for understanding. Understanding and a cultural shift. This shift I refer to can be thought of in different ways. First, there needs to be more respect for those of us who endure these risks. Respect is important for us, as I have written about in past articles, because it enhances our sense of worth. Second—and I harbor no delusions as to the improbability of this—payors need to understand, appreciate and perhaps even compensate us for the risks we take. Although there have been billing unit “modifiers” that have allowed us to request more compensation for our services, there needs to be greater efforts to lobby for more remuneration when the physical risks I’ve mentioned above can be monetized. If we must wear lead for hours on end to protect ourselves from radiation—at the price of the joints and muscles in our necks and backs—we need to be compensated for that. When we are involved in potentially infectious laser procedures, necessitating the use of barely breathable laser masks and hard-to-see-out-of tinted goggles, we need to bill for that and be compensated. During lithotripsy cases to pulverize urinary system stones, we must wear ear protection to spare our hearing from the damaging decibels emitted by the stone-busting machine. The military gives hazardous duty pay, as do other professions. Why not for us?
But getting back to my original point, I reviewed some material from the literature that was illuminating. Writing in Anesthesiology (2000;93[4]:922-930) in the article “Cause-Specific Mortality Risks of Anesthesiologists,” the authors concluded that: “Anesthesiologists had an increased risk of death from suicide, … drug related death, … death from other external causes … and death from cerebrovascular disease. Male anesthesiologists had an increased risk for death from HIV and viral hepatitis. … Substance abuse and suicide represent significant occupational hazards for anesthesiologists.”
Apparently much has been written regarding cancer spread and anesthesia exposure. This can be looked at from differing points of view, but the two approaches are interrelated: Does exposure to anesthetic agents or the OR environment contribute to the development of cancer, or does anesthesia choice merely mitigate the spread or severity of existing cancer? In a paper titled “Pancreatic Cancer and Microenvironments: Implications of Anesthesia,” the authors observed that “evidence shows that perioperative factors, including surgical manipulation, anesthetics, or analgesics, might alter the tumor microenvironment and cancer progression” (Cancers [Basel] 2022;14[11]:2684).
Certainly, with regard to the development of cancer and anesthesia exposure in surgical patients, the data are mixed. Writing in Frontiers of Oncology (2021;11:803266) the authors reported: “In vitro and in vivo studies have shown that when breast, ovarian and renal cell carcinomas cells are exposed to volatile gases there is … an increase in growth, angiogenic and migration factors.” (This effect was not shown, however, to be present in non-small cell lung cancer, where exposure to volatile anesthetic agents appeared to have been somewhat protective.)
And finally, writing in the International Journal of Physiology, Pathophysiology and Pharmacology (2013;5[1]:1-10) in “The Effects of Anesthetics on Tumor Progression,” the authors concluded: “Volatile anesthetics are often protective against hypoxia; however, this very protective mechanism may lead to tumor growth and a poor prognosis. … A good approach is to avoid regimens that are potentially harmful and favor these potentially beneficial. The former includes volatile anesthetics, systemic opioids, and ketamine; while the latter includes regional block, local anesthetics, and propofol. In addition, multidisciplinary strategies need to be implemented to reduce perioperative stress.”
But what of anesthesiologists who, unlike the acute surgical patient, endure long-term and continuous exposure to anesthetic gases? Are the implications for us and the potential for the development of cancer different? The answer is not clear. But if inhalational anesthetics, the vapors of which have been inhaled by anesthesia staff over many years and potentially affect us in ways unlike IV, orally ingested or local anesthetics, can have potentially deleterious consequences for us, one has to ask: Should not more research be done in this area to protect us?
Sherer is a retired anesthesiologist and an author. His book “Into the Ether” was published in 2021. Watch for Sherer’s quarterly column “Wake-up Call” in future issues.
Editor’s note: The views expressed in this commentary belong to the author and do not necessarily reflect those of the publication.