Surgical pharmacists should be familiar with the working characteristics of the surgical department. (1) Disease characteristics (tumor location, staging, pathological and molecular diagnosis, and oncologic emergencies). (2) Patient characteristics (age, liver and kidney damage, comorbidities such as pleural effusion and ascites, poor physical condition, multi-course treatments, and multiple departments). (3) Treatment characteristics (radical surgery, elective surgery, emergency surgery, comorbidity treatment, and infection management). (4) Medication treatment (drug selection, combination medication, medication route, dose adjustment, drug-drug interaction, and adverse reactions). Based on clinical evidence, surgical pharmacists provide perioperative medication management of stress, anti-infection, anesthesia, pain, blood sugar, thrombosis, PONV, nutrition, and blood pressure, by professional knowledge of pharmacotherapeutics and pharmacokinetics.

Focusing on the whole process perioperative management of surgical oncology patients, surgical pharmacists take the following steps for treatment path management.

Before surgery: (1) Obtain complete medical history from patients. Comprehensively sort out the preoperative medication, especially multi-course treatments and chemotherapy with limited cumulative doses. Record all prescription and non-prescription drugs, TCM, and health care products. (2) Develop an individualized treatment plan. Based on the drug list, surgical plan and pathophysiology should be discussed in MDT meetings, with emphasis on contraindications and precautions.

During surgery: (1) Antibiotics standardized use. (2) Pay attention to drug-drug interaction, drug compatibility, and adverse reactions. Focus on rational use of sedatives, narcotics, antiemetic drugs, and airway management. (3) Review surgical records, MRPs, and postoperative orders, and timely adjust the treatment plan based on comorbidity and relevant indicators.

After surgery: (1) Re-evaluate the patient cases, including postoperative pain, nausea, vomiting, postoperative nutrition, thrombosis prevention, and hemodynamic evaluation. (2) Analyze the efficacy, safety and compliance of perioperative drugs, and actively carry out therapeutic drug monitoring when necessary. (3) Conciliation medication usage after patients return to the ward whose physiological and biochemical indexes tend to be stable.

The whole process of therapeutic education to patients: (1) During perioperative period, therapeutic education includes perioperative pain management, nutritional support, nausea and vomiting caused by operation, venous thrombosis, and blood glucose changes. (2) During period of treatment at home, surgical pharmacists provide education about nutritional support, exercise and rehabilitation mode, as well as drug storage.

Follow-up: (1) Make a highly operable follow-up plan. (2) Establish exclusive follow-up management files for patients, update and manage them dynamically. (3) Follow-up can be carried out by a variety of methods, including telephone, home visits, short messages, and apps like WeChat, to ensure the continuity and integrity of information10. (4) Pay attention to the new MRPs in each follow-up, and intervene in time to avoid serious adverse reactions.

Pharmacy service: provide pharmaceutical care after surgical treatment, including rational use of antitumor drugs, adverse reaction management, long-term management of cancer pain, blood pressure, blood glucose, and postoperative nutrition, etc.

Infection is a common cause of death in patients with cancer11. As cancer patients frequently receive surgery, radiotherapy, chemotherapy, and immunosuppressive therapy, they are more susceptible to infection because of reduced immune function. (1) For preventive use of anti-infective drugs, surgical pharmacists should take surgical incision types and risk factors into consideration. (2) For therapeutic use of anti-infective drugs, surgical pharmacists should clarify clinical indications and pathogens, then select antibiotics with high curative effect and low toxicity according to antibacterial activity, pharmacokinetic characteristics, adverse reactions, and cost.

Anesthetics reduce anxiety, maintain intraoperative hemodynamic stability, and reduce postoperative adverse reactions. Non-steroidal antiinflammatory drugs have analgesic effects and act by inhibiting cyclooxygenase12. Etomidate enhances the inhibition of the neurotransmitter γ-aminobutyric acid and has stable cardiorespiratory profile and no cardiovascular or respiratory depression13. As an intravenous hypnotic drug, propofol acts through the potentiation of the inhibitory neurotransmitter γ-aminobutyric acid13. Surgical pharmacists should be familiar with the pharmacology, pharmacokinetics, and pharmacotherapeutics of anesthesia-related drugs, to provide medication suggestions for drug selection and dosage adjustment.

Cancer patients often have persistent pain in perioperative period, which causes inflammation, hypothalamic pituitary axis activation, and sympathetic system overreaction, leading to immunosuppression. Surgical pharmacists participate in the comprehensive pain management, by performing preoperative evaluation, discussing in MDT meetings, and continuously monitoring analgesic effect, to prevent the transformation of acute pain to chronic pain, to help patients receive the best supportive care, and to reduce rates of adverse reactions.

It's more difficult to make blood glucose management in cancer patients with diabetes. Multiple factors may contribute to the progression of cancer in obesity and type 2 diabetes, leading to poor healing and infection14. Surgical pharmacists should pay attention to blood glucose management by the following steps: (1) Evaluate the impact of previous antitumor treatment and high-risk factors on blood glucose before operation. Evaluate the potential risk patients will have and stratify them. (2) Multi-point blood glucose monitoring is recommended for all patients in perioperative period. (3) Keep blood glucose monitoring after operation. Diet control, oral hypoglycemic drugs, insulin, and nutritional support are used to control blood glucose.

Venous thromboembolism (VTE), which is divided into deep-vein thrombosis and pulmonary embolism, is one of the important causes of mortality among cancer patients15. (1) Surgical pharmacists should actively discuss about VTE prevention and treatment in the MDT meeting, participate in the development of VTE management, and conduct risk assessment of VTE and bleeding for patients. (2) Surgical pharmacists provide the whole process of monitoring services throughout admission, transition to the hospitalization unit and discharge, take timely appropriate preventive intervention according to VTE risk factors, and adjust treatment strategies based on the results of assessment to reduce or avoid the occurrence of nosocomial VTE and the rate of mortality and disability. (3) For the treatment of VTE, the thrombus site and area and contraindications to anticoagulation need to be taken into account. (4) Pharmacologic therapies in anticoagulation are the core treatment, and the risk of thrombosis and bleeding should be balanced to make reasonable individualized treatment.

PONV affect recovery, even lead to dehydration, electrolyte imbalance, and wound dehiscence. Important risk factors for postoperative nausea and vomiting include female, no history of smoking, history of nausea and vomiting after surgery, history of motion sickness, age < 50 years, and obesity. 5-hydroxy tryptamine 3 receptor antagonists, neurokinin type-1 receptor antagonists, corticosteroids, phenothiazines, and anticholinergics are drugs commonly used. Surgical pharmacists can provide lifestyle and diet adjustment education for patients with high-risk factors. For patients taking multiple drugs in combination, therapeutic drug monitoring should be performed at the same time, with attention to adverse reactions. For example, corticosteroids can lead to postoperative blood glucose changes, delayed wound healing, and the increased risk of infection16.

Malnutrition is common in cancer patients, related to lower performance status, lower response to treatment, and increased treatment-related toxicity17. Surgical pharmacists can carry out whole-process nutrition management for patients according to the following process. (1) Preoperative nutritional screening, including tumor assessment, eating ability, important organ function assessment, energy consumption level, stress level, inflammatory indicators, metabolic status, as well as psychological status and physical activity assessment. (2) Perioperative nutritional support. The daily energy requirements for patients in the perioperative window are 25 to 30 kcals/kg/day18. Based on clinical manifestations of patients, parenteral or enteral nutrition is recommended. (3) Follow-up evaluation of nutritional intervention and patient education on daily diet is conducted after surgery.

Some anticancer agents are closely associated with hypertension19, which are mainly divided into two categories: vascular endothelial growth factor (VEGF) signaling pathway inhibitors that reduce effective capillary beds by reducing nitric oxide production and increasing endothelin-1 production20,21; some monoclonal antibodies targeting the epidermal growth factor receptor21. Surgical pharmacists can provide blood pressure management for patients: (1) Comprehensive evaluation before surgery about history of hypertension, blood pressure, medication, and especially the effect of previous anti-tumor therapy on blood pressure. (2) Abnormal blood pressure is mainly manifested as elevated preoperative blood pressure, hypertension during induction of anesthesia or at the end of surgery, hypotension at the late stage of anesthesia induction, unstable intraoperative blood pressure, and postoperative hypertension. Choose appropriate drugs to control blood pressure according to clinical practice. (3) Strict monitoring of blood pressure and timely treatment should be performed after surgery.

At present, the practice of integration of medication in surgical oncology is still being continuously explored. Throughout the entire diagnosis and treatment process (before hospitalization, before surgery, during surgery, after surgery, and after discharge), pharmacists-led medication integration is conducive to a more comprehensive understanding of medication use. Surgical pharmacists take the following steps for medication integration. (1) Obtain the complete medication history, especially of the patients who take multiple drugs due to chronic diseases. (2) Evaluate whether the long-term medications are still suitable in the perioperative period. Use of short-term perioperative medications should include careful consideration of patient's surgical characteristics, tumor characteristics, preoperative physical status, medication history, and especially drug-drug interaction. (3) Actively conduct therapeutic drug monitoring, and monitoring of efficacy and adverse events after surgery.