Methodology for scientific evaluation of palliative surgery

Indicators of surgery and survival in oncology inpatients requiring surgical evaluation for palliation

BACKGROUND

We sought to determine the clinical presentation, management, and outcomes associated with surgical consultation for symptom palliation in oncology inpatients.

MATERIALS AND METHODS

We reviewed the medical records of inpatients for whom surgical consultations were requested (January 2000 to September 2006) at a tertiary referral cancer center to identify those who underwent surgical palliative evaluation (defined as consultation for symptoms attributable to an advanced or incurable malignancy). We used the Cox proportional hazards model to identify prognostic factors associated with overall survival (OS) and logistic regression to identify factors associated with surgical intervention.

RESULTS

Surgical consultation was requested for 1,102 inpatients; 442 (40%) met the criteria for surgical palliative evaluation. Gastrointestinal obstruction was the most common complaint (43%), while wound complications/infection and gastrointestinal bleeding accounted for 10% and 8%, respectively. The median OS was 2.9 months. Adverse prognostic factors for OS included > or = 2 radiologically evident disease sites (HR = 1.4; 95% CI, 1.1-1.8) and carcinomatosis/sarcomatosis (HR = 1.4; 95% CI, 1.1-1.7). Palliative surgical procedures were performed in 119 (27%) patients, with a 90-day morbidity and mortality rate of 40% and 7% respectively. Patients with wound complications (OR = 3.3; 95% CI, 1.4-7.6), intestinal obstruction (OR = 1.9; 95% CI, 1.1-3.2), or an intact primary/recurrent tumor (OR = 3.6; 95% CI, 2.2-6.0) were more likely to undergo surgical intervention. Patients with ascites were less likely to undergo surgery (OR = 0.4; 95% CI, 0.2-0.8).

CONCLUSIONS

Surgical palliative evaluations accounted for 40% of inpatient surgical consultations. Given that OS in this population is short and surgery is associated with considerable morbidity and mortality, non-operative management is desirable.

The Surgeon and Palliative Care

The incidence of cancer will continue to rise in the United States as the population ages. Despite the many advances in cancer prevention, detection, and treatment of neoplastic diseases, the number of people succumbing to their cancers will similarly increase. As these patients encounter symptoms toward the end of life, palliative means, both surgical and nonsurgical, must be employed to alleviate pain and suffering. This article reviews the definitions of palliative care, methods for evaluating quality of life and effect of interventions, unique aspects of surgical palliation, attitudes of surgeons concerning palliative surgery, and data from palliative surgery studies.