Decision making on surgical palliation based on patient outcome data

Improving the palliative-procedure decision-making process for patients with peritoneal carcinomatosis: A secondary analysis

BACKGROUND

Peritoneal carcinomatosis (PC) is common in patients with advanced gynecologic and gastrointestinal cancers. Frequently, patients with PC undergo palliative surgery or procedures to manage disease-related complications and side effects. However, there are limited data regarding patients' and family caregivers' decision-making processes about these procedures. Thus, we sought to describe the decision-making experiences of patients with PC who elect to pursue palliative surgical procedures and their family caregivers.

METHODS

We conducted a secondary analysis of qualitative data collected during a pilot randomized controlled trial of BOLSTER, a nurse-led telehealth intervention for patients with PC and their caregivers after an acute hospitalization and palliative procedure. Participants in both study arms described their experiences in semi-structured interviews. We re-analyzed coded qualitative data with a focus on understanding decision-making experiences surrounding palliative surgery and procedures using conventional content analysis.

RESULTS

Interviews from 32 participants, 23 patients and 9 caregivers, were analyzed. Participants reported their decision-making was complicated by illness uncertainty and a desire for clear, effective communication with surgical and medical oncology teams. Participants requested more information about the impact of palliative procedures on their daily life. Several also noted that, without improved understanding, a misalignment between patient and family caregiver goals and palliative procedures may inadvertently increase suffering.

CONCLUSION

Discussions related to patients' goals and preferences can improve the quality of treatment decision-making in patients with PC and their caregivers. Future research should test interventions to improve advanced cancer patients' illness understanding and decision-making surrounding palliative surgery and procedures.

Trajectories of Patient-Reported Outcomes After Palliative Gastrointestinal Surgery in Advanced Cancer: Is Good Quality of Life Sustainable?

To evaluate the trajectories and sustainability of health-related quality of life (HRQoL) outcomes after palliative gastrointestinal (GI) surgery and perioperative factors associated with HRQoL improvement postsurgery.

Background

Palliative patients face a wide range of physical, emotional, social, and functional challenges. In evaluating the efficacy of palliative surgical interventions, a major pitfall of traditional surgical outcome measures is that they fall short of measuring outcomes that are meaningful to patients during end-of-life. HRQoL tools may provide a more comprehensive assessment of the true value and impact of palliative surgery.

Methods

We prospectively recruit advanced cancer patients undergoing palliative GI surgery. The Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire was administered before and at regular intervals after surgery. HRQoL improvement was defined as ≥4-points increment in FACT-G total score over baseline. Duration of sustained HRQoL improvement above this threshold and factors associated with varying extents of HRQoL change were evaluated.

Results

Of the 65 patients, intestinal obstruction was the most common indication for surgery (70.8%). The mean baseline FACT-G total score was 70.7 (95% CI: 66.3-75.1). Forty-six (70.8%) patients experienced HRQoL improvement after surgery. This HRQoL improvement was sustained over a median duration of 3.5 months and was driven mainly by improvements in patients' physical and emotional well-being. Albumin was significantly associated with the extent of HRQoL improvements (P = 0.043).

Conclusion

A clinically significant and sustained improvement in HRQoL was observed after palliative GI surgery. Patients with higher preoperative albumin levels were more likely to experience HRQoL improvements.

Palliative Surgery for Advanced Cancer: Clinical Profile, Spectrum of Surgery and Outcomes from a Tertiary Care Cancer Centre in Low-Middle-Income Country

Objectives:

Palliative surgery for cancer plays an important role in the overall management, especially in low-middle countries with a significant burden of advanced cancers. There is a paucity of literature related to the field of palliative surgery. In this study, we present the clinical spectrum, profile of surgical interventions and outcomes of palliative surgical procedures performed at a tertiary cancer centre involving multiple organ systems.

Materials and Methods:

A retrospective analysis of prospectively maintained surgical oncology database of a tertiary care cancer centre was performed. Patients fulfilling the criteria of palliative surgery were analysed for clinical spectrum, indications for surgery, palliative surgical procedures and post-operative outcomes.

Results:

A total of 678 out of 8300 patients fulfilled the criteria for palliative surgery. Palliative surgical procedures were performed most commonly for gastro-oesophageal malignancies (36.4%) followed by colorectal cancers (24%) and breast cancer (12%). Palliative mastectomy was the most common procedure performed for advanced breast cancer and 7% of sarcoma patients had amputations. Symptom relief could be achieved in 80–90% of patients and post-operative morbidity was relatively high among hepatobiliary, gastrointestinal and gynaecological cancer patients.

Conclusion:

Globally, a significant number of cancer patients need palliative surgical intervention, especially in LMIC with a high burden of advanced cancers. Results of the current study indicate that gastrointestinal cancer patients constitute a major proportion of patients undergoing palliative surgery. Overall results of the current study indicate that excellent palliation can be achieved in majority of patients with acceptable morbidity and hospital stay.

QOL assessment after palliative surgery for malignant bowel obstruction caused by peritoneal dissemination of gastric cancer: a prospective multicenter observational study

BACKGROUND

Patients with peritoneal dissemination of gastric cancer have poor oral intake caused by malignant bowel obstruction (MBO). Palliative surgery has often been undertaken to improve quality of life (QOL), but few prospective studies on palliative surgery in this patient population have been published.

PATIENTS AND METHODS

We prospectively investigated the significance of palliative surgery using patient-reported QOL measures. Patients underwent palliative surgery by small intestine/colon resection or small intestine/colon bypass or ileostomy/colostomy for MBO. The primary endpoint was change in QOL assessed at baseline, 14 days, 1 month, and 3 months following palliative surgery using the Euro QoL Five Dimensions (EQ-5D™) questionnaire and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire gastric cancer module (QLQ-STO22). Secondary endpoints were postoperative improvement in oral intake and surgical complications.

RESULTS

Between April 2013 and March 2018, 63 patients were enrolled from 14 institutions. The mean EQ-5D™ utility index baseline score of 0.6 remained consistent. Gastric-specific symptoms mostly showed statistically significant improvement from baseline. Forty-two patients (67%) were able to eat solid food 2 weeks after palliative surgery and 36 patients (57%) tolerated it for 3 months. The rate of overall morbidity of ≥ grade III according to the Clavien-Dindo classification was 16% (10 patients) and the 30-day postoperative mortality rate was 3.2% (2 patients).

CONCLUSIONS

In patients with MBO caused by peritoneal dissemination of gastric cancer, palliative surgery did not improve QOL while improving solid food intake, with an acceptable postoperative morbidity and mortality rate.

In Search of the Optimal Outcome Measure for Patients with Advanced Cancer and Gastrointestinal Obstruction: A Qualitative Research Study

BACKGROUND

Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study is to delineate the symptom burden and experience of these patients.

PATIENTS AND METHODS

Twenty patients with advanced cancer and GIO described symptoms at time of surgical consultation. We analyzed the content of interview transcripts and ranked symptoms by frequency and according to an assessment of relevance conducted by an expert panel (surgeons, palliative care physicians, nurses, and patients/caregivers).

RESULTS

Among the 20 study patients, malignancy types included colorectal (n = 9), gastric (n = 4), urothelial/renal (n = 3), and other (n = 4), whereas sites of obstruction were the small bowel (n = 11), gastric outlet (n = 3), and large bowel (n = 6). Thirteen patients (65%) had received chemotherapy within 6 weeks. Imaging evidence of a primary/recurrent tumor was documented in 13 patients (65%), carcinomatosis in 11 (55%), and ascites in 16 (80%). Thirty patient symptoms were identified on qualitative interviewing. Seven GIO-specific items were identified as relevant by the expert panel and will be added to the core symptom assessment inventory for further testing.

CONCLUSIONS

We identified symptoms of importance that can be used to assess outcome after treatment of patients with advanced cancer and GIO. Testing for validity and reliability will be required before formal survey development.

Current role of palliative interventions in advanced pancreatic cancer

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management

OBJECTIVE

To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO).

BACKGROUND

MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life.

METHODS

Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital.

RESULTS

Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)].

CONCLUSIONS

VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.

Palliative Care in Surgery: Defining the Research Priorities

OBJECTIVE

To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field.

BACKGROUND

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care.

METHODS

The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps.

RESULTS

To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients.

CONCLUSIONS

Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.

Multicentre observational study of quality of life after surgical palliation of malignant gastric outlet obstruction for gastric cancer

BACKGROUND

Quality of life (QoL) is a key component in decision-making for surgical palliation, but QoL data in association with surgical palliation in advanced gastric cancer are scarce. The aim of this multicentre observational study was to examine the impact of surgical palliation on QoL in advanced gastric cancer.

METHODS

The study included patients with gastric outlet obstruction caused by incurable advanced primary gastric cancer who had no oral intake or liquid intake only. Patients underwent palliative distal/total gastrectomy or bypass surgery at the physician's discretion. The primary endpoint was change in QoL assessed at baseline, 14 days, 1 month and 3 months following surgical palliation by means of the EuroQoL Five Dimensions (EQ-5D™) questionnaire and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire gastric cancer module (QLQ-STO22). Secondary endpoints were postoperative improvement in oral intake and surgical complications.

RESULTS

Some 104 patients (23 distal gastrectomy, 9 total gastrectomy, 70 gastrojejunostomy, 2 exploratory laparotomy) were enrolled from 35 institutions. The mean EQ-5D™ utility index scores remained consistent, with a baseline score of 0·74 and the change from baseline within ± 0·05. Gastric-specific symptoms showed statistically significant improvement from baseline. The majority of patients were able to eat solid food 2 weeks after surgery and tolerated it thereafter. The rate of overall morbidity of grade III or more according to the Clavien-Dindo classification was 9·6 per cent (10 patients) and the 30-day postoperative mortality rate was 1·9 per cent (2 patients).

CONCLUSION

In patients with gastric outlet obstruction caused by advanced gastric cancer, surgical palliation maintained QoL while improving solid food intake, with acceptable morbidity for at least the first 3 months after surgery. Registration number 000023494 (UMIN Clinical Trials Registry).

Palliative Care in Surgery: Defining the Research Priorities

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet, these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social, and spiritual well-being and quality of life. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. The objective of this article was to describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. We propose a research agenda to address these gaps and provide a road map for future investigation.

Rethinking autonomy: decision making between patient and surgeon in advanced illnesses

Patients with advanced illness such as advanced stage cancer presenting with the need for possible surgical intervention can be some of the most challenging cases for a surgeon. Often there are multiple factors influencing the decisions made. For patients they are facing not just the effects of the disease on their body, but the stark realization that the disease will also limit their life. Not only are these factors a consideration when patients are making decisions, but also the desire to make the decision that is best for themselves, the autonomous decision. Also included in this process for the patient facing the possible need for an intervention is the surgeon. While patient autonomy remains one of the main principles within medicine, guiding treatment decisions, there is also the surgeon's autonomy to be considered. Surgeons determine if there is even a possible intervention to be offered to patients, a decision making process that respects surgeons' autonomous choices and includes elements of paternalism as surgeons utilize their expertise to make decisions. Included in the treatment decisions that are made and the care of the patient is the impact patients' outcomes have on the surgeon, the inherent drive to be the best for the patient and desire for good outcomes for the patient. While both the patient's and surgeon's autonomy are a dynamic interface influencing decision making, the main goal for the patient facing a palliative procedure is that of making treatment decisions based on the concept of shared decision making, always giving primary consideration to the patient's goals and values. Lastly, regardless of the decision made, it is the responsibility of surgeons to their patients to be a source of support through this challenging time.

Palliative surgery: incidence and outcomes

OBJECTIVES

To describe the goals of treatment, decision-making, incidence, and outcomes of surgical palliation in advanced cancer.

DATA SOURCES

Journal articles, research reports, state of the science papers, and clinical guidelines.

CONCLUSION

Surgical palliation is common in advanced cancer settings, and is indicated primarily in settings where the goals of treatment are focused on quality of life, symptom control, and symptom prevention. More research is needed to guide evidence-based best practices in palliative surgery.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses practicing in clinical and research settings have a responsibility to arm themselves with knowledge related to the indications and options of palliative procedures, and the impact of surgery on quality of life for patients and families facing advanced cancer.

Surgical management of soft tissue sarcomas: extremity sarcomas

Wide surgical resection is the recommended treatment for extremity soft tissue sarcomas. Chemotherapy and/or radiotherapy may improve local control, but with marginal effect on overall survival. Advanced reconstructive techniques and multidisciplinary care, including plastic surgery, may allow a higher rate of limb salvage. This report focuses on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.

Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review

IMPORTANCE

Care of patients with malignant bowel obstruction caused by peritoneal metastases may present an ethical dilemma for surgeons when nonoperative management fails.

OBJECTIVE

To characterize outcomes of palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis to guide decision making about surgery and postoperative interventions for patients with terminal illness.

EVIDENCE REVIEW

We searched PubMed, EMBASE, Cochrane Library, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature Plus, and Google Scholar and performed manual searches of selected journals from inception to August 30, 2012, with no filters, limits, or language restrictions. We used database-specific combinations of the terms intestinal obstruction, malignant, surgery or surgical, and palliat*. We included studies reporting outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis from any primary malignant neoplasm and excluded case studies, curative surgery, isolated percutaneous procedures, stenting for intraluminal lesions, and studies in which benign and malignant obstructions could not be distinguished. We assessed quality with the Newcastle-Ottawa Scale.

FINDINGS

We screened 2347 unique articles, selected 108 articles for full-text review, and included 17 studies. Surgery was able to palliate obstructive symptoms for 32% to 100% of patients, enable resumption of a diet for 45% to 75% of patients, and facilitate discharge to home in 34% to 87% of patients. Mortality was high (6%-32%), and serious complications were common (7%-44%). Frequent reobstructions (6%-47%), readmissions (38%-74%), and reoperations (2%-15%) occurred. Survival was limited (median, 26-273 days), and hospitalization for surgery consumed a substantial portion of the patient's remaining life (11%-61%).

CONCLUSIONS AND RELEVANCE

Although palliative surgery can benefit patients, it comes at the cost of high mortality and substantial hospitalization relative to the patient's remaining survival time. Preoperatively, surgeons should present realistic goals and limitations of surgery. For patients choosing surgery, clarifying preferences for aggressive postoperative interventions preoperatively is critical given the high complication rate and limited survival after surgery for malignant bowel obstruction.

Outcome measures other than morbidity and mortality for patients with incurable cancer and gastrointestinal obstruction

OBJECTIVE

To prospectively evaluate outcome measures of patients undergoing palliative surgical evaluation for gastrointestinal obstruction.

METHODS

Patients with an incurable malignancy undergoing consultation for gastrointestinal obstruction were prospectively enrolled from November 2009 to July 2012. We evaluated two patient-reported outcome measures of quality of life (Functional Assessment of Cancer Therapy-General [FACT-G]) and treatment satisfaction (Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-General Version 1 [FACIT-TS-G]) and five observational outcome measures (symptom improvement, 30 "good days," ability to tolerate diet at discharge, discharge home, and death within 90 days).

RESULTS

Of 53 patients enrolled, 13 had gastric outlet obstruction, 22 had small bowel obstruction, and 18 had large bowel obstruction. Patient-reported measures could not be analyzed because only 19 patients (36%) completed the FACT-G and FACIT-TS-G survey at 1-month follow-up. However, we were able to obtain results for the 5 clinical observational outcomes in all patients. Symptom improvement was obtained in 41 (77%) patients, 30 "good days" in 40 (75%), ability to tolerate diet at discharge in 45 (85%), discharge to home in 46 (87%), and 18 (34%) of patients died within 90 days of evaluation. Large bowel obstruction was associated with symptom improvement, and noncolorectal cancer histology and carcinomatosis were negatively associated with having 30 "good days." The ability to tolerate oral intake at discharge was associated with Eastern Cooperative Oncology Group performance status and no recent chemotherapy administration. Death within 90 days was independently associated with noncolorectal cancer histology, ascites, and nonsurgical treatment.

CONCLUSIONS

Observational outcome measures can provide follow-up data and the identification of variables associated with outcome for patients who are unable to respond to outpatient surveys.

Can patient reported outcomes help identify the optimal outcome in palliative surgery?

BACKGROUND

The purpose of this pilot study was to determine whether an open-ended questionnaire captures severe symptoms in cancer patients undergoing palliative surgical consultation that a structured, validated quality-of-life assessment does not capture.

METHODS

We prospectively used the Functional Assessment of Cancer Therapy-General (FACT-G) and an open-ended questionnaire to assess the symptoms of patients with incurable malignancies who underwent palliative surgical consultation at our institution between January 2011 and September 2012.

RESULTS

Of the 69 patients enrolled, the most common indications for consultation were bowel obstruction (54%), jaundice (13%), wound problems (10%), and gastrointestinal bleeding (7%). Of the severe symptoms patients reported, 76% were identified with the FACT-G alone, 22% were identified with the open-ended questionnaire alone, and 2% were duplicate responses captured with both the FACT-G and open-ended questionnaire. The open-ended questionnaire captured 68 instances of severe symptoms in 47 patients that the FACT-G did not capture; of these symptoms, 52 were considered to be highly relevant to surgery and potential outcome measures.

CONCLUSIONS

An open-ended questionnaire can identify severe symptoms that a global quality of life survey cannot capture and could be used in conjunction with a global survey to reassess symptoms after palliative surgical consultation.

Palliative treatment and the role of surgical resection in gastric cancer

Adenocarcinoma of the stomach is often diagnosed in the late stages of the disease. Surgical resection of all gross and microscopic disease is essential for curative treatment. Complete resection is often not achievable when patients present with advanced stage IV cancer. In the absence of symptoms, chemotherapy without resection has been the standard of care in most major centers. With improvements in response to chemotherapy and less invasive surgical approaches, patients with metastatic gastric cancer have had better survival outcomes than in the past. The challenge today when treating these patients is in defining who will benefit from more aggressive interventions. Reviewing the literature for guidance is difficult because the goals of treatment are often not clearly defined. Finding the proper balance of aggressiveness needed to extend survival while preserving and maximizing quality of life is a decision that clinicians have to make with increasing frequency. This review will attempt to provide a framework to aid in determining what role, if any, gastrectomy has in the management of patients with stage IV gastric cancer.

The clinical value of non-curative resection followed by chemotherapy for incurable gastric cancer

BACKGROUND

The clinical value of a non-curative resection for gastric cancer is still controversial. We analyzed the clinical outcomes of patients who underwent non-curative gastric resection.

METHODS

Data from a total of 178 patients who underwent non-curative resection for advanced gastric cancer at Seoul St. Mary's hospital were reviewed. Factors related to the incurability were classified as peritoneal metastasis (P), liver metastasis (H), extra-abdominal metastasis (X), direct adjacent organ invasion that was unresectable (T). The clinicopathologic data, survival, and quality of life of patients were evaluated.

RESULTS

The overall median survival time was 12.1 months, and that for the patients with gastrectomy with chemotherapy was 14.3 months. Operation-related complications occurred in 20 patients (11.2 %). Five patients (2.8 %) died of postoperative complications within 30 days, and 43 patients (24.2 %) had symptoms and signs of gastric outlet obstruction or uncontrolled bleeding. The mean duration of postoperative hospital stay was 15.9 days for those symptomatic patients, and the symptom-relieved period was 8.6 months.

CONCLUSIONS

There might be a role for non-curative resection followed by chemotherapy for incurable gastric cancer, in terms of survival, and this treatment approach should be carefully considered because of the high mortality rate associated with the disease. A large, randomized, prospective study is warranted to prove the benefit of non-curative resection in patients with incurable gastric cancer.

Patient reasoning in palliative surgical oncology

BACKGROUND

The purpose of this study was to determine the patient reasoning behind treatment choice after palliative surgical consultation.

METHODS

Patients undergoing palliative surgical consultation were prospectively enrolled in this observational cohort study (11/2009-5/2011) and administered an open-ended questionnaire asking for their reasoning in choosing their treatment strategy.

RESULTS

Of 98 patients enrolled, 54 were treated non-operatively and 44 with surgery. Patient responses indicating their reason for treatment selection were categorized into (1) quality of life or symptom relief, (2) unclear or response not related to treatment strategy, (3) increase length of life, (4) treat the cancer, (5) concerns over surgical complications, (6) doctor's recommendation, (7) religious reasons for treatment choice, and (8) for family. The most frequently cited reason for treatment selection was symptom relief or quality of life improvement in 46 patients. Thirty-eight patients cited their doctor's recommendation while 20 patients selected their treatment to increase length of life or treat their cancer. Only 2 patients cited concerns over surgical complications as their reason for choosing their treatment strategy.

CONCLUSIONS

The most common reasons for treatment selection in palliative surgical consultation include symptom relief or improvement in quality of life and the doctor's recommendation with few patients listing concerns over surgical morbidity.

Frequent and early death limits quality of life assessment in patients with advanced malignancies evaluated for palliative surgical intervention

BACKGROUND

The purpose of this study was to determine the feasibility and optimal timing of quality of life assessment for patients undergoing palliative surgical evaluation.

METHODS

Patients with an advanced malignancy undergoing consultation for palliative surgical intervention were prospectively enrolled from November 2009 to January 2011. Follow-up quality of life assessment was performed using validated instruments at 1 and 3 months post-enrollment. Univariate analysis of variables was performed to identify clinicopathologic variables associated with questionnaire completion.

RESULTS

Of 77 patients enrolled, the most common clinical presentations included bowel obstruction (32 %), abdominal pain (21 %), wound complications (18 %), and gastrointestinal bleeding (11 %). Of the 77 patients, 34 (44 %) were treated with nonoperative/nonprocedural care, 9 (12 %) with endoscopic or interventional radiologic procedures, and 34 (44 %) with surgery. Follow-up questionnaires were obtained at 1 month and 3 months in 48 % and 15 %, respectively. A total of 31 patients (40 %) died prior to study completion. On univariate analysis, death was the only factor associated with questionnaire response. All other demographic, clinical, and treatment variables were not associated with response to questionnaires. There were no significant differences in baseline or follow-up quality of life scores between patients treated with surgical intervention or nonoperative management.

CONCLUSIONS

Death during the study period was a significant factor in limiting adequate follow-up assessment. Future studies attempting to obtain follow-up data on patients evaluated for palliative surgical intervention may require larger patient numbers to account for frequent early death in this population and anticipate the need to account for the high rate of missing data in statistical analysis.

Morbidity and mortality after non-curative gastrectomy for gastric cancer in elderly patients

BACKGROUND AND OBJECTIVES

This study examined the surgical outcome of non-curative resection in elderly patients with gastric cancer.

METHODS

The study reviewed 278 patients who underwent non-curative resection for advanced gastric cancer. The clinicopathological features of elderly patients (≥ 75 years, n = 257) and younger patients (<75 years, n = 21) were compared.

RESULTS

Although no difference was observed in terms of preoperative performance, there were distinct differences in terms of albumin level, presence of symptoms, and the rate of comorbidities between the two groups. The postoperative morbidity and mortality rate did not differ between the two groups. Age, preoperative performance status, preoperative transfusion, and presence of comorbidity were not independent predictors of postoperative complications. However, the extent of gastric resection and combined resection were closely related to postoperative complications in patients with non-curative gastrectomy.

CONCLUSIONS

In a setting of non-curative resection for gastric cancer, age was not a limiting factor. Rather, the risk of postoperative morbidity should be considered carefully in total gastrectomy and combined resection.

Communication as a core skill of palliative surgical care

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills.

Optimal indications of surgical palliation for incurable advanced gastric cancer presenting with malignant gastrointestinal obstruction

BACKGROUND

Decision-making for surgical palliation remains one of the most challenging clinical scenarios. We investigated the optimal indications for surgical palliation in advanced gastric cancer (AGC) patients presenting with gastrointestinal (GI) obstruction.

METHODS

A retrospective analysis was performed on 53 consecutive patients who underwent surgical palliation for GI obstruction caused by AGC between 2000 and 2007 at Osaka National Hospital. The clinical course of each patient was followed until death. Postoperative improvement of oral intake, achievement of hospital discharge, and implementation of chemotherapy in each patient were documented and used as a triad to assess the quality of life (QOL). Prognostic factors for overall survival were investigated by univariate and multivariate analyses. In addition, postoperative morbidity and mortality rates were recorded.

RESULTS

Of the entire patient cohort, 64% demonstrated a QOL improvement by having achieved the triad. Performance status (PS) of 1 or less was the only significant predictive factor for QOL improvement. The median survival time (MST) of the whole patient cohort following surgical palliation was 161 days, while the MSTs of patients fulfilling the triad and of those failing to achieve the triad were 253 and 60 days, respectively, with a significant difference between them (P < 0.0001). PS of 1 or less (hazard ratio 0.265, P = 0.0008) and recurrent disease (hazard ratio 0.394, P = 0.043) were identified as significant independent prognostic factors for longer survival on multivariate analysis. Overall morbidity and 30-day postoperative mortality rates were 24.5% (13 patients) and 7.5% (4 patients) respectively.

CONCLUSIONS

In AGC patients presenting with GI obstruction, surgical palliation was beneficial in patients with PS of 0-1 and those with recurrent disease, in terms of improved QOL and prolonged survival, with acceptable operative morbidity and mortality rates.

Communication skills in palliative surgery: skill and effort are key

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills.

Management of stage IV rectal cancer: Palliative options

Approximately 30% of patients with rectal cancer present with metastatic disease. Many of these patients have symptoms of bleeding or obstruction. Several treatment options are available to deal with the various complications that may afflict these patients. Endorectal stenting, laser ablation, and operative resection are a few of the options available to the patient with a malignant large bowel obstruction. A thorough understanding of treatment options will ensure the patient is offered the most effective therapy with the least amount of associated morbidity. In this review, we describe various options for palliation of symptoms in patients with metastatic rectal cancer. Additionally, we briefly discuss treatment for asymptomatic patients with metastatic disease.

Soft tissue sarcoma presenting with metastatic disease: outcome with primary surgical resection

BACKGROUND

The objective of this study was to assess patient, tumor, and treatment factors that affected overall survival in a group of patients who underwent surgery for soft tissue sarcoma (STS) and presented with American Joint Commission on Cancer stage IV disease.

METHODS

A retrospective review was undertaken of a single institution's database from the years 1986 to 2006 in all patients who met the following inclusion criteria: 1) surgical management of the primary tumor was undertaken, and 2) metastatic disease was present at the time of initial presentation. In total, 112 patients were identified who met the inclusion criteria.

RESULTS

The 5-year survival rate for the entire group was 17%. In univariate analysis, the variables that were identified as statistically significant for predicting improved overall survival were resection of metastatic disease (P = .003), <4 pulmonary metastases (P = .05), and the presence of lymph node metastases versus pulmonary metastases (P = .0002). In multivariate analysis, only the presence of lymph node metastases versus pulmonary metastases retained statistical significance (P = .05). The 5-year survival rate for patients who had lymph nodes metastases at diagnosis was 59%, whereas it was only 8% for patients who presented with pulmonary metastases.

CONCLUSIONS

Patients who presented with metastatic STS had a very poor prognosis despite aggressive surgical management of their primary tumor. The current results indicated that, although patients with isolated lymph node metastases may be cured by surgical resection, patients with pulmonary metastases are unlikely to be cured even with aggressive surgical management and should be treated with palliation of symptoms as the main objective.

A prospective evaluation of the durability of palliative interventions for patients with metastatic breast cancer

BACKGROUND

Although systemic therapy for metastatic breast cancer (MBC) continues to evolve, there are scant data to guide physicians and patients when symptoms develop. In this article, the authors report the frequency and durability of palliative procedures performed in the setting of MBC.

METHODS

From July 2002 to June 2003, 91 patients with MBC underwent 109 palliative procedures (operative, n=76; IR n=39, endoscopic n=3). At study entry, patients had received a mean of 6 prior systemic therapies for metastatic disease. System-specific symptoms included neurologic (33%), thoracic (23%), musculoskeletal (22%) and GI (14%). The most common procedures were thoracostomy with or without pleurodesis (27%), craniotomy with resection (19%) and orthopedic open reduction/internal fixation (19%).

RESULTS

Symptom improvement at 30 days and 100 days was reported by 91% and 81% of patients, respectively, and 70% reported continued benefit for duration of life. At a median interval of 75 days from intervention (range, 8-918 days), 23 patients (25%) underwent 61 additional procedures for recurrent symptoms. The durability of palliation varied with system-specific symptoms. Patients with neurologic or musculoskeletal symptoms were least likely to require additional maintenance procedures (P<.0002). The 30-day complication rate was 18% and there were no procedure-related deaths. At a median survival of 37.4 mos from MBC diagnosis (range, 1.6-164 months) and 8.4 months after intervention (range, 0.2-73 months), 7 of 91 patients remained alive.

CONCLUSIONS

Palliative interventions for symptoms of MBC are safe and provide symptom control for the duration of life in 70% of patients. Definitive surgical treatment of neurologic or musculoskeletal symptoms provided the most durable palliation; interventions for other symptoms frequently require subsequent procedures. The longer median survival for patients with MBC highlights the need to optimize symptom control to maintain quality of life.

Defunctioning stoma in high ASA grade, aged patients, with bowel occlusion due to advanced cancer: is it still worthwhile?

PURPOSE

The aim of this study was to assess the role of defunctioning stoma (DS) in elderly high-risk patients with bowel obstruction from advanced colorectal cancer, by exploring consistent variables of outcome, because every other procedure was unfeasible.

MATERIALS AND METHODS

A 6-year survey in a single surgery unit (between 1999 and 2004) was retrospectively evaluated, allowing to collect a cohort of 75 patients, aged over 65, who overall presented such critical condition. Pre-operatively, American Society of Anaesthesiologist grade classification was used. Post-operative course was monitored by focusing on gauging symptom relief. So, a validated assessment scale was employed to evaluate physical distress symptoms, graduated on a Likert scale and compared at baseline and day 7, on days 7 and 30, post-operatively. Length of hospital stay (LHS), morbidity, in-hospital (within 30 days) and overall mortality (within 6 months) were also assessed. Paired t test was used as statistical analysis to ascertain improvement of symptoms.

RESULTS

All symptoms improved significantly (range, p < 0.05 to p < 0.01) within the surveyed time, with exception of vomiting on day 30 (p = 0.14). Average LHS was 22.8 (standard deviation, +/-3.856) days. Overall morbidity was detected in 68 (91%) patients. In-hospital and overall mortality rates accounted for 27 (35.8%) patients and for 48 (100%) patients, respectively.

CONCLUSIONS

The role of DS was effective to improve symptom relief but was poor in terms of morbidity and mortality control. So, ethical concerns have to be addressed, and medical treatment or stenting for left-side obstructions only should be considered as alternative procedures.

A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer

OBJECTIVE

To obtain prospective outcomes data on patients (pts) undergoing palliative operative or endoscopic procedures for malignant bowel obstruction due to recurrent ovarian cancer.

METHODS

An institutional study was conducted from July 2002 to July 2003 to prospectively identify pts who underwent an operative or endoscopic procedure to palliate the symptoms of advanced cancer. This report focuses on pts with malignant bowel obstruction due to recurrent ovarian cancer. Procedures performed with an upper or lower gastrointestinal (GI) endoscope were considered "endoscopic." All other cases were classified as "operative." Following the procedure, the presence or absence of symptoms was determined and followed over time. All pts were followed until death.

RESULTS

Palliative interventions were performed on 74 gynecologic oncology pts during the study period, of which 26 (35%) were for malignant GI obstruction due to recurrent ovarian cancer. The site of obstruction was small bowel in 14 (54%) cases and large bowel in 12 (46%) cases. Palliative procedures were operative in 14 (54%) pts and endoscopic in the other 12 (46%). Overall, symptomatic improvement or resolution within 30 days was achieved in 23 (88%) of 26 patients, with 1 (4%) postprocedure mortality. At 60 days, 10 (71%) of 14 pts who underwent operative procedures and 6 (50%) of 12 pts who had endoscopic procedures had symptom control. Median survival from the time of the palliative procedure was 191 days (range, 33-902) for those undergoing an operative procedure and 78 days (range, 18-284) for those undergoing an endoscopic procedure.

CONCLUSION

Patients with malignant bowel obstructions due to recurrent ovarian cancer have a high likelihood of experiencing relief of symptoms with palliative procedures. Although recurrence of symptoms is common, durable palliation and extended survival are possible, especially in those patients selected for operative intervention.

Surgical palliation: getting back to our roots

This article provides an overview of the approach to patients who may benefit from palliative care. While the article's details lend themselves to the treatment of complications secondary to advanced malignancies, the data herein can also be extrapolated to other chronic, terminal diseases. Guidelines for patient selection are discussed, using currently available outcomes data as a platform for the critical decision making process. Suggestions for a multidisciplinary team approach are offered, using the palliative triangle as the ideal model of communication and cooperation. Finally, methods for measuring success are detailed, along with proposals for how to better equip the surgeons of tomorrow with the knowledge and experience needed to tackle these difficult and intimate problems.

Using the intensive care unit to teach end-of-life skills to rotating junior residents

BACKGROUND

This study tested the effectiveness and perceived value of a palliative/end-of-life (P/EOL) curriculum for junior residents implemented during an intensive care unit (ICU) rotation.

METHODS

Residents rotating through the ICU over a 6-month period completed pre- and post-curriculum surveys evaluating their self-assessed efficacy in providing P/EOL care and attitudes towards P/EOL care. Scores were analyzed using a paired Student t test.

RESULTS

Seventeen of 19 (90%) residents completed both the pre- and post-curriculum evaluations. The P/EOL curriculum increased self-assessed efficacy ratings in the domains of pain management (P = .04), psychosocial knowledge (P = .001), communicator knowledge (P = .001), professional knowledge (P = .002), and manager knowledge (P < .001). The rotation was rated as being valuable in preparing residents to care for patients near the end-of-life (P < .05), with surgery residents indicating it to be the most valuable rotation in their training program for learning about P/EOL care.

CONCLUSIONS

An ICU P/EOL curriculum improves self-assessed efficacy scores across multiple domains in P/EOL care and is seen as a valuable educational experience.

Palliation of colorectal cancer

Patients with advanced incurable colorectal cancer (CRC) face a grim prognosis. The goal of palliative intervention is directed at alleviating disease-related symptoms and improving quality of life. The provision of optimal palliative care for these patients is a compound and demanding process. This dilemma becomes more challenging when patients with advanced metastatic colorectal disease present with an incurable and asymptomatic primary lesion. Treatment options are numerous and include a variety of surgical and nonsurgical interventions. Most data regarding the role of surgery in palliation of CRC are from retrospective, nonrandomized case series. Surgical resection may provide good palliation of symptoms and prevent future tumor-related complications. Metal stents are also able to provide good palliative relief of obstruction and should be used when appropriate. The best palliative care will often require a multidisciplinary approach that involves input from surgical and nonsurgical teams, where treatment plans will be made in accordance with the wishes of the patient and family with a goal of decreasing morbidity and a focus on quality of life.

Palliative management of gastric cancer

Advanced gastric cancer and its palliative treatment have a long and interesting history. Today, gastric adenocarcinoma is the second leading cause of cancer death worldwide. Unfortunately, many cases are not diagnosed until late stages of disease, which underscores the importance of the palliative treatment of gastric cancer. Palliative care is best defined as the active total care of patients whose disease is not responsive to curative treatment. Although endoscopy is the most useful method for securing the diagnosis of gastric adenocarcinoma, computed tomography may be useful to assess local and distant disease. The main indication for the institution of palliative care is the presence of advanced gastric cancer for which curative treatment is deemed inappropriate. The primary goal of palliative therapy of gastric cancer patients is to improve quality, not necessarily length, of life. Four main modalities of palliative therapy for advanced gastric cancer are discussed: resection, bypass, stenting, and chemotherapy. The choice of modality depends on a variety of factors, including individual patient prognosis and goals, and should be made on case-by-case basis. Future directions include the discovery and development of serum or stool tumor markers aimed at prevention, improving prognostication and stratification, and increasing awareness and education.

Ethical issues in research to improve the management of malignant bowel obstruction: challenges and recommendations

Research to improve the care of patients with malignant bowel obstruction (MBO) is urgently needed. In particular, there is an urgent need for high-quality descriptive research, including prospective cohort studies, as well as randomized controlled trials to define optimal management strategies. However, investigators and clinicians face numerous barriers in conducting high-quality research in this patient population. These barriers include lack of funding, difficulties in identifying eligible patients, and a variety of practical and methodological challenges of designing these studies. In addition, there are a variety of ethical challenges that arise in the design and conduct of studies of MBO and particularly in the conduct of clinical trials. In this article, we address four categories of ethical issues: study design, recruitment, informed consent, and Institutional Review Board review. For each, we outline salient issues and suggest recommendations for enhancing the ethics of MBO studies, including interventional trials.

Teaching Palliative Care and End-of-Life Issues: A Core Curriculum for Surgical Residents

BACKGROUND

Most surgical training programs have no curriculum to teach palliative care. Programs designed for nonsurgical specialties often do not meet the unique needs of surgeons. With 80-hour workweek limitations on in-hospital teaching, new methods are needed to efficiently teach surgical residents about these problems.

METHODS

A pilot curriculum in palliative surgical care designed for residents was presented in three 1-hour sessions. Sessions included group discussion, role-playing exercises, and instruction in advanced clinical decision making. Residents completed pretest, posttest, and 3-month follow-up surveys designed to measure the program's success.

RESULTS

Forty-seven general surgery residents from Brown University participated. Most residents (94%) had "discussed palliative care with a patient or patient's family" in the past. Initially, 57% of residents felt "comfortable speaking to patients and patients' families about end-of-life issues," whereas at posttest and at 3-month intervals, 80% and 84%, respectively, felt comfortable (P < .01). Few residents at pretest (9%) thought that they had "received adequate training in palliation during residency," but at posttest and at 3-month follow-up, 86% and 84% of residents agreed with this statement (P < .01). All residents believed that "managing end-of-life issues is a valuable skill for surgeons." Ninety-two percent of residents at 3-month follow-up "had been able to use the information learned in clinical practice."

CONCLUSIONS

With a reasonable time commitment, surgical residents are capable of learning about palliative and end-of-life care. Surgical residents think that understanding palliative care is a useful part of their training, a sentiment that is still evident 3 months later.

Current role of surgical therapy in gastric cancer

Surgery is currently the only potentially curative treatment for gastric cancer. Since the inception of the gastrectomy for cancer of the stomach, there has been debate over the bounds of surgical therapy, balancing potential long-term survival with perioperative morbidity and mortality. This review delineates the current role of surgery in preoperative staging, curative resection, and palliative treatment for gastric cancer.

Palliative surgery for advanced cancer: lessons learned in patient selection and outcome assessment

INTRODUCTION

When considering the appropriate and effective use of palliative procedures, a surgeon is often confronted with a full range of multidisciplinary treatment options and technical considerations that could potentially relieve some of the symptoms of an advanced malignancy. Practitioners must often deliberate over complex choices that can greatly impact a patient's final days.

METHODS

Advances in the understanding of surgical palliation are reviewed with emphasis on elements required for sound clinical decision making.

RESULTS

Palliation of complications from advanced cancer demands the highest level of surgical judgment. Although consideration of risk in terms of treatment-related toxicity, morbidity and mortality is an important part of the surgical decision making process. Attention to this element should not be the sole factor in making decisions about palliative therapy. Decisions are best made on endpoints such as the probability of symptom resolution, the impact on overall quality of life, pain control, and cost effectiveness.

CONCLUSIONS

Regardless of the anatomic site and cause leading to the need for palliative intervention, deliberations over surgical palliation must consider the medical condition and performance status of the patient, the extent and prognosis of the cancer, the availability and success of nonsurgical management, and the individual patient's quality and expectancy of life. Therapy for symptoms must remain flexible and individualized to continually meet the patient's unique and ever changing needs.

Effectiveness of Palliative Procedures for Intra-Abdominal Sarcomas

BACKGROUND

Nearly half of patients with intra-abdominal (retroperitoneal, visceral, or pelvic) sarcoma undergo more than one operation. When the objective shifts from cure to palliation, the clinical quandary of doing no harm and maximizing benefit is magnified. Knowledge of the effectiveness of a procedure at achieving its palliative intent, as well as its attendant morbidity and mortality, is therefore paramount during this deliberation.

METHODS

A retrospective review was performed of all patients with a diagnosis of intra-abdominal sarcoma who underwent a palliative procedure between 1982 and 2003. A procedure was defined as palliative if it was explicitly performed to relieve symptoms.

RESULTS

Ten percent (112 of 1084) of patients with a diagnosis of intra-abdominal sarcoma underwent a total of 156 palliative procedures. The most frequent system for which a palliative procedure was performed was gastrointestinal (68 of 156; 44%). Overall, 71% of patients had improvement of symptoms 30 days after the operation, whereas only 54% of patients remained symptom free after 100 days. Although 54% of gastrointestinal tract obstructive symptoms were successfully relieved at 30 days, only 23% of patients remained symptom free at 100 days. The overall operative morbidity was 29%, and postoperative mortality was 12%. Patients undergoing procedures intended to palliate gastrointestinal obstruction encountered the greatest morbidity (19 of 40; 48%).

CONCLUSIONS

Successful palliation of many symptoms associated with advanced intra-abdominal sarcoma may be achieved. However, even in highly selected patients, the progressive and pervasive nature of the disease limits the opportunity to attain sustained relief for gastrointestinal obstructive symptoms.

Ethics of palliative surgery in patients with cancer

BACKGROUND

Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base.

METHOD AND RESULTS

Pertinent moral challenges are addressed and analysed with respect to prevailing perspectives in normative ethics. The vulnerability of patients with non-curable cancer calls for moral awareness. Demands regarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the 'duty to help', benevolence, respect of autonomy and proper patient information. Moreover, variations in definition of palliative surgery as well as limited scientific evidence with respect to efficacy, effectiveness and efficiency pose methodological and moral problems. Therefore, a definition of palliative surgery that addresses these issues is provided.

CONCLUSION

Both surgical skill and much moral sensibility are required to improve palliative care in surgical oncology. This should be taken into account not only in clinical practice but also in education and research.

Surgical palliative care

Surgery has always played a pivotal role in care of the patient with cancer, independent of treatment intent. Recent advances have expanded that role, not only in terms of modalities available, but more broadly in terms of the expectations of the surgeon as physician involved in the interdisciplinary care of the patient with symptomatic, incurable disease.