A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC)

Impact of early vs late palliative care referrals on healthcare utilization in patients with pancreatic cancer

PURPOSE

The purpose of this study was to examine the impact of early versus late palliative care referral (PCR) following pancreatic cancer diagnosis.

METHODS

Patients diagnosed with PDAC who received a PCR between 2014 and 2020 at a major academic institution were identified. PCR was classified as early (< 30 days) or late (≥ 30 days) based on time from definitive diagnosis. Data were obtained on number of emergency department (ED) visits, intensive care unit (ICU) admissions, and hospital admissions.

RESULTS

Among 1458 patients with PDAC, 419 (28.7%) received PCR, among which 67.3% (n = 282) received a late PCR. Of those who received PCR, the majority were White (85%) and male (54.8%), with a median age of 62 years at time of diagnosis. Patients who received an early PCR more commonly presented with stage 4 disease at diagnosis (early: n = 91, 69% vs. late: n = 132, 47%), whereas patients who received a late PCR more commonly presented with stage 1, 2, or 3 disease (early: n = 40, 30.5% vs. late: n = 150, 53.2%) (p < 0.001). Patients who received early PCR had fewer median ED visits (1 vs. 2, p < 0.001) and hospital admissions (1 vs. 2, p < 0.001) compared with patients who received late PCR. However, after performing recurrent-event Cox-proportional hazards models, the timing of PCR did not impact hospital admission (HR 0.88, 95% CI 0.68, 1.14; p = 0.3).

CONCLUSION

Timing of PCR for patients with PDAC was not associated with healthcare utilization. Further prospective trials are needed to study the patient-centered impact of early integration of palliative care services into multidisciplinary pancreatic cancer teams.

Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer: A Randomized Clinical Trial

Importance

Specialist palliative care benefits patients undergoing medical treatment of cancer; however, data are lacking on whether patients undergoing surgery for cancer similarly benefit from specialist palliative care.

Objective

To determine the effect of a specialist palliative care intervention on patients undergoing surgery for cure or durable control of cancer.

Design, Setting, and Participants

This was a single-center randomized clinical trial conducted from March 1, 2018, to October 28, 2021. Patients scheduled for specified intra-abdominal cancer operations were recruited from an academic urban referral center in the Southeastern US.

Intervention

Preoperative consultation with palliative care specialists and postoperative inpatient and outpatient palliative care follow-up for 90 days.

Main Outcomes and Measures

The prespecified primary end point was physical and functional quality of life (QoL) at postoperative day (POD) 90, measured by the Functional Assessment of Cancer Therapy-General (FACT-G) Trial Outcome Index (TOI), which is scored on a range of 0 to 56 with higher scores representing higher physical and functional QoL. Prespecified secondary end points included overall QoL at POD 90 measured by FACT-G, days alive at home until POD 90, and 1-year overall survival. Multivariable proportional odds logistic regression and Cox proportional hazards regression models were used to test the hypothesis that the intervention improved each of these end points relative to usual care in an intention-to-treat analysis.

Results

A total of 235 eligible patients (median [IQR] age, 65.0 [56.8-71.1] years; 141 male [60.0%]) were randomly assigned to the intervention or usual care group in a 1:1 ratio. Specialist palliative care was received by 114 patients (97%) in the intervention group and 1 patient (1%) in the usual care group. Adjusted median scores on the FACT-G TOI measure of physical and functional QoL did not differ between groups (intervention score, 46.77; 95% CI, 44.18-49.04; usual care score, 46.23; 95% CI, 43.08-48.14; P = .46). Intervention vs usual care group odds ratio (OR) was 1.17 (95% CI, 0.77-1.80). Palliative care did not improve overall QoL measured by the FACT-G score (intervention vs usual care OR, 1.09; 95% CI, 0.75-1.58), days alive at home (OR, 0.87; 95% CI, 0.69-1.11), or 1-year overall survival (hazard ratio, 0.97; 95% CI, 0.50-1.88).

Conclusions and Relevance

This randomized clinical trial showed no evidence that early specialist palliative care improves the QoL of patients undergoing nonpalliative cancer operations.

Trial Registration

ClinicalTrials.gov Identifier: NCT03436290.

Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial

Importance

Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations.

Objective

To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers.

Design, Setting, and Participants

From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients.

Intervention

Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation.

Main Outcomes and Measures

The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed.

Results

In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99).

Conclusions and Relevance

To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers.

Trial Registration

ClinicalTrials.gov Identifier: NCT03611309.

Informed Consent and Shared Decision Making in the Perioperative Environment

Informed consent and shared decision making (SDM) are crucial portions of preoperative patient management. Informed consent is a standard for surgery from both a legal and ethical standpoint, involving disclosure of potential risks of a procedure and ensuring patient understanding of these risks. SDM is a process in which a clinician and patients decide between two or more treatment plans, taking into account the patient's goals and values. SDM is a particularly important aspect of patient-centered care when two or more treatment options exist or in situations where an indicated treatment may not align with the patient's long-term goals. This article details aspects of and issues surrounding informed consent and SDM.

A Case Series on Pain Accompanying Photoimmunotherapy for Head and Neck Cancer

One of the most severe side effects of photoimmunotherapy (PIT) for head and neck cancer is pain. As there are presently no detailed reports on pain and pain management in PIT, we conducted a retrospective case series study. We conducted a retrospective study of five patients who had received PIT at the National Cancer Center Hospital East between January 2021 and June 2022 using medical chart data. All patients experienced pain, evidenced by an increased numerical rating scale (NRS) after PIT, regardless of the illumination method. The daily change in mean NRS rating shows that the pain was highest on the day of PIT, with ratings of 6.8 and 7.8 for the frontal and cylindrical diffuser methods, respectively; it dropped the following day quickly. Four of the five patients received fentanyl injections for postoperative pain management beginning on postoperative day (POD) 0. All patients who underwent therapy using a cylindrical diffuser required postoperative pain management with opioid drugs. Pain after PIT tended to be most intense immediately after or one hour after illumination and declined the following day, suggesting the need to have a pain relief plan in place in advance.

Patient-reported symptoms at discharge and risk of complications after gynecologic surgery

OBJECTIVE

Current gaps in knowledge limit clinicians from fully implementing patient-reported outcomes in routine post-operative care.

METHODS

This prospective study assessed symptoms via the gynecologic module of the MD Anderson Symptom Inventory (MDASI-PeriOp-GYN) in patients who underwent open laparotomy.

RESULTS

At discharge, patient-reported moderate to severe (≥4 on a 0-10 scale) abdominal bloating or abdominal cramping, combined with length of stay of ≥4 days, were found to be associated with a higher risk of 30-day post-operative grade II-IV complications by the Clavien-Dindo system (all p values <0.01). Also, length of stay of ≥4 days and moderate to severe urinary urgency at discharge were found to be associated with the need for re-admission (all p values <0.01).

CONCLUSION

This study defined the clinically meaningful symptoms that related to the risk of developing important complications after discharge from major open gynecological surgery.These findings support the integration of assessment of patient-reported outcomes into patient-centered post-operative care.

Palliative and Supportive Care Consultation for Patients With Malignant Gastrointestinal Obstruction is Associated With Broad Interdisciplinary Management

OBJECTIVE

The aim of this study was to assess rates of palliative care (PC) involvement in the care of patients with malignant gastrointestinal obstruction (GIO) and its influence on interdisciplinary team involvement.

BACKGROUND

Malignant GIO is an advanced oncologic diagnosis with associated poor prognosis. Data regarding PC and interdisciplinary team involvement in these patients is lacking.

METHODS

We identified consecutive surgical consultations for GIO in cancer patients at a single institution from August 2017 to July 2019. Clinical characteristics were collected. Rates of PC consultation, ACP discussion, code status change to do not resuscitate, and interdisciplinary service consultation were evaluated.

RESULTS

We identified 200 patients with consultations for GIO, of whom 114 (57%) had malignant GIO and were included in our study. Of these patients, 95 (83%) had stage IV disease; 68 (60%) had peritoneal metastasis, and 70 (61%) had other intra-abdominal recurrence or metastasis. PC consultation was obtained in 69 patients (61%). PC consultation was associated with higher rates of ACP discussion (64% vs 29%; P < 0.001), code status change to do not resuscitate (30% vs 2%; P < 0.001), nonsurgical procedure (46% vs 11%; P < 0.001), discharge to hospice (30% vs 7%; P < 0.001), and involvement of spiritual care (48% vs 22%; P = 0.01), social work (77% vs 42%, P < 0.001), psychology/psychiatry (42% vs 4%, P < 0.001), nutrition (86% vs 62%, P = 0.006), physical therapy (54% vs 31%, P = 0.02), and occupational therapy (42% vs 16%, P = 0.004).

CONCLUSIONS

PC consultation benefits patients with malignant GIO by facilitating comprehensive interdisciplinary care, ACP discussions, and transition to hospice care, where appropriate. Diagnosis of malignant GIO should be a trigger for PC consultation or, in facilities with limited PC resources, consideration of deliberately broad interdisciplinary consultation.

Missed Opportunities and Health Disparities for Advance Care Planning Before Elective Surgery in Older Adults

Importance

Advance care planning (ACP) prepares patients and caregivers for medical decision-making, yet it is underused in the perioperative surgical setting, particularly among older adults undergoing high-risk procedures who are at risk for postoperative complications. It is unknown what patient factors are associated with perioperative ACP documentation among older surgical patients.

Objective

To assess ACP documentation among high-risk patients 65 years and older undergoing elective surgery.

Design, Setting, and Participants

In this observational cohort study including 3671 patients 65 years and older undergoing elective surgery at a tertiary academic center in California, electronic health record data were linked to the National Surgical Quality Improvement Project outcomes data and the California statewide death registry. The study was conducted from January 1 to December 31, 2019. Data were analyzed from January to May 2022.

Exposures

Elective surgery requiring an inpatient admission.

Main Outcomes and Measures

ACP documentation, defined as a discussion regarding goals of care documented in an ACP note, an advance directive, or a physician order for life-sustaining treatment (POLST) form, within 90 days before elective surgery requiring inpatient admission. Multivariate regression was performed to identify factors associated with missing ACP.

Results

Among 3671 patients (median [IQR] age 72 [65-94] years; 1784 [48.6%] female; 401 [10.9%] Asian, 155 [4.2%] Black, 284 [7.7%] Latino/Latina, 2647 [72.1%] White, and 184 [5.0%] of other races or ethnicities, including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, other, and unknown or declined to respond, combined owing to small numbers), 539 (14.7%) had ACP documentation in the 90-day presurgery window. Of these 539, 448 (83.1%) had advance directives, and 60 (11.1%) had POLST forms. The 30-day and 1-year mortality were 0.7% (n = 27) and 6.6% (n = 244), respectively. Missing ACP was significantly associated with male sex (adjusted odds ratio [aOR], 1.39; 95% CI, 1.14-1.69) and having a non-English preferred language (aOR, 1.78; 95% CI, 1.18-2.79). Medicare insurance was significantly associated with having ACP (aOR for missing ACP, 0.63; 95% CI, 0.40-0.95).

Conclusions and Relevance

In this study, perioperative ACP was uncommon, particularly in men, individuals with a non-English preferred language, and those without Medicare insurance coverage. The perioperative setting may represent a missed opportunity for ACP for older surgical patients. When addressing ACP for surgical patients, particular attention should be paid to overcoming language-related disparities.

Advance care planning in patients undergoing surgery to resect pancreatic adenocarcinoma: Underlying tension between balancing hope and realism

BACKGROUND

The timing and the dose of Advanced Care Planning in patients with pancreatic ductal adenocarcinoma undergoing curative-intent resection are generally dictated by the surgeon performing the operation.

METHODS

A qualitative investigation using 1:1 interviews with 40 open-ended questions was conducted with a convenience sample of 10 high-volume pancreatic surgeons from across the country. The grounded theory approach was used for data analysis.

RESULTS

A total of 10 interviews were conducted with expert pancreatic surgeons-6 males and 4 females. During preoperative counseling, all surgeons attempt to motivate patients by emphasizing hope, optimism, and the fact that surgery offers the only opportunity for cure. All surgeons discuss the possibility of recurrence as well as postoperative complications; however, a majority perceived that patients do not fully appreciate the likelihood of recurrence or postoperative complications. All surgeons acknowledged the importance of end-of-life conversations when death is imminent. Seventy percent of surgeons had mixed opinions regarding benefits of preoperative Advanced Care Planning in the preoperative setting, while 20% felt it was definitely beneficial, particularly that delivery of care aligned with patient goals. All surgeons emphasized that Advanced Care Planning should be led by a physician who both knows the patient well and understands the nuances of pancreatic ductal adenocarcinoma management. Most common barriers to in-depth Advanced Care Planning discussion reported by surgeons include taking away hope, lack of time, and concern for sending "mixed messages."

CONCLUSION

We identified that surgeons experience a fundamental tension between promoting realistic long-term goals and expectations versus focusing on hope and enabling an overly optimistic perception of prognosis.

Cytotoxic, Antitumor and Toxicological Profile of Passiflora alata Leaf Extract

Passiflora alata or passion fruit is a native flowering plant from Amazon, geographically spread from Peru to Brazil. The plant has long been used in folks medicine for its pharmacological properties and is included in the Brazilian Pharmacopoeia since 1929. The aim of this study was to evaluate the potential cytotoxic and antitumor activities of Passiflora alata leaf extract (PaLE) in S180-tumor bearing mice. The percentage of cell proliferation inhibition (% CPI) and IC₅₀ in relation to 4 tumor cell lines were determined in PC3, K-562, HepG2 and S180 cell lines using the MTT assay. PaLE showed a CPI > 75% and greater potency (IC₅₀ < 30 µg/mL) against PC3 and S180 cell lines. PaLE showed antitumor activity in treatments intraperitoneally (36.75% and 44.99% at doses of 100 and 150 mg/kg/day, respectively). Toxicological changes were shown in the reduced body mass associated with reduced food consumption, increased spleen mass associated with histopathological increase in the white pulp of the spleen and increased number of total leukocytes with changes in the percentage relationship between lymphocytes and neutrophils. Our outcomes corroborate the conclusion that PaLE has antitumor activity in vitro and in vivo with low toxicity.

Improving quality in colon and rectal surgery through palliative care

Palliative care is a medical discipline that emphasizes quality of life and can be provided in parallel with recovery-directed treatments in colon and rectal surgery. Palliative care is receiving increasing attention and investigation for its potential to improve quality and outcomes for a wide spectrum of patients by benefiting symptom management, supporting complex health care decision making and facilitating care transitions. Primary palliative care refers to the application of palliative care principles by clinicians of all disciplines whereas specialty palliative care is a multidisciplinary approach and includes a clinician with advanced training and experience.

Palliative Care and End-of-Life Considerations for the Frail Patient

Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.