10.1245/s10434-006-9222-6
Annals of Surgical Oncology 14:1257-1263 (2007)
© 2007 Society of Surgical Oncology
The Surgeon and Palliative Care
Yale D. Podnos, MD, FACS and
Lawrence D. Wagman, MD, MPH
Department of General Oncologic Surgery, City of Hope National Medical Center, Duarte, CA, USA
Correspondence: Address correspondence and reprint requests to: Lawrence D. Wagman; Department of General Oncologic Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA 91010, USA; E-mail: lwagman{at}coh.org
 |
ABSTRACT
|
|---|
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.
Key Words: Surgery • Palliation • Quality of life • Education
|
INTRODUCTION
|
|---|
As the population in the United States grows and ages, the incidence of cancer will continue to increase. As evidence of this already occurring, an estimated 1,372,910 people will be diagnosed with neoplasms in the United States during 2005.1 Despite the many advances in education, prevention, detection, and treatment of neoplastic diseases, the number of people succumbing to their cancers will increase from approximately 550,000 in 2002 to over 570,000 estimated in 2005.1,2 This number will undoubtedly rise as the number of older Americans doubles to over 86 million by 2050.3 For an individual patient, as the disease progresses, an array of symptoms becomes manifest that greatly affects the patient’s quality of life, burden the patient’s family, and tax the health care system. In fact, worries of becoming burdensome to family and care-givers and fear over dying in pain serve as significant detriments to a patient’s overall quality of life.4
To combat many of these concerns in end of life care, the field of palliative medicine in the United States came into being as an extension of the successful hospice movement begun in Connecticut in 1974.5 Since then, the number of facilities providing multi-specialty palliative care has increased tremendously. However, it was not until recently that the field of palliative care and, in particular, surgical palliation of patients with advanced malignancies, shed its status as an underground cause and came to the forefront. Facilitating this change was the formulation of specific definitions of palliative care. Foremost among these definitions is that of the World Health Organization. Declared in 1997, it defines palliation as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering, by the means of early identification, impeccable assessment, treatment of pain and other problems, including physical and spiritual."6 The Institute of Medicine defined palliation as seeking "to prevent, relieve, reduce, or soothe the symptoms of disease or disorder without affecting a cure."7 Additionally, palliative surgery has been defined as " . . . limited to operations performed to relieve symptoms. The operations may be inclusive of treating the disease process with curative intent, but in all cases the management of symptoms should be an element of the intervention. Specifically, operations with curative intent in asymptomatic patients that results in residual disease or positive margins should be considered noncurative, not palliative."8
To achieve the aforementioned ends, philosophies of palliation have been stated.9 These paradigms stress the integral and inevitable process of death as part of one’s life and strive to help the patient accept their situation and achieve a sense of closure while getting ready for death. In providing support and care for terminally ill cancer patients, an interdisciplinary team concentrating on quality of life parameters (physical, psychological, social, and spiritual) is assembled to affect interventions aimed not necessarily at extension of life but on maximizing life enjoyment and reducing suffering. It is with these parameters that surgeons may begin to focus on ameliorating symptoms and improve a dying patient’s quality of life.
Across the spectrum of advanced cancer, symptoms commonly arise that detrimentally affect quality of life. They often occur in groups or clusters (e.g., nausea, vomiting, abdominal distention) and stem from a common cause (e.g., intestinal obstruction). Locally advanced or metastatic disease from cancers, such as lung, colorectal, melanoma, ovarian, hepatobiliary, and pancreatic primaries often cause devastating symptoms. Pain is the most common patient complaint, occurring in approximately 80% of patients.10 Wound complications and odor affected 22% of patients. The gastrointestinal symptom cluster that includes abdominal pressure and nausea and vomiting affected 19% and 16% of patients, respectively. Jaundice, immobility, and dysphagia were also cited as major symptoms requiring palliation. Most of these signs and symptoms are manifestations of the specific cancers, primary disease location, extent, and metastatic spread and may be amenable to operative palliation.
Surgery plays a great role in the treatment and improvement of these progressively moribund patients. A retrospective study by Krouse et al. found that 13% of all operations in a quaternary cancer center over a 1-year period were palliative in nature.11 Neurosurgical, thoracic, and orthopedic surgical procedures were those most likely utilized in the palliative setting. The most common primary cancer diagnoses were lung (pleural effusions), colorectal (bowel obstruction), breast (bony metastases and pleural effusions), and prostate (bony metastases).
|
METHODS FOR EVALUATING PALLIATIVE SURGERY
|
|---|
In assessing the outcomes of any palliative endeavor, measured quality of life factors are classified as physical, psychological, spiritual, and social. Physical quality of life pertains to the prevalence, intensity, and duration of symptoms, such as pain, nausea, vomiting, insomnia, and anorexia brought about by disease progression. Psychological quality of life deals with patients’ emotions and psychologic concerns. It is in this realm that communication by the surgeon may play a large role in ameliorating the devastating impact of end-of-life symptoms on quality of life.12,13 Spiritual quality of life describes the philosophic aspect of life and the sense of spirituality. Inherent in this are the use of religion or other cultural mechanisms by which we derive comfort and/or purpose. Finally, social quality of life depicts the health of personal relationships and social interactions and greatly affects patient attitudes regarding end of life. Sexuality and familial relationships serve as extremely important aspects of social quality of life. Measurements of these quality of life parameters are best done by the patient, for only the patient experiences (and thus can assess) their quality.
Much of the difficulty in palliative medicine arose from the dearth of scientific data evaluating its successes and failures. Once standardized definitions of palliation existed, methods for its measurement became available. While not exclusive, the most commonly used tools are the Functional Assessment of Cancer Therapy (FACT) and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires. Both are standardized tools with excellent validity that can be used in conjunction with supplemental disease-specific modules to tailor investigation for particular primary cancers. By being patient-reported quality of life measurements, these tools decrease the bias of physician reporting. The Karnofsky Performance Status and Eastern Cooperative Oncology Group tools are patient performance indicators that are physician assessed. Though often used to communicate outcome of palliative efforts, they weakly correlate with a patient’s quality of life.14
Regardless of the tool used, outcome assessment in palliative operations focuses on patient-reported quality of life, response of symptoms to interventions, length of response, and overall influence of operative morbidity compared with relief of targeted symptoms. In an effort to bring these factors together, the Palliative Surgery Outcome Score (PSOS) was devised.15 The score, defined as the number of symptom-free, nonhospitalized days divided by the number of hospitalized days (up to 180), is a measure of success and duration of interventions while factoring in perioperative morbidity. It measures the proportion of postoperative days that the patient is free of targeted symptoms and out of the hospital in the 6 months after the surgical intervention. The PSOS considers the facts that symptom relief may not be attainable or lasting and that perioperative morbidity may negate potential benefits. The time interval is limited to 180 days because many patients, due to the progressive nature of their cancers, will have had the specific symptom recur by that time.16 A score of 0.70 was determined by patient interviews to represent a successful intervention.17 This score reflected that the patient enjoyed 70% of postoperative time without the specific symptom and out of the hospital. Using measurements such as this will allow practitioners to have quantitative, comparative data to relate to patients in a risk/benefit discussion. Globally, they serve as a means to compare specific interventions, perform comparisons between studies, and prepare meta-analyses.
|
SURGEONS ATTITUTES TOWARD PALLIATION
|
|---|
Despite the persistent variability and broad nature of the exact definitions of palliative surgery, its use is widespread. A survey of the members of the Society of Surgical Oncology published in 2002 revealed that approximately 21% of all operations done by these specialists are palliative in nature.18 Survey participants were comprised of 60% who defined their practice as general oncologic surgery, 47% practiced in a university setting and 36% practiced at a designated cancer center. Their distinction of whether a procedure was palliative or curative was made pre-operatively by 43% of respondents, postoperatively by 27%, and by patient prognosis in 30%. The goals of surgical palliation were most often symptom management and maintenance of patient independence. The practicing surgical oncologists in this group were relatively young, with a median age of 48.5 years. They reported a mean of only 5 h of instruction in palliative care in medical school, corresponding to a time that was 20 years before the Institute of Medicine Declaration of Palliative Care. Additionally, 30% of those responding received no instruction in either residency or fellowship training. Recent studies reiterate the lack of training provided by residency review committee approved surgical residencies in the field of palliative care. The deficiency is recognized and currently being addressed by entities governing medical student and resident education.19,20 A survey by Galante et al. comprised of 10% surgical oncologists and 40% general surgeons with a mean age of 50 years showed that 39% of survey respondents received no palliative care training and that the median number of hours spent in palliative education was 0.21 In this latest study, decisions to treat a series of theoretical patients with palliative surgery were elicited. The decisions to intervene surgically were most often affected by the preoperative functional status of the patient, expectation for extended survival, and surgeon perceived potential for symptom management.
Because of the frequency of palliative operations and complexity of these cases (both technically and emotionally), the American College of Surgeons formed a Task Force of Palliative Care and the American Board of Surgery mandated that all surgery residents receive training in family and patient counseling and the management of specific signs and symptoms. Additionally, a Palliative Care Symposium was published in the Journal of the American College of Surgeons examining palliative care definitions, measurements, and applications for surgeons and another prominent review was recently featured in the British Journal of Surgery.22,23 Future studies will elucidate whether these efforts at expanding knowledge and scope of practice in surgical palliation translate into greater surgical consultative and operative input in the care of those with advanced malignancies. Moreover, with improved and consistent metrics, studies can determine if that input corresponds with improvements and prolongation of patients’ quality of life.
The dilemmas that are encountered by surgical oncologists are often times ethical matters difficult to navigate and, as such, training in the communication and implementation of palliation and its goals could be helpful to the physician, patient and family. Communication difficulties are common between these groups when discussing the transition from a curative to a palliative plan.24 Ethical dilemmas occur commonly in surgical oncology practices. These dilemmas include providing honest information without obliterating hope, preserving patient choice, fostering the use of advanced directives without implying hopelessness, and knowing how to negotiate the conflict when the patient and family have different goals of care.25 Good communication between all parties could facilitate a smooth transition to palliative care and alleviate or at least ameliorate both patient and family concerns. Most decisions are made in the context, both real and perceived, of life and death. Therefore, particular attention and focus should be taken to address the operative goals, perioperative course, and expected risks and benefits, as these factors most commonly are large sources of concern for family members and caregivers.26
|
EFFECT OF SURGERY AS PALLIATION
|
|---|
As surgeons, our desire to cure patients of their cancers is the predominate goal. Historically, this focus on cure resulted in diminished interest once it was ascertained that cure is unattainable. However, the increasing interest in palliation with favorable and reproducible results is changing that posture. To date, several studies have documented the utility of surgery for the control and improvement of symptoms. A recent prospective study by McCahill et al. of 59 patients found that approximately 80% of patients with preoperative symptoms achieved resolution of the dominant symptom.10 Seventy-eight percent of patients with initial complaints of pain were relieved by an operation. Morbidity was 14% and was predominately related to surgical wounds. However, in those with postoperative survival less than 6 months, only 36% were successfully palliated (as defined by a PSOS of 0.70 or greater). These results were consistent with those from Miner et al. in which patients not deriving a benefit from palliative operations had shorter postoperative survival.27 Clearly, some patients present to surgeons for palliation outside of the therapeutic timeframe. It thus becomes incumbent on the surgeon and multidisciplinary team to carefully select both the patients and symptoms that can be successfully palliated.
Major operations may be effective tools at palliating patients with advanced malignancies. For example, amputations can serve as effective means of controlling pain, bleeding, gangrene, and severe lymphedema in patients lacking chemotherapy or radiation alternatives.28 In patients with incurable liver tumors, transcatheter arterial chemoembolization, radioembolization, hepatic artery infusional chemotherapy, cryotherapy, and radiofrequency ablation each has utility in well-selected patients in controlling symptoms and possibly extending survival.29–33 Patients with malignant bowel obstructions who have abdominal explorations often benefit from the operative interventions that primarily include resections and bypasses.34,35 Many surgical and nonoperative (interventional radiology, invasive gastroenterology) tools are available to the surgical oncologist in treating these challenging patients. Additionally, the indications for palliative operative interventions in patients with advanced cancers are likely to expand as minimally invasive and endoscopic means are more commonly employed. Self-expanding metallic stents, routinely used in patients with esophageal cancer, have proven to be effective as means of palliation in patients with obstructing colorectal cancers and their use is expanding to gastric outlet and duodenal obstructions.36,37 In these studies, stenting effectively decreased otherwise necessary colostomy placement and lowered length of stay significantly, thereby increasing the PSOS.
|
RESOURCE UTILIZATION IN PALLIATIVE SURGERY
|
|---|
Perceptions regarding the futility of care often spill over into the concepts of palliative surgery. Expending time, effort, space, and revenue on incurable patients may be deemed by some as unreasonable. Despite the fact that cancer patients undergoing palliative operations are more likely to have greater disease severity and be more debilitated than those undergoing operations with curative intent, resource utilization is similar between the two groups.38 In a prospective study, Cullinane et al. followed the courses of 244 patients getting curative and 58 getting palliative operations at a cancer center over a 15-month period and analyzed the use and cost of a wide variety of hospital and outpatient resources. As would be expected, the palliative group had a larger proportion of breast, lung, bone, and soft tissue primary tumors and they were more likely to have undergone prior surgery, chemotherapy, and radiation. In-hospital mortality was 1 and 7% for patients getting curative and palliative operations, respectively. Length of stay and postoperative morbidity were not significantly different. Postoperatively, there was no difference in the total number of encounters, but the curative group was more likely to be seen for subsequent chemotherapy, radiation, or further surgery while the palliative patients were more likely to be seen for symptom management. Upon discharge, 9% of curative and 6% of palliative patients required care at locations other than home. These results show that patients undergoing palliative operations do not require significantly more health care resources than those patients getting operations with curative intent. However, the types of resources used by the palliative surgery patient are different and distinct. As the use of operations in palliative care continues to grow, these utilization factors become important in counseling and resource planning in order to educate patients and family and plan for necessary acute and longer–term resource needs.
|
GUIDELINES
|
|---|
Despite research showing that patients with incurable disease on a dedicated palliative care oncology unit have better documentation of care goals and plans, more symptoms assessed and managed, and fewer overall intervention, no clear guidelines exist for when and how to refer a patient to a palliative care specialist.39 Attempts have been made, however, to define the goals of palliative medicine and offer suggestions regarding their more widespread use. The American College of Surgeons published the "Principles Guiding Care at the End of Life" in 1998 to provide overall goals of palliative treatment (Table 1
).40 Once these principles and goals were established, clinical skills required by the practicing surgeon were defined (Table 2).41 Because of the difficulty in deciding when in the course of a disease a patient should be referred to a palliative medicine physician, the American Hospice Foundation recommended that palliative care be integrated into patient management at the diagnosis of any serious disease.42 This group also identified the essential skills for physicians practicing palliative medicine as: (1) the discussion of prognosis, (2) assessment of the patient’s entire quality of life, (3) establishment of goals, and (4) attention to grief and bereavement.
Received for publication June 16, 2006.
Accepted for publication June 26, 2006.
TOP
ABSTRACT
INTRODUCTION
