Medical Research: What is the background for this study?
Dr. Canter: Our data suggest that surgeons are improving in their ability to select patients for surgical intervention in cancer patients near their end of life. Our research suggests that surgeons may be operating on healthier patients who are anticipated to have a better recover from a palliative operation. These are patients who can perform activities of daily living without assistance, for example.
Our interest in the appropriate surgical care of people with late-stage cancer grew from observing terminally ill patients whose acute problems were addressed through surgery, and who then suffered complications resulting in lengthy stays in intensive care units, and even in death.
Unfortunately, it is quite common that this group of disseminated malignancy patients end up dying in the intensive care unit instead of being managed with less invasive interventions with hopes of returning home with their families, including with hospice care.
Medical Research: What are the main findings?
Dr. Canter: For the study, we used the American College of Surgeons National Surgical Quality Improvement Program between 2006 and 2010 to identify 21,755 patients with stage IV cancer. Over the five years in the study period, surgical interventions declined just slightly, from 1.9 percent to 1.6 percent of all procedures. The most frequent operations were procedures to alleviate bowel obstructions among cancer patients with metastatic disease. Also over time, the patients undergoing surgery were more independent and fewer had experienced dramatic weight loss or sepsis. These characteristics are generally associated with poorer surgical outcomes.
The patients’ rate of morbidity significantly decreased, from 33.7 percent in 2006 to 26.6 percent in 2010. Mortality declined as well, although more modestly, from 10. 4 percent to 9.3 percent over the study period.
Medical Research: What should clinicians and patients take away from your report?
Dr. Canter: Why surgeons continue to operate on patients at such high risk for complications and death is likely multifactorial. Some of it has to do with the patients and families, and what their expectations are. If the patient seems to be declining, the patient and the family may attribute this to an acute surgical process, when it is, in fact, related to their underlying cancer. When they see an acute process, they often think it can be fixed with an operation, when surgery may actually not fix the problem, or sometimes make it worse. In addition, in some cases, the surgeon as well as other members of the health care team also may be too optimistic about what the surgical outcome will be.
An important finding of this study was that just 3 percent of the patients with terminal cancer had Do Not Resuscitate (DNR) directives in place at the time of their surgery. DNRs, part of advanced directives used in end-of-life planning, direct physicians to withhold advanced life support if the patient stops breathing or their heart stops beating. These results imply that patients, families, oncologists, and other care providers, including surgeons, are often delaying discussions about the goals of the care and the priorities at the end of life. This is of critical importance since delaying end-of-life discussions can have serious consequences. This can lead to delayed referrals for palliative care and hospice. In addition, the patient risks undergoing multiple invasive, uncomfortable procedures in an attempt to prolong life, despite being against the patient’s goals of care and how they wish to spend their final days of life.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Canter: We think it is especially important that physicians and the treating team have end-of-life, goals-of-care discussions prior to the time that the patient comes into the hospital with an acute illness. This includes early referral of patients to palliative care treatment and to have a comprehensive end-of-life discussion to ensure that their goals of care are identified and respected as soon as patients are diagnosed with cancer, especially disseminated cancer since acute surgical problems may occur at any time and have dramatic impact of the patient’s end-of-life care.
MedicalResearch.com Interview with: Robert J Canter MD (2015). Many Patients With Disseminated Cancer Still Get Surgery