Surgeons increasingly selective in deciding whether to operate.
By Dorsey Griffith, UC Davis
The number of surgeries performed on terminally ill cancer patients has not dropped in recent years, despite more attention to the importance of less invasive care for these patients to relieve symptoms and improve quality of life. But new research from UC Davis also finds that the morbidity and mortality among patients with terminal cancer has declined because surgeons are selecting to operate on healthier patients.
The study, “Current Perioperative Outcomes for Patients with Disseminated Care Undergoing Surgery” was published online this week in the Journal of Surgical Research.
“Surgeons are becoming wiser,” said study lead author Sarah Bateni, a UC Davis resident surgeon. “Our research suggests that surgeons may be operating on healthier patients who are more likely to recover well from an operation. These are patients who can perform activities of daily living without assistance, for example.”
Bateni’s 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.
“It is common that patients end up dying in the intensive care unit instead of being managed with medication with hopes of returning home with their families, including with hospice care,” she said.
For the study, Bateni used the American College of Surgeons National Surgical Quality Improvement Program between 2006 and 2010 to identify 21,755 patients with stage IV cancer, meaning that the disease had metastasized, or spread, beyond the primary tumor site.
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 surgeries 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, a serious blood infection. These characteristics are generally associated with poorer surgical outcomes.
The patients’ rate of morbidity, a measure of illness, 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.
Why surgeons continue to operate on patients at such high risk for complications and death is due to several factors, Bateni said.
“Some of it has to do with the patients and families,” she said. “If the patient is uncomfortable, the family wants a solution. In some cases, the surgeon also may be too optimistic about what the surgical outcome will be.”
What Bateni also found 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.
Bateni said the study results imply that patients, families and care providers, including surgeons, are often delaying discussions about the goals of the care and the priorities at the end of life.
She cautioned that delaying end-of-life discussions can have serious consequences because it 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.
“It’s really important that the doctor has an end-of-life, goals-of-care discussion prior to the time that the patient comes into the hospital with an acute illness,” she said. ”Patients should be referred to a palliative care counselor or have a comprehensive end-of-life discussion to ensure that their goals are respected as soon as they are diagnosed with cancer, especially those with cancers that have a high mortality rate.”