- Email: [email protected]
Palliative Surgery: Incidence and Outcomes
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Seminars in Oncology Nursing, Vol 30, No 4 (November), 2014: pp 234-241
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES VIRGINIA SUN AND ROBERT S. KROUSE 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.
KEY WORDS: Palliative care, surgery, incidence, outcomes, quality of life
P
ALLIATIVE surgery is defined as surgical intervention in patients with incurable malignancy for symptoms attributable to their cancer.1 Palliative surgical care is increasingly recognized as an important component of comprehensive cancer care. Studies from a
Virginia Sun, RN, PhD: Assistant Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA. Robert S. Krouse, MD, FACS: Professor of Surgery, University of Arizona College of Medicine, Tucson, AZ; Staff General and Oncologic Surgeon, Southern Arizona Veterans Affairs Health Care System. Address correspondence to Virginia Sun, RN, PhD, Assistant Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, 1500 East Duarte Road, Duarte, CA 91010. e-mail: [email protected] Ó 2014 Elsevier Inc. All rights reserved. 0749-2081/3004-$36.00/0. http://dx.doi.org/10.1016/j.soncn.2014.08.005
tertiary cancer center showed that 12.5% of cases were done with a palliative intent,1 while 40% of inpatient surgical consultations met the criteria for palliative evaluation.1,2 Additionally, in a survey of cancer surgeons, it was estimated that 21% of all surgical procedures for cancer patients are for palliation.3 The diverse surgical indications to improve quality of life (QOL) in advanced cancer patients include hormonal imbalance, malignant fluid re-accumulation, obstructions, tumor bleeding or other local complications, and pain.4 These may be caused by the many various primary or metastatic cancers. The resulting symptoms are often debilitating, and patients experience a significant amount of distress, which may often severely impact QOL.5-7 The benefits of palliative surgery should always focus on QOL, symptom control, and symptom prevention.4,6 This article describes the goals of treatment, decision-making, incidence, and QOL outcomes of surgical palliation, with a focus on the most common indications for
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES
surgical palliation in patients with advanced cancer.
GOALS OF PALLIATIVE SURGERY: DECISIONMAKING, QOL OUTCOMES, AND SURVIVAL For patients contemplating palliative surgery, the primary decision-making factor has been shown to be the physical impact of uncontrolled symptoms. While surgical risks are inherent and may influence decision-making, patients often consider surgery as their best option.4 Secondary factors for decisionmaking included the social impact of symptoms and maintenance of hope.8 Family caregivers typically participate in the decision-making process, and they experience similar disruptions in overall QOL pre-operatively. Family distress is common both in the pre- and post-operative setting and uncertainty is the most significant spiritual wellbeing concern.9 Similarly, a study of patients with malignant gastric outlet obstruction requested patients to list and rank factors influencing their choice of palliative intervention.10 Patients listed physician’s recommendation and the desire to eat and drink normally as the most important factors influencing their decision. Such studies may ultimately identify the optimal outcome in palliative surgical assessment.11 The benefits and risks of surgical procedures are always of paramount importance, in the patient with advanced cancer. Frequently, survival is a secondary benefit of surgical palliation that should be considered. This is clearly an important goal for patients and families, even in the setting of incurable disease. Unfortunately, the literature frequently focuses exclusively on survival as an endpoint, leaving clinicians with little information on an intervention’s impact on QOL.7 A major dilemma in palliative surgery is the identification of measures of success. The surgical literature has been a poor guide for decision-making for this population of patients. Outcome measures related to QOL and symptom distress are not clearly defined and documented. Historically, the limited focus on palliation in the surgical literature has often been remiss in examining appropriate QOL outcomes.12 This is in contrast to the more common outcome measures of physiologic response (69%), survival (64%), and morbidity and mortality (61%). While it is imperative to understand these outcomes, they should not be the
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primary focus of palliative procedures, as they may not equate with an improvement in QOL.7 A series of studies conducted at the City of Hope focused on describing patient and family caregiver needs, decisions, and outcomes related to palliative surgery. The Decisions and Outcomes of Palliative Surgery (DOPS) study aimed to describe symptom relief and QOL in patients and family caregivers are not undergoing palliative surgery. As part of the overall project, a qualitative study of patients, family caregivers, and surgeons was conducted. Participants were interviewed presurgery and 2 to 4 weeks following surgery. The findings demonstrated that the physical impact of uncontrolled symptoms is the primary motivation to consider palliative surgery for both patients and family caregivers.8 Physicians revealed their challenges in maintaining patients’ health while trying to communicate an honest assessment of their status.8 Subsequent prospective descriptive studies of patients and family caregivers who were candidates for palliative surgery were conducted to assess QOL, symptoms, and the decision-making process. When compared with patients, family caregivers had similar disruptions in overall QOL pre-operatively. Family distress in the social well-being domain worsened over time, and the most significant spiritual well-being concern was a sense of uncertainty.5 Nurses can play an integral role in caring for patients and families in palliative surgery settings. This role is not only focused on managing physical symptoms and complications from surgical palliation, but also supporting treatment decisionmaking as well as caring for the needs of family caregivers. With meticulous comprehensive nursing care, physical, psychosocial, and spiritual distress can potentially be prevented or avoided.
COMMON INDICATIONS FOR SURGICAL PALLIATION The common indications for surgical palliation include malignant bowel obstruction (MBO), gastric outlet obstruction, wound/fistula, biliary obstruction, malignant ascites, and tumor-related bleeding. These indications and signs and symptoms for surgical palliation are listed in Table 1. Malignant Bowel Obstruction MBO is the most common indication for palliative surgical consultation.1 It occurs most
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TABLE 1. Common Indications for Surgical Palliation
Indications Malignant bowl obstruction
Gastric outlet obstruction Wound/fistula
Biliary obstruction
Malignant ascites
Tumor-related bleeding
Signs and Symptoms to Palliate Nausea and vomiting Pain Bloating Inability to eat Nausea and vomiting Pain Pain Odor Bleeding Pruritus Jaundice Bleeding Dyspnea Pain Bloating Nausea and vomiting Inability to eat Anemia Hemoptysis Hematemesis Melena/hematochezia Vaginal bleeding Hematuria
frequently with ovarian and colorectal cancers, but can occur with other abdominal and nonabdominal malignancies. MBO may be related to the tumor, its treatment, or benign etiologies, such as adhesions or internal hernia. The goals of treatment include relieving nausea and vomiting, allowing oral intake, and alleviating pain.13 The optimal procedure is that which is the quickest, safest, and most efficacious in alleviating the obstruction. Persistent obstructions in the face of conservative therapy (usually nasogastric decompression, hydration, and bowel rest) or evidence of complete obstructions are indications that a surgical procedure should be considered. Many patients may be deemed inoperable (6.2% to 50%) because of poor operative risk or contraindications to surgery.14 Poor operative risk must be assessed based on co-morbidities (eg, cardiac and pulmonary function), amount and location of metastatic disease (eg, overwhelming metastasis to the liver malfunction), and current functional status. Endoscopic procedures are suited for patients who are poor operative candidates or who decline an open operative intervention. Percutaneous endoscopic gastrostomy (PEG) tubes are generally welltolerated ‘‘venting’’ procedures that can alleviate
symptoms of intractable vomiting and nausea for upper GI obstructions, and complications are rare.15-17 In combination with other medical techniques, both open and percutaneous gastrostomy offers the possibility of intermittent oral intake. Somatostatin synthetic analogs, such as octreotide, can be helpful in managing symptoms related to MBO, and is likely not a risk if palliative surgery is considered.18 Improvement in QOL after surgery for MBO is variable (42% to 85%).19 Poor prognostic indicators include ascites, carcinomatosis, palpable intra-abdominal masses, multiple bowel obstructions, prior obstructions, and very advanced disease with poor performance status. Gastric Outlet Obstruction Surgical management of gastric outlet obstruction is somewhat controversial, and procedures are considered in the setting of persistent nausea, vomiting, eructation (burping), and early satiety. It typically occurs in the setting of gastric, peripancreatic, and duodenal tumors. The surgical options for gastric outlet obstruction are a bypass procedure (gastrojejunostomy) or a resection (antrectomy or pancreaticoduodenectomy). Laparoscopic gastrojejunostomy has been shown to have less pain, shorter hospital stays, lower postoperative morbidity, and earlier recovery of bowel movements than an open procedure.20 It has been shown that symptomatic patients (vomiting prior to operation) typically have a poor outcome (approximately 90% did not have relief of symptoms) to gastric bypass. In comparison, if patients were not symptomatic but had evidence of impending obstruction, only about 40% had a poor outcome.21 If endoscopic expertise is available, stenting is often preferable for gastric obstructions, although this is heavily dependent on operator ability. Stents for gastric outlet obstruction are noted to be quite successful (approximately 90%) with rare complications.22,23 Wound/Fistula There are multiple types of wounds related to advanced cancer that require surgical intervention, and wound problems represent approximately 10% of all palliative surgical consultations.1 These are often directly related to tumors, but may be caused by treatments such as surgical procedures or radiation therapy. Primary cancers that frequently lead to wound problems include breast cancer, skin cancers, soft tissue sarcomas, or soft tissue manifestations of other cancers
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES
(eg, lung cancer). Procedure-related wounds may be caused by node dissections, local resections, or simple incisions. Due to debilitation, patients may have pressure sores that complicate their overall course and lead to suffering. Fistulae, like wound problems, may occur in patients who are facing the end of life for various reasons. Fistulae are a heterogeneous group of problems, and are simply a communication of one structure to another, including bowel to bowel, bowel to skin, or pancreas to skin. Fistulae may be a complication of procedures, such as pancreatic fistulae after a resection, or may be caused by other treatments (such as a radiation therapy). These problems may be extremely difficult to cure, and indications for surgical options are rare. Prevention is of primary importance for wound problems and fistulae in palliative care settings. For example, resection of a nodal or soft tissue metastasis can simply be excised to avoid the potential wound problems that will ensue if ignored. Another preventative consideration is related to pressure wounds. This entails ensuring patients are not stationary for long periods of time. In addition, many wounds, especially related to radiation injury or in the severely malnourished, may not heal. Therefore, the goals of treatment should be on control of pain, odor, and drainage. Meticulous wound care is of primary importance. This component of care has been shown to have great impact on QOL. For example, controlling odor and seepage has been shown to lead to less isolation, greater comfort, and increased psychosocial wellbeing.24 While surgical options for wounds are limited, operative intervention has been reported in 38% and primarily involves incision and drainage or debridement.1 Additional morbid surgical options may include amputations, limb perfusions, and major head and neck resections. While these options may seem quite radical in the setting of palliation, they may be reasonable solutions based on symptoms and if the patient can withstand a large procedure. Biliary Obstruction Biliary obstructions are common as a result of pancreatic and cholangiocarcinomas. Blockages must be treated expediently because this will lead to hyperbilirubinemia, which may become symptomatic, leading to pruritus, bleeding diathesis, and liver failure. There are multiple surgical options to bypass the biliary system, and these include cholecystojejunostomy, choledochojeju-
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nostomy, or choledochoduodenostomy. While these procedures may be undertaken with a laparoscope, few surgeons have the technical skills for this procedure.25 In the appropriate operative candidate, a pancreaticoduodenectomy (Whipple procedure) is an option if there is limited local nodal disease, although there is little data upon which to base such decisions. Endoscopic stenting has been shown to have similar success rate as surgery with less morbidity.26,27 However, the risk of recurrent biliary obstruction before death is higher in patients undergoing endoscopic stent placement. Malignant Ascites Ascites may be caused by overwhelming liver metastasis, cirrhotic liver disease, or carcinomatosis. It can be a difficult management problem, and treatment may be determined by the extent of ascites, condition of patient, or etiology. If ascites is minimal, no therapy is indicated. Treatments will be necessary with larger volumes of ascites, which can lead to discomfort, fullness, or respiratory problems. Surgical options should be considered if diuretics are no longer helping or percutaneous aspirations are becoming painful and frequent. In addition to improving patient comfort, a reasonable indication for surgical interventions is to ease the burden of care. Probably the simplest surgical techniques are the insertion of permanent intraperitoneal drainage catheters. This will allow serial drainage of fluid, and the patient and/or caregiver can be trained to drain excess peritoneal fluid when the patient is symptomatic. The success rates for permanent intraperitoneal catheters functioning until death are quite high (90%).28,29 Major complications are obstruction and infection, and are approximately 17%,27 although catheter sepsis has been reported to be 35%.30 To avoid infection, nurses must follow patients closely and provide education to patients and caregivers on drainage and care of the catheter. Another option for malignant ascites is a peritoneovenous shunt. This approach is seldom used today because of the risk for catastrophic complications, including sepsis, disseminated intravascular coagulation, heart failure, and pulmonary embolism.31 Hyperthermic intraperitoneal chemotherapy without cytoreduction is an accepted approach for palliation of malignant ascites, and the procedure can be performed laparoscopically in an attempt to minimize complications.32 A much more invasive surgical technique includes a major debulking of carcinomatosis
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followed by intraperitoneal hyperthermic chemotherapy, but this procedure should only be available at specialized institutions.33 Tumor-Related Bleeding Tumor-related bleeding is frequently difficult to treat, especially with patients who may have a coagulopathy related to illness or treatments. Therefore, alternatives such as radiation, embolization, or local packing may be optimal alternatives to a major operation. If bleeding is caused by a superficial tumor, such as recurrent breast or skin cancer, a resection might offer the best option, even if the wound cannot be closed. Other tumors, such as head and neck or limb soft tissue sarcomas, are often in close proximity to major vessels and controlling them may be difficult and morbid. In these cases, interventional radiologic approaches may be best. If bleeding is slower, radiotherapy techniques may be considered. Symptoms related to visceral tumors include hemoptysis (eg, primary or metastatic lung tumors), hematemasis (eg, gastric cancer), melena or hematochezia (eg, colorectal tumors), vaginal bleeding (eg, cervical or endometrial carcinomas), or hematuria (eg, renal or bladder tumors). Operative approaches may be quite difficult, and the risks unreasonable. For example, surgical intervention for gastrointestinal bleeding is infrequently required in palliative surgical evaluation (14%) and most often involves bowel resection.34 Indications for surgical involvement will be related to location of the tumor and whether another approach is less morbid and has a reasonable chance at success. For example, rectal tumor bleeding, which would necessitate a complex procedure that often includes an intestinal stoma, may be better served with non-surgical treatments to avoid an operation (eg, radiation therapy or interventional radiology embolization).
ideally patients who are undergoing palliative surgery should have access to concomitant palliative care early in the decision-making process and throughout the treatment course. This can allow for better support and can also make the transition from a focus on disease-modifying treatment to more symptom-focused care less jarring. This also recognizes that QOL involves not just physical suffering associated with surgical palliation, but also concerns within the psychosocial and spiritual dimensions. As an integral member of the multidisciplinary team caring for cancer patients undergoing palliative surgical procedures, nurses must engage in conversations with patients and their families and, among themselves, broaden their assessments to be able to ensure physical comfort, address psychological needs, and identify goals of care and social and spiritual sources of distress. Figure 1 illustrates an adapted version of the City of Hope Quality of Life model that addresses some of the specific needs of cancer patients in surgical palliation, focusing on the four key domains of QOL.37 Palliative care nurses working in clinical or research settings can use this model to guide clinical practice and a research agenda in palliative surgery. The inclusion of specialized nursing personnel, such as wound, ostomy, and continence nurses (WOCNs), in the care of patients in palliative surgery settings can be helpful in formulating
EARLY PALLIATIVE CARE IN SURGERY: IMPLICATIONS FOR ONCOLOGY NURSING PRACTICE AND RESEARCH Recent studies of concomitant palliative care with standard oncologic care have demonstrated that patients with concomitant treatment had improved health-related quality of life (HRQOL), reduction in symptom burden, and potential to reduce use of aggressive treatment at end of life,35 while having improvement in survival.36 Therefore,
FIGURE 1. City of Hope Quality of Life Model applied to surgical palliation. (Adapted with permission from ‘‘Quality of Life from Long-Term Cancer Survivors,’’ by B.R. Ferrell et al., 1995, Oncology Nursing Forum, 22(6), 915-922. Copyright 1995 by Oncology Nursing Society.)
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES
a comprehensive nursing care plan for treatment of wounds and management of ostomies.24 In addition to meticulous care in the peri- and postoperative settings to alleviate physical, psychosocial, and spiritual/existential suffering, nurses should educate patients and families on what to expect before and after surgical palliation. Early seminal work in the nursing literature suggests that interventions designed to adequately prepare patients for surgery resulted in improved outcomes.38-40 Being prepared for a major event such as a surgery in palliative settings can decrease anxiety and distress, improve coping abilities, and promote recovery without major complications.41 Palliative care is a model that is provided in a multidisciplinary setting; therefore, nurses should be aware of supportive care services available to patients and families within their institutions, and engage them in the care of surgical patients. There is currently a paucity of prospective palliative studies in the surgical literature.42 This has occurred for many reasons, including ethical considerations in surgical palliative care studies.43 Issues such as vulnerability of patients or the clinician as the researcher are not exclusive to palliative research, but they certainly are highlighted in the advanced cancer setting. There are matters unique to palliative research itself, such as the lack of clarity of the risk–benefit relationship. Another concern is with randomization, which can be quite difficult, especially if there is a placebo arm. A placebo arm is likely impossible in a palliative surgery trial. Finally, there are issues unique to surgical palliative research, in that surgery is obviously quite invasive. In addition, once a procedure is completed it is difficult or impossible to reverse, unlike a chemotherapy trial where the medication can be stopped. In addition to ethical concerns, there are other barriers to surgical research for patients with advanced cancer. These include surgeon and procedure variability, patient and family agreement to participate in a trial, the consent process (especially if there are mental status changes or no family member available), inaccessibility of patients based on referring practitioner bias or patients being in hospice care and the high attrition rate asso-
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ciated with palliative surgical interventions. This has proved difficult in outcomes assessment for prospective observational studies comparing operative to non-operative management. In a recent prospective observational study of patients undergoing palliative surgical consultation, 40% of the patients died before completion of the study at 3 months.44 However, research in the advanced cancer patient is important to pursue to improve patient care related to treatment alternatives, but also to improve the care of cancer patients in surgical palliation settings. Importantly, as standard methods of research may not be applicable or possible in the palliative surgery setting, nurse researchers must consider alternative methodologies to examine optimal care questions. This likely will mean utilizing comparative effectiveness techniques to include alternative outcome measures (rather than survival, mortality, and morbidity), as well as novel statistical maneuvers to assess surgical treatment benefit. In addition, surgical questions beyond the outcomes of an actual operation should be examined, such as costs, communication issues, and symptom prevention.
CONCLUSION Palliative procedures are an important and integral component of the comprehensive care of cancer patients. If a surgical procedure is considered, the patient, family, and treating teams must have a firm understanding of realistic goals of success that focus on QOL. In addition, the chances of attaining those goals must be understood. Finally, the risks of the procedure, including worsening of symptoms and death, must be clearly described. As long as these criteria are met, surgical procedures may be undertaken in the setting of terminal cancer. Clearly, this will also mean that early palliative care is indicated, an interdisciplinary team approach should be utilized, and each issue must receive individualized attention. It is imperative that oncology nurses understand the myriad of approaches and indications for surgical palliation and its potential impact on QOL and the wellbeing of the patient and their families.
REFERENCES 1. Badgwell B, Smith K, Liu P, Bruera E, Curley S, Cormier J. Indicators of surgery and survival in oncology inpatients
requiring surgical evaluation for palliation. Support Care Cancer 2009;17:727-734.
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2. Krouse RS, Nelson RA, Farrell BR, et al. Surgical palliation at a cancer center: incidence and outcomes. Arch Surg 2001;136:773-778. 3. McCahill LE, Krouse R, Chu D, et al. Indications and use of palliative surgery-results of society of surgical oncology survey. Ann Surg Oncol 2002;9:104-112. 4. Wallen GR, Baker K, Stolar M, et al. Palliative care outcomes in surgical oncology patients with advanced malignancies: a mixed methods approach. Quality Life Res 2012;21:405-415. 5. Podnos YD, Juarez G, Pameijer C, Choi K, Ferrell BR, Wagman LD. Impact of surgical palliation on quality of life in patients with advanced malignancy: results of the decisions and outcomes in palliative surgery (dops) trial. Ann Surg Oncol 2007;14:922-928. 6. Badgwell B, Krouse R, Klimberg SV, Bruera E. Outcome measures other than morbidity and mortality for patients with incurable cancer and gastrointestinal obstruction. J Palliat Med 2014;17:18-26. 7. Badgwell B, Bruera E, Klimberg SV. Can patient reported outcomes help identify the optimal outcome in palliative surgery? J Surg Oncol 2014;109:145-150. 8. Ferrell B, Chu D, Wagman L, et al. Patient and surgeon decision making regarding surgery for advanced cancer. Oncol Nurs Forum 2003;30:E106-E114. 9. Borneman T, Chu DZ, Wagman L, et al. Concerns of family caregivers of patients with cancer facing palliative surgery for advanced malignancies. Oncol Nurs Forum 2003;30:997-1005. 10. Schmidt C, Gerdes H, Hawkins W, et al. A prospective observational study examining quality of life in patients with malignant gastric outlet obstruction. Am J Surg 2009;198:92-99. 11. Badgwell BD, Aloia TA, Garrett J, Chedister G, Miner T, Krouse R. Indicators of symptom improvement and survival in inpatients with advanced cancer undergoing palliative surgical consultation. J Surg Oncol 2013;107:367-371. 12. Thomay AA, Jaques DP, Miner TJ. Surgical palliation: getting back to our roots. Surg Clin North Am 2009;89:27-41. vii-viii. 13. Daine P, Stilos K, Moura S, et al. Nurses’ experiences caring for patients and families dealing with malignant bowel obstruction. Int J Palliat Nurs 2013;19:593-598. 14. Frago R, Ramirez E, Millan M, Kreisler E, del Valle E, Biondo S. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg 2014;207:127-138. 15. Chi DS, Phaeton R, Miner TJ, et al. A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer. Oncologist 2009;14:835-839. 16. Badgwell BD, Contreras C, Askew R, Krouse R, Feig B, Cormier JN. Radiographic and clinical factors associated with improved outcomes in advanced cancer patients with bowel obstruction. J Palliat Med 2011;14:990-996. 17. Rath KS, Loseth D, Muscarella P, et al. Outcomes following percutaneous upper gastrointestinal decompressive tube placement for malignant bowel obstruction in ovarian cancer. Gynecol Oncol 2013;129:103-106. 18. Kucukmetin A, Naik R, Galaal K, Bryant A, Dickinson HO. Palliative surgery versus medical management for bowel obstruction in ovarian cancer. Cochrane Database Syst Rev 2010;(7):CD007792. 19. Hope JM, Pothuri B. The role of palliative surgery in gynecologic cancer cases. Oncologist 2013;18:73-79. 20. Takeno A, Takiguchi S, Fujita J, et al. Clinical Study Group of Osaka University UGIG. Clinical outcome and indica-
tions for palliative gastrojejunostomy in unresectable advanced gastric cancer: Multi-institutional retrospective analysis. Ann Surg Oncol 2013;20:3527-3533. 21. Spanheimer PM, Cyr AR, Liao J, et al. Complications and survival associated with operative procedures in patients with unresectable pancreatic head adenocarcinoma. J Surg Oncol 2014;109:697-701. 22. Endo S, Takiguchi S, Miyazaki Y, et al. Clinical Study Group of Osaka University UGIG. Efficacy of endoscopic gastroduodenal stenting for gastric outlet obstruction due to unresectable advanced gastric cancer: a prospective multicenter study. J Surg Oncol 2014;109:208-212. 23. Pavlidis TE, Pavlidis ET. Role of stenting in the palliation of gastroesophageal junction cancer: a brief review. World J Gastrointest Surg 2014;6:38-41. 24. Graves ML, Sun V. Providing quality wound care at the end of life. J Hosp Palliat Nurs 2013;15:66-74. 25. Krouse RS. Advances in palliative surgery for cancer patients. J Support Oncol 2004;2:80-87. 26. Moss AC, Morris E, Leyden J, MacMathuna P. Malignant distal biliary obstruction: A systematic review and metaanalysis of endoscopic and surgical bypass results. Cancer Treat Rev 2007;33:213-221. 27. Coupe NA, Cox K, Clark K, Boyer M, Stockler M. Outcomes of permanent peritoneal ports for the management of recurrent malignant ascites. J Palliat Med 2013;16:938-940. 28. O’Neill MJ, Weissleder R, Gervais DA, Hahn PF, Mueller PR. Tunneled peritoneal catheter placement under sonographic and fluoroscopic guidance in the palliative treatment of malignant ascites. AJR Am J Roentgenol 2001;177:615-618. 29. Barnett TD, Rubins J. Placement of a permanent tunneled peritoneal drainage catheter for palliation of malignant ascites: a simplified percutaneous approach. J Vasc Interv Radiol 2002;13:379-383. 30. Tapping CR, Ling L, Razack A. Pleurx drain use in the management of malignant ascites: Safety, complications, longterm patency and factors predictive of success. Br J Radiol 2012;85:623-628. 31. Cavazzoni E, Bugiantella W, Graziosi L, Franceschini MS, Donini A. Malignant ascites: pathophysiology and treatment. Int J Clin Oncol 2013;18:1-9. 32. Valle M, Van der Speeten K, Garofalo A. Laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (hipec) in the management of refractory malignant ascites: a multiinstitutional retrospective analysis in 52 patients. J Surg Oncol 2009;100:331-334. 33. Facchiano E, Risio D, Kianmanesh R, Msika S. Laparoscopic hyperthermic intraperitoneal chemotherapy: Indications, aims, and results: a systematic review of the literature. Ann Surg Oncol 2012;19:2946-2950. 34. Miner T, Jaques D, Shriver C. A prospective evaluation of patients undergoing surgery for the palliation of an advanced malignancy. Ann Surg Oncol 2002;9:696-703. 35. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer the project enable ii randomized controlled trial. JAMA 2009;302:741-749. 36. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-742. 37. Ferrell BR, Dow KH, Leigh S, Ly J, Gulasekaram P. Quality of life in long-term cancer survivors. Oncol Nurs Forum 1995;22:915-922.
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38. Dumas RG, Johnson BA. Research in nursing practice: a review of five clinical experiments. Int J Nurs Studies 1972;9:137-149. 39. Johnson BA, Johnson JE, Dumas RG. Research in nursing practice. the problem of uncontrolled situational variables. Nurs Res 1970;19:337-342. 40. Dumas RG, Leonard RC. The effect of nursing on the incidence of postoperative vomiting. Nurs Res 1963;12:12-14. 41. Knobf MT. Being prepared: essential to self-care and quality of life for the person with cancer. Clin J Oncol Nurs 2013;17:255-261.
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42. Miner TJ, Jaques DP, Tavaf-Motamen H, Shriver CD. Decision making on surgical palliation based on patient outcome data. Am J Surg 1999;177:150-154. 43. Krouse RS, Easson AM, Angelos P. Ethical considerations and barriers to research in surgical palliative care. J Am Coll Surg 2003;196:469-474. 44. Badgwell B, Krouse R, Cormier J, Guevara C, Klimberg VS, Ferrell B. Frequent and early death limits quality of life assessment in patients with advanced malignancies evaluated for palliative surgical intervention. Ann Surg Oncol 2012;19:3651-3658.
Seminars in Oncology Nursing, Vol 30, No 4 (November), 2014: pp 234-241
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES VIRGINIA SUN AND ROBERT S. KROUSE 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.
KEY WORDS: Palliative care, surgery, incidence, outcomes, quality of life
P
ALLIATIVE surgery is defined as surgical intervention in patients with incurable malignancy for symptoms attributable to their cancer.1 Palliative surgical care is increasingly recognized as an important component of comprehensive cancer care. Studies from a
Virginia Sun, RN, PhD: Assistant Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA. Robert S. Krouse, MD, FACS: Professor of Surgery, University of Arizona College of Medicine, Tucson, AZ; Staff General and Oncologic Surgeon, Southern Arizona Veterans Affairs Health Care System. Address correspondence to Virginia Sun, RN, PhD, Assistant Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, 1500 East Duarte Road, Duarte, CA 91010. e-mail: [email protected] Ó 2014 Elsevier Inc. All rights reserved. 0749-2081/3004-$36.00/0. http://dx.doi.org/10.1016/j.soncn.2014.08.005
tertiary cancer center showed that 12.5% of cases were done with a palliative intent,1 while 40% of inpatient surgical consultations met the criteria for palliative evaluation.1,2 Additionally, in a survey of cancer surgeons, it was estimated that 21% of all surgical procedures for cancer patients are for palliation.3 The diverse surgical indications to improve quality of life (QOL) in advanced cancer patients include hormonal imbalance, malignant fluid re-accumulation, obstructions, tumor bleeding or other local complications, and pain.4 These may be caused by the many various primary or metastatic cancers. The resulting symptoms are often debilitating, and patients experience a significant amount of distress, which may often severely impact QOL.5-7 The benefits of palliative surgery should always focus on QOL, symptom control, and symptom prevention.4,6 This article describes the goals of treatment, decision-making, incidence, and QOL outcomes of surgical palliation, with a focus on the most common indications for
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES
surgical palliation in patients with advanced cancer.
GOALS OF PALLIATIVE SURGERY: DECISIONMAKING, QOL OUTCOMES, AND SURVIVAL For patients contemplating palliative surgery, the primary decision-making factor has been shown to be the physical impact of uncontrolled symptoms. While surgical risks are inherent and may influence decision-making, patients often consider surgery as their best option.4 Secondary factors for decisionmaking included the social impact of symptoms and maintenance of hope.8 Family caregivers typically participate in the decision-making process, and they experience similar disruptions in overall QOL pre-operatively. Family distress is common both in the pre- and post-operative setting and uncertainty is the most significant spiritual wellbeing concern.9 Similarly, a study of patients with malignant gastric outlet obstruction requested patients to list and rank factors influencing their choice of palliative intervention.10 Patients listed physician’s recommendation and the desire to eat and drink normally as the most important factors influencing their decision. Such studies may ultimately identify the optimal outcome in palliative surgical assessment.11 The benefits and risks of surgical procedures are always of paramount importance, in the patient with advanced cancer. Frequently, survival is a secondary benefit of surgical palliation that should be considered. This is clearly an important goal for patients and families, even in the setting of incurable disease. Unfortunately, the literature frequently focuses exclusively on survival as an endpoint, leaving clinicians with little information on an intervention’s impact on QOL.7 A major dilemma in palliative surgery is the identification of measures of success. The surgical literature has been a poor guide for decision-making for this population of patients. Outcome measures related to QOL and symptom distress are not clearly defined and documented. Historically, the limited focus on palliation in the surgical literature has often been remiss in examining appropriate QOL outcomes.12 This is in contrast to the more common outcome measures of physiologic response (69%), survival (64%), and morbidity and mortality (61%). While it is imperative to understand these outcomes, they should not be the
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primary focus of palliative procedures, as they may not equate with an improvement in QOL.7 A series of studies conducted at the City of Hope focused on describing patient and family caregiver needs, decisions, and outcomes related to palliative surgery. The Decisions and Outcomes of Palliative Surgery (DOPS) study aimed to describe symptom relief and QOL in patients and family caregivers are not undergoing palliative surgery. As part of the overall project, a qualitative study of patients, family caregivers, and surgeons was conducted. Participants were interviewed presurgery and 2 to 4 weeks following surgery. The findings demonstrated that the physical impact of uncontrolled symptoms is the primary motivation to consider palliative surgery for both patients and family caregivers.8 Physicians revealed their challenges in maintaining patients’ health while trying to communicate an honest assessment of their status.8 Subsequent prospective descriptive studies of patients and family caregivers who were candidates for palliative surgery were conducted to assess QOL, symptoms, and the decision-making process. When compared with patients, family caregivers had similar disruptions in overall QOL pre-operatively. Family distress in the social well-being domain worsened over time, and the most significant spiritual well-being concern was a sense of uncertainty.5 Nurses can play an integral role in caring for patients and families in palliative surgery settings. This role is not only focused on managing physical symptoms and complications from surgical palliation, but also supporting treatment decisionmaking as well as caring for the needs of family caregivers. With meticulous comprehensive nursing care, physical, psychosocial, and spiritual distress can potentially be prevented or avoided.
COMMON INDICATIONS FOR SURGICAL PALLIATION The common indications for surgical palliation include malignant bowel obstruction (MBO), gastric outlet obstruction, wound/fistula, biliary obstruction, malignant ascites, and tumor-related bleeding. These indications and signs and symptoms for surgical palliation are listed in Table 1. Malignant Bowel Obstruction MBO is the most common indication for palliative surgical consultation.1 It occurs most
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TABLE 1. Common Indications for Surgical Palliation
Indications Malignant bowl obstruction
Gastric outlet obstruction Wound/fistula
Biliary obstruction
Malignant ascites
Tumor-related bleeding
Signs and Symptoms to Palliate Nausea and vomiting Pain Bloating Inability to eat Nausea and vomiting Pain Pain Odor Bleeding Pruritus Jaundice Bleeding Dyspnea Pain Bloating Nausea and vomiting Inability to eat Anemia Hemoptysis Hematemesis Melena/hematochezia Vaginal bleeding Hematuria
frequently with ovarian and colorectal cancers, but can occur with other abdominal and nonabdominal malignancies. MBO may be related to the tumor, its treatment, or benign etiologies, such as adhesions or internal hernia. The goals of treatment include relieving nausea and vomiting, allowing oral intake, and alleviating pain.13 The optimal procedure is that which is the quickest, safest, and most efficacious in alleviating the obstruction. Persistent obstructions in the face of conservative therapy (usually nasogastric decompression, hydration, and bowel rest) or evidence of complete obstructions are indications that a surgical procedure should be considered. Many patients may be deemed inoperable (6.2% to 50%) because of poor operative risk or contraindications to surgery.14 Poor operative risk must be assessed based on co-morbidities (eg, cardiac and pulmonary function), amount and location of metastatic disease (eg, overwhelming metastasis to the liver malfunction), and current functional status. Endoscopic procedures are suited for patients who are poor operative candidates or who decline an open operative intervention. Percutaneous endoscopic gastrostomy (PEG) tubes are generally welltolerated ‘‘venting’’ procedures that can alleviate
symptoms of intractable vomiting and nausea for upper GI obstructions, and complications are rare.15-17 In combination with other medical techniques, both open and percutaneous gastrostomy offers the possibility of intermittent oral intake. Somatostatin synthetic analogs, such as octreotide, can be helpful in managing symptoms related to MBO, and is likely not a risk if palliative surgery is considered.18 Improvement in QOL after surgery for MBO is variable (42% to 85%).19 Poor prognostic indicators include ascites, carcinomatosis, palpable intra-abdominal masses, multiple bowel obstructions, prior obstructions, and very advanced disease with poor performance status. Gastric Outlet Obstruction Surgical management of gastric outlet obstruction is somewhat controversial, and procedures are considered in the setting of persistent nausea, vomiting, eructation (burping), and early satiety. It typically occurs in the setting of gastric, peripancreatic, and duodenal tumors. The surgical options for gastric outlet obstruction are a bypass procedure (gastrojejunostomy) or a resection (antrectomy or pancreaticoduodenectomy). Laparoscopic gastrojejunostomy has been shown to have less pain, shorter hospital stays, lower postoperative morbidity, and earlier recovery of bowel movements than an open procedure.20 It has been shown that symptomatic patients (vomiting prior to operation) typically have a poor outcome (approximately 90% did not have relief of symptoms) to gastric bypass. In comparison, if patients were not symptomatic but had evidence of impending obstruction, only about 40% had a poor outcome.21 If endoscopic expertise is available, stenting is often preferable for gastric obstructions, although this is heavily dependent on operator ability. Stents for gastric outlet obstruction are noted to be quite successful (approximately 90%) with rare complications.22,23 Wound/Fistula There are multiple types of wounds related to advanced cancer that require surgical intervention, and wound problems represent approximately 10% of all palliative surgical consultations.1 These are often directly related to tumors, but may be caused by treatments such as surgical procedures or radiation therapy. Primary cancers that frequently lead to wound problems include breast cancer, skin cancers, soft tissue sarcomas, or soft tissue manifestations of other cancers
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES
(eg, lung cancer). Procedure-related wounds may be caused by node dissections, local resections, or simple incisions. Due to debilitation, patients may have pressure sores that complicate their overall course and lead to suffering. Fistulae, like wound problems, may occur in patients who are facing the end of life for various reasons. Fistulae are a heterogeneous group of problems, and are simply a communication of one structure to another, including bowel to bowel, bowel to skin, or pancreas to skin. Fistulae may be a complication of procedures, such as pancreatic fistulae after a resection, or may be caused by other treatments (such as a radiation therapy). These problems may be extremely difficult to cure, and indications for surgical options are rare. Prevention is of primary importance for wound problems and fistulae in palliative care settings. For example, resection of a nodal or soft tissue metastasis can simply be excised to avoid the potential wound problems that will ensue if ignored. Another preventative consideration is related to pressure wounds. This entails ensuring patients are not stationary for long periods of time. In addition, many wounds, especially related to radiation injury or in the severely malnourished, may not heal. Therefore, the goals of treatment should be on control of pain, odor, and drainage. Meticulous wound care is of primary importance. This component of care has been shown to have great impact on QOL. For example, controlling odor and seepage has been shown to lead to less isolation, greater comfort, and increased psychosocial wellbeing.24 While surgical options for wounds are limited, operative intervention has been reported in 38% and primarily involves incision and drainage or debridement.1 Additional morbid surgical options may include amputations, limb perfusions, and major head and neck resections. While these options may seem quite radical in the setting of palliation, they may be reasonable solutions based on symptoms and if the patient can withstand a large procedure. Biliary Obstruction Biliary obstructions are common as a result of pancreatic and cholangiocarcinomas. Blockages must be treated expediently because this will lead to hyperbilirubinemia, which may become symptomatic, leading to pruritus, bleeding diathesis, and liver failure. There are multiple surgical options to bypass the biliary system, and these include cholecystojejunostomy, choledochojeju-
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nostomy, or choledochoduodenostomy. While these procedures may be undertaken with a laparoscope, few surgeons have the technical skills for this procedure.25 In the appropriate operative candidate, a pancreaticoduodenectomy (Whipple procedure) is an option if there is limited local nodal disease, although there is little data upon which to base such decisions. Endoscopic stenting has been shown to have similar success rate as surgery with less morbidity.26,27 However, the risk of recurrent biliary obstruction before death is higher in patients undergoing endoscopic stent placement. Malignant Ascites Ascites may be caused by overwhelming liver metastasis, cirrhotic liver disease, or carcinomatosis. It can be a difficult management problem, and treatment may be determined by the extent of ascites, condition of patient, or etiology. If ascites is minimal, no therapy is indicated. Treatments will be necessary with larger volumes of ascites, which can lead to discomfort, fullness, or respiratory problems. Surgical options should be considered if diuretics are no longer helping or percutaneous aspirations are becoming painful and frequent. In addition to improving patient comfort, a reasonable indication for surgical interventions is to ease the burden of care. Probably the simplest surgical techniques are the insertion of permanent intraperitoneal drainage catheters. This will allow serial drainage of fluid, and the patient and/or caregiver can be trained to drain excess peritoneal fluid when the patient is symptomatic. The success rates for permanent intraperitoneal catheters functioning until death are quite high (90%).28,29 Major complications are obstruction and infection, and are approximately 17%,27 although catheter sepsis has been reported to be 35%.30 To avoid infection, nurses must follow patients closely and provide education to patients and caregivers on drainage and care of the catheter. Another option for malignant ascites is a peritoneovenous shunt. This approach is seldom used today because of the risk for catastrophic complications, including sepsis, disseminated intravascular coagulation, heart failure, and pulmonary embolism.31 Hyperthermic intraperitoneal chemotherapy without cytoreduction is an accepted approach for palliation of malignant ascites, and the procedure can be performed laparoscopically in an attempt to minimize complications.32 A much more invasive surgical technique includes a major debulking of carcinomatosis
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followed by intraperitoneal hyperthermic chemotherapy, but this procedure should only be available at specialized institutions.33 Tumor-Related Bleeding Tumor-related bleeding is frequently difficult to treat, especially with patients who may have a coagulopathy related to illness or treatments. Therefore, alternatives such as radiation, embolization, or local packing may be optimal alternatives to a major operation. If bleeding is caused by a superficial tumor, such as recurrent breast or skin cancer, a resection might offer the best option, even if the wound cannot be closed. Other tumors, such as head and neck or limb soft tissue sarcomas, are often in close proximity to major vessels and controlling them may be difficult and morbid. In these cases, interventional radiologic approaches may be best. If bleeding is slower, radiotherapy techniques may be considered. Symptoms related to visceral tumors include hemoptysis (eg, primary or metastatic lung tumors), hematemasis (eg, gastric cancer), melena or hematochezia (eg, colorectal tumors), vaginal bleeding (eg, cervical or endometrial carcinomas), or hematuria (eg, renal or bladder tumors). Operative approaches may be quite difficult, and the risks unreasonable. For example, surgical intervention for gastrointestinal bleeding is infrequently required in palliative surgical evaluation (14%) and most often involves bowel resection.34 Indications for surgical involvement will be related to location of the tumor and whether another approach is less morbid and has a reasonable chance at success. For example, rectal tumor bleeding, which would necessitate a complex procedure that often includes an intestinal stoma, may be better served with non-surgical treatments to avoid an operation (eg, radiation therapy or interventional radiology embolization).
ideally patients who are undergoing palliative surgery should have access to concomitant palliative care early in the decision-making process and throughout the treatment course. This can allow for better support and can also make the transition from a focus on disease-modifying treatment to more symptom-focused care less jarring. This also recognizes that QOL involves not just physical suffering associated with surgical palliation, but also concerns within the psychosocial and spiritual dimensions. As an integral member of the multidisciplinary team caring for cancer patients undergoing palliative surgical procedures, nurses must engage in conversations with patients and their families and, among themselves, broaden their assessments to be able to ensure physical comfort, address psychological needs, and identify goals of care and social and spiritual sources of distress. Figure 1 illustrates an adapted version of the City of Hope Quality of Life model that addresses some of the specific needs of cancer patients in surgical palliation, focusing on the four key domains of QOL.37 Palliative care nurses working in clinical or research settings can use this model to guide clinical practice and a research agenda in palliative surgery. The inclusion of specialized nursing personnel, such as wound, ostomy, and continence nurses (WOCNs), in the care of patients in palliative surgery settings can be helpful in formulating
EARLY PALLIATIVE CARE IN SURGERY: IMPLICATIONS FOR ONCOLOGY NURSING PRACTICE AND RESEARCH Recent studies of concomitant palliative care with standard oncologic care have demonstrated that patients with concomitant treatment had improved health-related quality of life (HRQOL), reduction in symptom burden, and potential to reduce use of aggressive treatment at end of life,35 while having improvement in survival.36 Therefore,
FIGURE 1. City of Hope Quality of Life Model applied to surgical palliation. (Adapted with permission from ‘‘Quality of Life from Long-Term Cancer Survivors,’’ by B.R. Ferrell et al., 1995, Oncology Nursing Forum, 22(6), 915-922. Copyright 1995 by Oncology Nursing Society.)
PALLIATIVE SURGERY: INCIDENCE AND OUTCOMES
a comprehensive nursing care plan for treatment of wounds and management of ostomies.24 In addition to meticulous care in the peri- and postoperative settings to alleviate physical, psychosocial, and spiritual/existential suffering, nurses should educate patients and families on what to expect before and after surgical palliation. Early seminal work in the nursing literature suggests that interventions designed to adequately prepare patients for surgery resulted in improved outcomes.38-40 Being prepared for a major event such as a surgery in palliative settings can decrease anxiety and distress, improve coping abilities, and promote recovery without major complications.41 Palliative care is a model that is provided in a multidisciplinary setting; therefore, nurses should be aware of supportive care services available to patients and families within their institutions, and engage them in the care of surgical patients. There is currently a paucity of prospective palliative studies in the surgical literature.42 This has occurred for many reasons, including ethical considerations in surgical palliative care studies.43 Issues such as vulnerability of patients or the clinician as the researcher are not exclusive to palliative research, but they certainly are highlighted in the advanced cancer setting. There are matters unique to palliative research itself, such as the lack of clarity of the risk–benefit relationship. Another concern is with randomization, which can be quite difficult, especially if there is a placebo arm. A placebo arm is likely impossible in a palliative surgery trial. Finally, there are issues unique to surgical palliative research, in that surgery is obviously quite invasive. In addition, once a procedure is completed it is difficult or impossible to reverse, unlike a chemotherapy trial where the medication can be stopped. In addition to ethical concerns, there are other barriers to surgical research for patients with advanced cancer. These include surgeon and procedure variability, patient and family agreement to participate in a trial, the consent process (especially if there are mental status changes or no family member available), inaccessibility of patients based on referring practitioner bias or patients being in hospice care and the high attrition rate asso-
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ciated with palliative surgical interventions. This has proved difficult in outcomes assessment for prospective observational studies comparing operative to non-operative management. In a recent prospective observational study of patients undergoing palliative surgical consultation, 40% of the patients died before completion of the study at 3 months.44 However, research in the advanced cancer patient is important to pursue to improve patient care related to treatment alternatives, but also to improve the care of cancer patients in surgical palliation settings. Importantly, as standard methods of research may not be applicable or possible in the palliative surgery setting, nurse researchers must consider alternative methodologies to examine optimal care questions. This likely will mean utilizing comparative effectiveness techniques to include alternative outcome measures (rather than survival, mortality, and morbidity), as well as novel statistical maneuvers to assess surgical treatment benefit. In addition, surgical questions beyond the outcomes of an actual operation should be examined, such as costs, communication issues, and symptom prevention.
CONCLUSION Palliative procedures are an important and integral component of the comprehensive care of cancer patients. If a surgical procedure is considered, the patient, family, and treating teams must have a firm understanding of realistic goals of success that focus on QOL. In addition, the chances of attaining those goals must be understood. Finally, the risks of the procedure, including worsening of symptoms and death, must be clearly described. As long as these criteria are met, surgical procedures may be undertaken in the setting of terminal cancer. Clearly, this will also mean that early palliative care is indicated, an interdisciplinary team approach should be utilized, and each issue must receive individualized attention. It is imperative that oncology nurses understand the myriad of approaches and indications for surgical palliation and its potential impact on QOL and the wellbeing of the patient and their families.
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