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.”
For more information about the UC Davis Comprehensive Cancer Center visit www.cancer.ucdavis.edu