Surgery in terminal cancer patients can successfully reduce symptoms and distress, easing discomfort in their final months of life, according to a study by City of Hope researchers.
About a fifth of cancer surgeries are done for palliation — the relief of pain and other symptoms — not for cure, researchers said. Yet few researchers have studied the value of palliative surgery. Writing in the February issue of Annals of Surgical Oncology, the City of Hope research team reported that such surgeries reduce the frequency of cancer symptoms and distress from pain for several months after the procedures.
“We hope that patients understand that even though their cancer may not be curable, surgery is still a viable option,” said Betty Ferrell, Ph.D., R.N., research scientist in the Department of Nursing Research & Education and one of the study authors. She and colleagues in the Division of Surgery and her own department have led efforts to bring palliative surgery to the forefront, urging practitioners to consider issues of quality of life in administering treatment.
Lawrence D. Wagman, M.D., professor of surgery and director of City of Hope’s Liver Tumor Program, was the study’s senior author.
Palliative treatment includes procedures that can shrink a tumor or control spread so that patients can breathe, eat, move more comfortably and feel less pain. Historically, surgeons have been reluctant to operate when patients have no chance of cure, since little research was available on whether such surgeries offered benefit. Attitudes began to change within the last decade, when organizations such as the World Health Organization and the Institute of Medicine addressed the value of palliation to ease suffering.
Still, when City of Hope researchers surveyed members of the national Society of Surgical Oncologists in 2000, they found that most surgeons had received little training in palliative care. About 90 percent of the doctors surveyed said they received 10 hours or less of palliative care education during medical school, and 79 percent said they had 10 hours or less of palliative care training during their surgical residencies.
The recent study provides direction for further investigation and refinement of palliative care.
Called the Decisions and Outcomes in Palliative Surgery trial, the study comprised 104 patients who underwent palliative operations at City of Hope. Researchers tracked each patient’s visits with a health-care practitioner and interviewed patients to determine their levels of distress from pain, frequency and severity of pain, and measures of quality of life at key milestones: before surgery, three weeks after surgery and each month for the subsequent six months.
The researchers found that patients actually reported lower quality of life three weeks after surgery — when they were still recovering from their procedures and most likely to experience related discomfort and depression — but felt less distress from symptoms and less frequent symptoms within two months of surgery. Symptom relief persisted for about five months after the procedures.
Further research will determine which surgeries in particular are most helpful for the relief of symptoms, investigators said.
Wagman notes that that some palliative surgeries can be done through minimally invasive techniques, which usually result in a quicker recovery time. For example, surgeons may now use laparoscopic or endoscopic procedures to install stents in the bile ducts or small intestines of patients with gastrointestinal cancers, reducing blockage symptoms and discomfort.
“Our next step is to understand which patients truly benefit from such surgeries, so we can offer the appropriate procedures to those who we expect will recover well from procedures and truly see relief from discomfort,” said Wagman. “Considering that cancer is expected to take the lives of nearly 560,000 Americans this year alone, it’s important to consider how we can best contribute to the quality of life of these patients.”
Authors also included Gloria Juarez, Ph.D., R.N., of the Department of Nursing Research & Education, former City of Hope surgical oncology fellows Yale D. Podnos, M.D., M.P.H., and Colette Pameijer, M.D., and Kyong Choi of Vital Research, a research design and analysis firm. The American Cancer Society funded the study.