Surgical Tribune America

Terminally ill cancer patients far more poorly after surgery

By Surgical Tribune
November 09, 2016

SACRAMENTO, Calif., USA: Patients with disseminated advanced cancer who undergo surgery are far more likely to have long hospital stays, readmissions and referrals to extended care facilities and to die, researchers at the University of California Davis Medical Center in Sacramento have found. Their study highlights the dilemma physicians and surgeons face when their terminally ill cancer patients are diagnosed with a condition that may benefit from surgery, such as bowel obstruction, as well as the need for substantive discussions about the risks of surgery and implications on future quality of life.

“We commonly consult with patients who have acute surgical conditions and advanced cancer, and it has left us to weigh the risks and benefits of surgical intervention,” said lead author Dr. Sarah B. Bateni, a fourth-year surgery resident. “It’s important to carefully examine their risks before proposing surgery, and to understand their goals for their remaining days .”

For the study, Bateni and colleagues examined the cases of approximately 18,000 patients who had Stage 4 (metastatic) cancer and went on to undergo surgery. The cases were matched with patients who had similar characteristics, such as age, sex and functional status before surgery, and underwent similar operations, but did not have Stage 4 cancer.

They found that the group of patients with Stage 4 cancer spent more time in hospital (32 percent vs. 20 percent), were readmitted to hospital more frequently (16 percent vs. 10 percent), were more often referred to another facility, such as skilled nursing (16 percent vs. 13 percent), and had higher mortality within 30 days of the procedure (8 percent vs. 2.5 percent) than their counterparts who did not have late-stage cancers.

What was most surprising, Bateni said, was that the Stage 4 cancer patients who did not have any complications during their hospitalization ended up staying in hospital longer, were readmitted more often, were more often discharged to other facilities and had higher 30-day mortality compared with patients who did not have Stage 4 cancer.

“Stage 4 cancer really is an indicator of the frailty of these patients and is itself a risk factor for readmission, prolonged stays in the hospital and discharge to other facilities,” she said.
Bateni and her co-authors concluded that doctors and surgeons need to speak with their terminally ill cancer patients about their end-of-life goals, palliative care, and the risks and benefits of surgery.
“We all need to clarify the goals of care for patients with advanced cancer prior to providing—or even discussing—the potential surgical interventions,” she said.

Given that the prevailing wisdom has been that surgery is the only treatment option for these patients, the researchers now plan to analyze the outcomes of Stage 4 cancer patients with conditions that are considered operable, but who do not undergo surgery.

The study, titled “Increased rates of prolonged length of stay, readmissions, and discharge to care facilities among postoperative patients with disseminated malignancy: Implications for clinical practice,” was published in the Oct. 25 issue of the PLOS ONE journal.

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