Early palliative care ‘did not show a benefit’ for patients undergoing cancer surgery
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Key takeaways:
- The specialist intervention failed to produce significant improvements in quality-of-life scores or OS.
- Early palliative care also did not cause patient distress or disrupt the treatment process.
Palliative care specialist services provided around the time of cancer surgery with curative intent failed to significantly improve patient outcomes, results of a randomized study showed.
The findings, published in JAMA Surgery, revealed that early specialist palliative care for this group of patients, who underwent major abdominal operations to cure or control their cancer, did not produce a quality-of-life or OS benefit compared with surgery alone.
"As we consider expanding specialist palliative care to more patients, we need to be careful and test the effects on different populations and not just assume that it will have the same beneficial effects it has on other settings,” Myrick C. Shinall Jr., MD, PhD, associate professor of surgery and medicine at Vanderbilt University Medical Center, told Healio. “Our study shows that this population would not be a very good use of the scarce resource of available palliative care clinicians.”
Background
Accumulating data have shown that specialist palliative care improves patient outcomes in medical oncology, according to Shinall. The evidence has led ASCO to recommend palliative care along with active treatment for patients with advanced malignancies, he added.
"As surgeons, we were curious to see if palliative care would have the same effect on surgical oncology outcomes, and that was our motivation for leading this study,” Shinall said.
Methodology
Shinall and colleagues conducted a single-center randomized clinical trial to assess the effects of providing early palliative care services to patients scheduled to undergo surgical resection with curative intent or to provide durable cancer control.
The study included 235 adults (median age, 65 years; interquartile range, 56.8-71.1; 60% men) who underwent intra-abdominal cancer surgery at Vanderbilt University Medical Center between March 1, 2018, and Oct. 28, 2021.
Researchers randomly assigned study participants in a 1:1 ratio to either early palliative care intervention or usual care in concert with their scheduled surgical procedure.
Palliative care services included a preoperative consultation, in addition to specialist inpatient and outpatient follow-up for 90 days after surgery.
Physical and functional quality-of-life (QoL) scores at postoperative day 90 as determined by the Functional Assessment of Cancer Therapy–General (FACT-G) Trial Outcome Index (TOI) served as the study’s primary endpoint. Secondary endpoints included overall QoL at day 90 after surgery as measured by the FACT-G questionnaire, days alive at home until postoperative day 90 and 1-year OS.
Key findings
Investigators reported no significant differences between the groups with respect to adjusted median FACT-G TOI scores of physical and functional QoL (intervention group score = 46.77, 95% CI, 44.18-49.04; usual care group score = 46.23, 95% CI, 43.08-48.14).
An adjusted analysis produced an OR of 1.17 (95% CI, 0.77-1.8) when comparing the interventional group vs. those who received usual care.
Early palliative care did not improve overall QoL care (OR = 1.09; 95% CI, 0.75-1.58), days alive at home until postoperative day 90 (OR = 0.87; 95% CI, 0.69-1.11) or 1-year OS (HR = 0.97; 95% CI, 0.5-1.88) compared with usual care.
Clinical implications
"There may be surgical patients who could benefit from early palliative care, but these findings suggest this does not apply to the broader surgical oncology population,” Shinall told Healio.
To have a beneficial effect, Sinall said specialist palliative care during surgery could be limited to those patients who have difficult-to-control symptoms, those who may face more complicated treatment decisions after surgery or those who already expressed concern about end-of-life planning.
“However, in our general surgical oncology population, early palliative care did not show a benefit,” he said.
Results of the study suggest that early palliative care may not be an appropriate use of limited resources among a population of patients undergoing surgery with curative intent, according to Jason Michael Johanning, MD, MS, of the department of surgery at University of Nebraska Medical Center, and colleagues.
“But rather than throwing the baby out with the bathwater, their work helps define important questions to be addressed by further investigations,” they wrote in an accompanying editorial. “The surgical community must now focus on optimal patient selection, who and when best to provide optimal palliative care support, and how best to measure the impact of palliative care delivery in the surgical setting.”
References :
- Johanning JM, et al. JAMA Surg. 2023; doi:10.1001/jamasurg.2023.1406.
- Shinall MC, et al. JAMA Surg. 2023;doi:10.1001/jamasurg.2023.1396.
For more information :
Myrick C. Shinall Jr., MD, PhD, can be reached at Vanderbilt University Medical Center, 1161 21st Ave. S, Room D5203 MCN, Nashville, TN 37232; email: ricky.shinall@vumc.org.
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