Palliative Care No Boon for Patients Undergoing Abdominal Surgery for Cancer

Specialist palliative care did not improve quality of life for patients undergoing major abdominal surgeries for cancer compared with usual care, the randomized SCOPE trial showed.

Adjusted median scores on the Functional Assessment of Cancer Therapy-General (FACT-G) Trial Outcome Index measure of physical and functional quality of life were about the same between the intervention and usual care groups (46.77 vs 46.23, P=0.46), reported Myrick C. Shinall Jr, MD, PhD, of the Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues.

Overall 90-day quality-of-life scores, which included all four domains of the FACT-G, were also similar (OR 1.09, 95% CI 0.75-1.58, P=0.66), as were days alive at home (OR 0.87, 95% CI 0.69-1.11, P=0.26) and 1-year overall survival (HR 0.97, 95% CI 0.50-1.88, P=0.92), they noted in JAMA Surgery.

The authors pointed out that these surgical patients "likely have low palliative care needs compared with other cancer populations."

"I think this adds to our evidence base of knowing where, in a systematic way, involving palliative care is generally helpful, and where it does not seem to be as helpful," Shinall told MedPage Today.

Changes in anxiety, depression, and life space from baseline to 90 days post-surgery were smaller than the calculated minimal clinically important difference. Caregiver burden and time to adjuvant therapy were also similar between the groups.

Shinall and team noted that the minimal changes in quality of life were similar to other studies, and that patients had relatively high baseline quality of life compared with the general U.S. population.

"What I don't want people to take away from this is that specialist palliative care is not good for surgical patients," Shinall said. "I think that what it shows is that for a broadly defined population, there's not a measurable benefit to palliative care, but there still may be subpopulations or patients with specific needs ... who could benefit."

Shinall said that based on his participation in the trial as a specialist palliative care provider, subgroups such as those who received hyperthermic intraperitoneal chemotherapy, and those with highly impaired quality of life before surgery or a "serious symptom burden" may benefit more from specialist palliative care than the group at large. "When I was seeing these patients as a palliative care provider, [I] found that I had a lot to talk about with them," he added.

Though palliative care is typically given at the end of life, the authors noted that many surgeries for cancer "impose a burdensome recovery and have high rates of recurrence." Based on findings from other studies that specialist palliative care improved quality of life for patients undergoing medical oncology treatment, Shinall's group hypothesized that the same would be true, physically and functionally, for surgical oncology patients.

Shinall also pointed out that specialist palliative care did not do any harm, which had been a concern to surgeons. "Was this going to be distressing to patients with having a palliative care provider involved in the care of the patients, be upsetting to the patients or make them think about death or dying, these kind of things?" Shinall said. "And it really doesn't appear that that was the case."

In an invited commentary, Jason Michael Johanning, MD, MS, of the University of Nebraska Medical Center in Omaha, and colleagues wrote, "Ultimately Shinall et al. have given us pause to reconsider the role of routine perioperative-specialist palliative care consultation in surgical oncology for curative intent. But rather than throwing the baby out with the bathwater, their work helps define important questions to be addressed by further investigations," including which patients could benefit, when, and how best to measure the impact of such care.

Shinall noted that "if we're going to make sort of programmatic changes or programmatic expansions of who the patient population is for palliative care specialists, it behooves us to test it first to see again if this is going to be a good use of scarce resources."

For the SCOPE (Surgery for Cancer With Option of Palliative Care Expert) trial, conducted from March 2018 through October 2021 at a single academic urban referral center, Shinall and colleagues included 235 adults undergoing one of eight scheduled non-palliative abdominal operations for cancer, who were randomly assigned to the usual care group or the specialist palliative care intervention in a 1:1 ratio. Median age was 65, 60% were men, and 95.3% were white. The most common operations were radical cystectomy, pancreatectomy, and partial hepatectomy, and the most common cancers were bladder cancer, colorectal cancer, and pancreatic cancer.

The specialist palliative care intervention consisted of preoperative consultation, inpatient visits twice weekly or more during the postoperative hospital stay, three follow-up clinic visits or phone calls before postoperative day 90, and an inpatient visit if the patient was readmitted to the hospital. Palliative care included assessment and treatment of pain, nausea, constipation, sleep disturbances, delirium, immobility, and psychosocial or spiritual distress.

Limitations of the study included potentially unmeasured aspects of the patient's experience, a lack of generalizability due to the study being conducted at a single center, and a potential lack of palliative care needs in a heterogenous patient population.

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