Psychosocial Factors Impact Cancer Surgery Outcomes

Kristin Jenkins

March 19, 2019

Complications from cancer surgery are not simply a physical or biomedical matter, new research indicates.

The presence of two or more psychosocial risk factors such as a lack of resourcefulness, depression, alcohol abuse, or the absence of social support independently tripled the risk of complications after surgery among cancer patients with comorbidities, say investigators.

Results from a prospective observational study of 142 patients with gastrointestinal (GI) cancer showed that the postoperative complication rates were 28% higher in those with a comorbid condition who had at least one psychosocial risk factor compared to peers with no psychosocial risks (54.4% vs 26.2%; P = .039).

More dramatically, the study showed that the presence of multiple psychosocial risk factors independently conferred a 3.37-fold increased risk of postoperative complications in patients with a comorbid condition (P = .036).

"We believe that these psychosocial risk factors are proxy measures for one's ability to cope with the stress of unplanned postoperative events and to comply with appropriate postoperative follow-up," say Ira L. Leeds, MD, of Johns Hopkins University School of Medicine, in Baltimore, Maryland, and colleagues.

"Further investigation is required to identify the modifiability of this risk with ongoing preoperative optimization efforts, and also whether a similar but attenuated effect is present in those without comorbidities," the authors write.

The study was published in the April issue of Annals of Surgical Oncology.

"What's attractive about our finding is that even in the 3- to 6-month period prior to cancer surgery, addressing psychosocial risk factors can have a direct impact on surgical outcome," Leeds told Medscape Medical News.

"If you can reduce complication rates by one third, this is a major reduction in the total complication burden of cancer care."

These findings come out of a broader trend in elective surgery known as "preoperative optimization," Leeds pointed out. Modifiable risk factors such as obesity, diabetes, and smoking are identified in preoperative "clearance visits" and treated in holistic care programs that focus on smoking cessation, weight loss, postop care planning, and so on prior to surgery.

However, little is known about the impact of psychological and social factors on short-term surgical outcomes, Leeds said.

"We are targeting the low-hanging fruit to ask, 'What would you put into a holistic preop care program if you knew what actually works and what doesn't?'" he said.

In patients with no comorbidities, the presence of one psychosocial risk factor did not increase the risk of postoperative complications, the study showed. However, the rate of unplanned readmission was 27.6% in comorbid patients with two or more psychosocial risk factors compared to 5.6% in comorbid patients with no psychosocial risks (P = .014).

"In patients who are already biomedically vulnerable, there is a compounding effect when two or more psychosocial risks are added to diabetes, congestive heart failure, or chronic obstructive pulmonary disease," Leeds said when discussing comorbidities.

"Patients get overwhelmed," he noted, adding, "Is this phenomenon reversible? We can't answer that yet."

Study Details

For the study, carried out between March and October 2017, the researchers conducted structured interviews with patients who had undergone an initial surgical consultation or who were having surgery that day for suspected or proven GI malignancy.

The 10-minute survey used standardized risk assessment questions. Among these, patients were asked to rate on a scale from 1 to 5 how well they tend to bounce back from a difficult event or might cope with caring for a minor postsurgical infection at home.

Of the 142 patients, 43.5% had high-risk biomedical comorbidities and 73.4% had at least one psychosocial risk, with 43% reporting that they smoked and 29% admitting to limited resourcefulness in the event of an emergency.

The median patient age was 65 years and more than half were men. A total of 58.2% underwent a resection for a hepato-pancreato-biliary primary tumor, and 31.9% underwent surgery for a primary colorectal tumor.

Patient outcomes 30 days after surgery were assessed using medical records. The most common complications included wound infection (23.1%), other sepsis (16.1%), and ileus (14.0%).

The authors note that psychosocial risk is not factored into contemporary surgical oncology risk assessment tools such as the National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator or tumor-specific predictive nomograms. Similarly, there are very few preoperative optimization programs that include psychosocial assessments.

"Our results suggest that there is an opportunity to test new interventions focused on managing psychosocial risks before surgery in order to improve outcomes, and that is what we plan to do next," said Leeds in a statement.

The study was supported by the National Cancer Institute, Research Foundation of the American Society of Colon and Rectal Surgeons, and Agency for Healthcare Research and Quality. Leeds and coauthors have reported no relevant financial relationships.

Ann Surg Oncol. 2019;26:936-944. Abstract

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