To Operate or Not? Navigating Gray Areas in Surgical Oncology

Decision to Operate Is Often Complex

Susan London

November 04, 2019

SEATTLE — The decision of whether or not to operate on a patient with cancer, especially advanced cancer, is often complex.

Dr Venu Pillarisetty

It is often a tough call — and it requires careful consideration of disease parameters, risk factors, surgical goals, and patient and family preferences, says Venu Pillarisetty, MD, an associate professor of surgery at the University of Washington and medical director of Continuous Performance Improvement at the Seattle Cancer Care Alliance.

"I deal with patients with complex decision making all the time," said Pillarisetty, a surgical oncologist whose main area of practice is pancreatic surgery.

"For a lot of these situations, the answer about whether to operate is not obvious, and I can't necessarily find literature to give you the right answer. Much of this is about coming up with a framework and ways to think about it," he commented.

Pillarisetty was speaking here at JADPRO Live, the annual meeting of the Advanced Practitioner Society for Hematology and Oncology (APSHO).

"Knowing when to operate is relatively easy, but when not to is the hard part," he proposed.

Tumor boards can help inform surgical decision making to some extent. "And certainly, for pancreatic disease, we have a multidisciplinary conference that includes surgeons, radiation oncologists, and medical oncologists, but probably as [important] or more importantly, palliative care people, social workers, and a whole host of other ancillary staff who can help us make good decisions about whether to recommend an operation or not," he continued.

"But what we really need to do is learn about the patient and the family, and their values and goals. In the end, the goals for surgical resection of advanced cancer need to be individualized," Pillarisetty continued.

That may require lengthy discussion, as patients often don't know what their goals are, especially if their diagnosis is fairly new.

"Effective communication with patients and family members about surgical decision-making requires time, patience, and insight," he said. In approaching these discussions, oncologists should be aware of their own biases regarding likely preferences and try to put them aside, he recommended. In addition, they should be aware of cultural and generational issues that may be at play.

A big thing is to listen without interrupting. It's super hard to do. Dr Venu Pillarisetty

"A big thing is to listen without interrupting. It's super hard to do, especially if you have a busy clinic going on," Pillarisetty noted. He recommends using periods of silence. "That's when things come out. You have to sit there and wait, and eventually the patient and family tell you what's on their mind. This is much more efficient from a time standpoint than talking too much."

Explaining Risks

Patients must be counseled about various surgical risks and complications, such as bleeding and infection, in terms that are meaningful to them, according to Pillarisetty.

"For a lot of patients, the worst-case scenario is not dying of an operation because they come in thinking, 'Oh well, then I won't have a slow, painful death. This is a way that I can die humanely,' " he elaborated. "But if you tell a patient, if you survive this operation, there's about a 50% chance you're going to wind up in a nursing home, boom, that person is out the door, they're gone."

When patients ultimately ask surgeons what they recommend, simply laying out the options and telling them it's their choice is not helpful. "I don't want that if I take my car to get serviced: 'You could either get the brakes replaced or not — it's totally up to you.' I want to know if my car is going to stop when I step on the brakes," Pillarisetty said.

Most patients coming in for a surgical consultation know little relevant information other than what they have read on the Internet, he said. "So it's really important for us as clinicians at every level to be able to give people advice and say honestly, based on what you understand and what you've learned about that person, what you would recommend for them."

Palliative Surgery

Although studies have shown that palliative care extends life, these interventions are mainly undertaken to alleviate symptoms, according to Pillarisetty. Surgical examples would be placing a gastrostomy tube to drain gastric contents and stop vomiting, and operating to relieve a malignant bowel obstruction.

"It's usually not going to substantially increase the length of somebody's life, but it can be as important as and, in many ways, more important than potentially curative therapy," he contended. "There are a lot of indications for palliative surgery, but you've got to make sure that you are doing it for the right reason. If you are going to call it palliative, hopefully, you are trying to make somebody feel better."

Realistic Goals and Plans

The healthcare team should help patients set realistic goals, including those for life expectancy, Pillarisetty advised. "People in general still have this feeling that technology will save us from everything, but nothing is going to save us from death in the end."

Patients for whom short-term decisions are being contemplated, especially whether to perform a palliative operation, will often benefit from counseling by their main oncology provider, he noted. Most often, that would be their medical oncologist.

"If you're from that side of the world, it's really critical for patients who are starting to decline to come up with realistic plans around their problems, because once they're in the hospital and emergency department, you don't have access to all of the people who know the patient well," he explained. "So it's really helpful to try to get all these plans made earlier, so that they don't become middle-of-the-night plans."

Candid Discussions

"It is essential that someone on the multidisciplinary team takes responsibility for candid discussions with the patient and family, especially in patients with incurable cancer," agreed Kelly M. McMasters, MD, PhD, oncology professor and chair of the Department of Surgery at the University of Louisville School of Medicine in Kentucky.

Good communication can improve outcomes, he emphasized.

Dr Kelly McMasters

"I am regularly astounded at how frequently patients and their families, yearning for someone to tell them the plain truth, have encountered physicians who have made the truth so elusive. Patients and families often say they want 'everything done' to treat the cancer. This is sometimes construed as an excuse to engage in overly aggressive treatment," McMasters told Medscape Medical News.

"This is when one good doctor, spending time with the patient and family, can make the difference between pursuing a course of futile therapy vs accepting palliative care. It can mean the difference between death with indescribable misery or death with dignity," he added.

End-of-life discussions should be initiated well in advance of the end of life for patients with terminal cancer, recommended McMasters, who is also past president of the Society of Surgical Oncology and current editor-in-chief of the society's journal, Annals of Surgical Oncology.

"Learning how to tell patients and families the plain truth in a compassionate way is essential. I tell my patients with advanced cancer that if it gets to the point that further treatment will cause more harm than good, I will tell them. When it gets to that point, I do tell them," McMasters said. "Futile therapy that only causes side effects or morbidity without benefit must be avoided. This includes surgery, chemotherapy, and radiation therapy. Yet it happens every day."

Pillarisetty has disclosed no relevant financial relationships. He receives unrelated research funding from AstraZeneca, Ipsen, and Merck, and is an advisory board participant for GSK and Imvax. McMasters has disclosed no relevant financial relationships.

2019 JADPRO Live. Presented October 25, 2019.

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