Palliative Care Is Less Often Offered to Surgical Oncology Patients for Symptom Management

By Lisa Rapaport

May 06, 2020

(Reuters Health) - Surgical oncology patients are less likely to receive palliative care consultations for symptom management than medical oncology patients, a recent study suggests.

Researchers conducted a retrospective analysis of medical records for 60 medical oncology patients and 60 surgical oncology patients who had inpatient palliative care consultations at Houston's University of Texas MD Anderson Cancer Center in 2016 and 2017.

Overall, similar proportions of patients in both groups received non-surgical palliative interventions: 35% of patients in surgical oncology and 45% in medical oncology (p = 0.35).

But the main reasons for palliative care differed between groups.

Pain management was the most common reason for palliative care in the medical oncology group, listed as the indication in 97% of cases, compared with only 62% of cases in surgical oncology.

In surgical oncology, advanced care planning was the most common reason for palliative care, listed as the indication in 32% of cases, compared with only 13% of medical oncology cases.

Patients on the surgical and medical services had relatively similar symptom profiles, except the medical patients had more dyspnea and pain. In medical oncology patients, palliative care consults more often yielded recommendations for changes in pain medications (98% vs. 75%) and bowel regimen medications (77% vs. 53%) and changes in code status to do-not-resuscitate (30% vs. 7%). Surgical oncology patients more often had recommendations for supportive counseling, depression management, and advanced care planning (32% vs. 15%).

"It is clear that early palliative care improves the quality of life for patients with advanced cancer," said senior study author Dr. Brian Badgwell, a professor of surgery at MD Anderson Cancer Center.

"If surgeons are primarily using palliative care for end of life discussions, we are missing out on opportunities to make patients feel better," Dr. Badgwell said by email.

Part of the problem may be that surgeons get very little exposure to palliative care during surgical training, Dr. Badgwell said. The study results offer fresh evidence that surgeons likely have a palliative care gap in their training, he added.

"Discussions at the end of life are difficult, and it can only benefit patients to have surgeons that are better trained in end of life communication and advanced care planning," Dr. Badgwell said. "It is also very likely that patients could have benefitted from having palliative care integrated earlier into their treatment."

Patients were similar in many ways, with a mean age of 60.3 years and 56.3 years, respectively, in the surgical and medical oncology groups (p = 0.11). They also had similar rates of metastatic or recurrent cancer, at 68% and 82%, respectively (p = 0.14).

In medical oncology, however, patients were more likely to have received systemic chemotherapy within the previous six weeks, at 52% compared with 22% in surgical oncology (p = 0.01).

Surgical oncology patients were more likely to be admitted for planned operations or procedures, at 20% versus 3% for medical oncology. But surgical oncology patients were less likely to be admitted for pain symptoms, at 2% compared with 32% for medical oncology.

Overall, 48 patients received a total of 75 non-surgical palliative procedures. Twenty-one surgical oncology patients received a total of 27 procedures, compared with a total of 48 procedures among 27 medical oncology patients.

One limitation of the study is that it was done at a single institution, and practices may vary elsewhere, the study team notes in the Journal of the American College of Surgeons.

In addition, medical records used for the analysis did not contain detailed information on the complex palliative care conversations that may have occurred, nor indicate how individual patient or family preferences might have influenced treatment decisions.

"This is a small study in one outstanding institution that happens to have one of the largest and best established palliative care in oncology programs in the world," said Dr. Miriam Rodin, a professor of geriatric medicine at St. Louis University School of Medicine, in Missouri.

"If utilization seems low it could simply be that the basic knowledge of how to keep patients comfortable has been well-disseminated already in this center," Dr. Rodin, who wasn't involved in the study, said by email.

Nationwide, there's a growing push in academic medicine to provide primary palliative care education in communication, symptom management, and patient and family support to surgical specialties, said Dr. Allyson Cook, an assistant clinical professor in palliative medicine and critical care medicine at the University of California, San Francisco.

"This integration will, I think, improve over time as more surgical trainees are exposed to palliative medicine and the broad range of support palliative care, both primary and specialty, can provide to our patients," Dr. Cook, who wasn't involved in the study, said by email.

Patients and families should also understand that they can ask for a palliative care consultation at any point when they feel like they need additional support - not only at the end of life, Dr. Cook added.

"Palliative medicine provides transdisciplinary support for patients with social work, chaplaincy, medical, and symptom management at any stage of illness, and early integration of palliative care allows for crucial rapport building, ongoing symptom control, and support for patients as they traverse their illness and treatment - whether that be surgery, chemotherapy, other disease-directed therapies, or end of life care," Dr. Cook said.

SOURCE: Journal of the American College of Surgeons, online April 17, 2020.