Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey

Abstract

Background: Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. Methods:We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care.Results: A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a universityaffiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experi ence, regional culture and training background impacted treatment (all p < 0.05). Conclusion:Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma. Contexte :Le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas sont complexes. Les décisions de fin de vie reposent sur un processus hautement variable qui dépend de multiples facteurs.Méthodes : Nous avons administré à des médecins un sondage international qualitatif à 40 questions afin de caractériser l'impact sur les soins exercé par différents facteurs, notamment médicaux, religieux, sociaux, relatifs à la formation et systémiques. Résultats :En tout, 258 cliniciens ont participé à ce sondage international. Les participants étaient en général des spécialistes (78 %), cumulaient en moyenne 16 ans d'expéri-ence dans le domaine hépatopancréatobiliaire (96 %) au sein d'un groupe affilié à une université (93 %). La plupart (91 %) ont dit croire que la résection est potentiellement curative. La majorité des cas faisaient l'objet de discussions préopératoires par des équipes multidisciplinaires (94 %) et en clinique d'évaluation médicale (68 %), mais rarement par une équipe de soins intensifs (21 %). Les soins palliatifs chirurgicaux peropératoires incluaient la double dérivation ou la non intervention en présence de tumeurs non résé-cables localement avancées (41 % et 49 % c. 14 % et 85 %, respectivement, chez les patients porteurs de métastases hépatiques). L'admission postopératoire aux soins ...

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