Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer

Abstract

ImportanceInvolvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations.ObjectiveTo determine whether surgeon–palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers.Design, Setting, and ParticipantsFrom October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients.InterventionSurgeon–palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network–recommended triggers for palliative care consultation.Main Outcomes and MeasuresThe primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed.ResultsIn total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon–palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon–palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], −0.07 [0.87] vs −0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99).Conclusions and RelevanceTo date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care–associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers.Trial RegistrationClinicalTrials.gov Identifier: NCT03611309

Early Integrated Palliative Care Within a Surgical Oncology Clinic

“…Overall, the rates of AD designation (85.4%) and documentation (56.3%) in our patient cohort after workflow integration were markedly higher than those previously reported in oncology patients, high-risk surgical patients, and the general population outside an end-of-life setting (26%-37%) . To our knowledge, this is the first initiative to establish a novel cohabiting unit of surgical and palliative care teams focused on improving the ACP process …”

“…Additionally, it helps promote goal-concordant, end-of-life care through advance care planning (ACP) . Although palliative care interventions mainly target the nonsurgical population, there is limited evidence regarding the benefits of these interventions (eg, facilitating decision-making and reducing health care resource utilization) for surgical candidates . Formalized incorporation of ACP in surgical patients remains historically low.…”

Palliative Care for Patients Undergoing Surgery—Reply

“…Prior randomized clinical trials have defined populations of patients with cancer who benefit from palliative care based on their diagnosis and treatment modality (eg, metastatic lung cancer treated with chemotherapy, hematologic malignancies treated with hematopoietic stem cell transplant). Our work along with the recently published work by Aslakson et al suggests that a finer-grained approach is needed to identify surgical patients with unmet palliative care needs. We agree with Hentsch et al that defining the population of surgical patients who would benefit from palliative care is the crucial question at this stage.…”

Palliative Care for Patients Undergoing Surgery

“…To the Editor Two important articles have been published in the JAMA Network in the last month regarding the early implementation of palliative care for patients undergoing surgery with a curative intent. Shinall et al investigated the effect of a palliative care intervention on physical and functional quality of life at 3 months, and Aslakson et al evaluated the effect of surgeon-palliative care co-management on patient-reported health-related quality of life at 3 months.…”