Optimizing the Care of Malignant Bowel Obstruction in Patients With Advanced Gynecologic Cancer

Abstract

PURPOSE: Malignant bowel obstruction (MBO) is a common and distressing complication in women with advanced gynecologic cancer. A pilot, interprofessional MBO program was launched in 2016 at a large Canadian tertiary cancer center to integrate these patients’ complex care needs across multiple disciplines and support women with MBO. METHOD: Retrospective analysis to evaluate the outcomes of women with advanced gynecologic cancer who were admitted to hospital because of MBO, before (2014 to 2016: baseline group) and after (2016 to 2018) implementation of the MBO program. RESULTS: Of the 169 women evaluated, 106 and 63 were in the baseline group and MBO program group, respectively. Most had ovarian cancer (n = 124; 73%) and had small-bowel obstruction (n = 131; 78%). There was a significantly shorter cumulative hospital length of stay (LOSsum) within the first 60 days of MBO diagnosis in the MBO program group compared with the baseline group (13 v 22 days, respectively; adjusted P = .006). The median overall survival for women treated in the MBO program was also significantly longer compared with the baseline group (243 v 99 days, respectively; adjusted P = .002). Using the interprofessional MBO care platform, a greater proportion of patients received palliative chemotherapy (83% v 56%) and less surgery (11% v 21%) in the MBO program group than in the baseline group, respectively. A subgroup of women (n = 11) received total parenteral nutrition for longer than 6 months. CONCLUSION: Implementation of a comprehensive, interprofessional MBO program significantly affects patient care and may improve outcomes. Unique to this MBO program is an integrated outpatient model of care and education that empowers patients to recognize MBO symptoms for early intervention.

Chemotherapy After Diagnosis of Malignant Bowel Obstruction is Associated with Superior Survival for Medicare Patients with Advanced Malignancy

“…The initiation of multidisciplinary team approaches for MBO patients has been associated with improved outcomes including shorter cumulative hospital stays, less surgical intervention, and longer survival. 50 Our data also suggest that greater use of palliative chemotherapy after a diagnosis and management of MBO may contribute to more favorable survival outcomes.…”

Supported self-management as a model for end-of-life care in the setting of malignant bowel obstruction: A qualitative study

“…Participants described instances where they were able to avoid emergency department visits or receive home care due to program facilitation. Another study by our group demonstrated that patients spent fewer days in hospital after MBO program adoption: their mean cumulative length of stay during the first 60 days after MBO diagnosis was shorter post-implementation (13 days [95% CI 10-16] vs. 22 days [18][19][20][21][22][23][24][25][26]; p = 0.006; adjusted for age, histology, platinum sensitivity, surgery) [12]. Literature reviews have shown that SMS may reduce health service utilization for non-malignant chronic diseases, but effect sizes were small and confined to cardiorespiratory conditions [27].…”

“…Recognizing these issues, we developed an outpatient SMS program for gynecologic cancer patients with MBO at Princess Margaret Cancer Centre (PM) in Toronto, Canada, with goals of enabling patients to engage in self-management, reducing physical and psychological distress, and facilitating care at home rather than in hospital. We previously demonstrated that cumulative hospital length of stay declined after program implementation [12], but were unable to evaluate critically important outcomes such as patients' sense of support, degree of distress, and capacity to self-manage. Such outcomes are not well captured with quantitative methods, particularly when the window for measurement may be only weeks.…”

Gaps in patient-physician communication at the time of malignant bowel obstruction from recurrent gynecologic cancer: a qualitative study

“…Programs focusing on outpatient follow-up of patients with MBO have been able to support patients in their desire to be at home, as well as addressing issues of nutrition. Lee et al provided patients with education on MBO symptoms and diagnosis, as well as frequent check-ins after discharge home [14]. A qualitative analysis showed that patients valued these interventions, and their daily concerns and changes in symptoms could be managed outpatient by an expert team, to prioritize their ability to be home [6].…”