Palliative Care for Major Nonpalliative Cancer Surgery?

Megan Brooks

May 15, 2023

Results of a randomized controlled trial do not support routine integration of specialty palliative care among patients undergoing major surgery for cancer with curative intent.

The trial did not show any meaningful benefit of preoperative consultation with a palliative care specialist in patients undergoing major nonpalliative cancer operations.

The primary outcome — physical and functional quality of life (QoL) at 90 days — was nearly identical between patients who received preoperative palliative care and those who did not, according to the researchers, led by Myrick Shinall Jr, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tennessee.

The article was published online May 10 in JAMA Surgery.

The findings may seem counterintuitive, given that specialist palliative care initiated concurrently with chemotherapy has been shown to improve quality of life.

The authors of an editorial published alongside the study explain that Shinall and colleagues have "given us pause to reconsider the role of routine perioperative-specialist palliative care consultation in surgical oncology for curative intent."

But the editorialists, led by Jason Michael Johanning, MD, MS, University of Nebraska Medical Center, Omaha, say it's too soon to dismiss palliative care for surgical oncology patients. "Rather than throwing the baby out with the bathwater, their work helps define important questions to be addressed by further investigations."

The SCOPE trial enrolled 235 adults scheduled to undergo major surgery for cure or durable control of abdominal cancer at one academic center in Tennessee. Overall, patients' mean age was 65 and 60% were men.  

Patients were randomly allocated to an early palliative care intervention or usual care. Palliative care included a preoperative consultation with palliative care specialists and postoperative inpatient and outpatient palliative care follow-up for 90 days. The researchers assessed QoL using the Functional Assessment of Cancer Therapy–General (FACT-G) Trial Outcome Index (TOI), which is scored from 0 to 56, with higher scores representing higher physical and functional QoL.

The results showed no significant difference in physical and functional QoL 90 days after surgery between the intervention and usual care group. Adjusted median FACT-G TOI scores were 46.77 with the palliative care intervention and 46.23 with usual care (P = .46).

Compared with usual care, early palliative care also did not improve the secondary outcomes of overall QoL (odds ratio [OR], 1.09), days alive at home until postoperative day 90 (OR, 0.87), or 1-year overall survival (hazard ratio, 0.97). 

"Given the study's strengths, the most likely explanation for these results is that this intervention does not improve these outcomes for this patient population," the authors write.

However, the authors and editorialists questioned whether certain patients may still benefit from palliative care.

"Some of these patients may have more needs and would benefit from specialist palliative care, and the lack of adverse effects demonstrated in this study should reassure referring clinicians that specialist palliative care is unlikely to distress or harm patients," the investigators say.

The researchers suggest future studies look at surgical populations with higher symptom burdens, such as patients undergoing organ transplant, for whom specialist palliative care could offer benefit.

The editorialists agreed that "the surgical community must now focus on optimal patient selection, who and when best to provide optimal palliative care support, and how best to measure the impact of palliative care delivery in the surgical setting."

Funding for the study was provided by the National Institutes of Health. The authors report no relevant financial relationships. Editorial author Johanning reported a pending patent for FUTUREASSURE.

JAMA Surg. Published online May 10, 2023. Abstract, Editorial

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