Often recommended to alleviate pain or other cancer complications, surgery for those with less than six months to live carries significant risks. Many will die as a result of an operation.
UC Davis surgical oncologist Robert Canter and colleagues have developed the first comprehensive tool to guide doctors and their patients in deciding whether surgery is the best option based on the risk of complications or death within 30 days after the proposed operation.
A paper published online today in Annals of Surgery describes the tool, called a “nomogram.” The tool allows physicians to plug in patient information such as clinical diagnoses, symptoms and laboratory test values to determine in real time an individual patient’s risk of surgical complications, or death.
“There is a real gap in the literature about the risks and benefits of surgery in these difficult and emotional circumstances,” Canter said. “This tool will allow clinicians, patients and families to make a more informed decision.”
Warren Tseng, a sixth-year surgery resident at UC Davis and first author on the study, said 40 percent of hospitalized patients referred to surgical oncologists for consultation have cancer that has metastasized, or spread to distant parts of the body. He also noted that 25 percent of all Medicare expenditures are made in the care of the 5 percent of patients who are in the last year of life.
“We are performing sometimes heroic acts to try to extend their lives, attempt to palliate symptoms and improve their quality of life, where maybe we are not doing them or the health care system any good,” Tseng said. “This clinical nomogram is intended to be a small tool that helps in the more complex and bigger problem of how we deal with people at the end of their lives with dignity.”
Canter, the study’s principal investigator, emphasized, however, that the nomogram is not designed to be prescriptive in terms of whether a patient gets a surgical intervention or not.
“We are not making any black-and-white recommendations, but we are helping people understand what the risks are in a more detailed way, to allow patients and clinicians a way to make a more informed decision,” he said.
To develop the nomogram, Canter and colleagues at UC Davis Cancer Center identified 7,447 patients with widespread cancer from data collected in 2005 through 2007 by the American College of Surgeons National Surgical Quality Improvement Program. They used a statistical formula and applied 53 different variables to come up with rates of complications and mortality for individual patients.
The researchers cite the hypothetical example of a 70-year-old with metastatic lung cancer admitted to the hospital with an obstructed intestine. In this case, the patient has lost more than 10 percent of his weight within the past six months, has difficulty breathing with moderate exertion, has poor kidney function and advanced malnutrition. After entering that information into a risk calculator, doctors determine that the patient has a 30 percent risk of dying and 40 percent chance of other complications within 30 days of the surgery.
Geoffrey Dunn, a surgeon at University of Pennsylvania Medical Center Hamot in Eerie, Pa., and chairman of the surgical palliative care committee for the American College of Surgeons, said he believes the tool will bring needed comfort to surgeons who find talking to advanced cancer patients and families about surgery risks and mortality challenging.
“Surgeons routinely make ill-advised decisions to pursue aggressive treatment in the last stages of disease,” Dunn said. “I think this will provide surgeons the reassurance there is data, tools to make this a more navigable situation and discussion.”
When the odds of a good surgical recovery are not favorable, doctors can more easily inform patients of alternatives, Dunn added.
“We don’t have to subject someone to all the problems and discomfort of an operation or have them die in the intensive care unit,” he said. “There is another way out of the dilemma. Let nature take its course, but continue to treat the pain, attend to their spiritual needs, and provide access and privacy for the family.”
In addition to Canter and Tseng, other authors of “Nomogram to Predict Risk of 30-day Morbidity and Mortality for Patients with Disseminated Malignancy Undergoing Surgical Intervention” included Xiaowei Yang, Hui Wang, Steve R. Martinez, Steven L. Chen, Frederick J. Meyers and Richard J. Bold, all of UC Davis. The full article will be published in the August issue of Annals of Surgery.
UC Davis Cancer Center is the only National Cancer Institute- designated center serving the Central Valley and inland Northern California, a region of more than 6 million people. Its top specialists provide compassionate, comprehensive care for more than 9,000 adults and children every year, and offer patients access to more than 150 clinical trials at any given time. Its innovative research program includes more than 280 scientists at UC Davis and Lawrence Livermore National Laboratory. The unique partnership, the first between a major cancer center and national laboratory, has resulted in the discovery of new tools to diagnose and treat cancer. Through the Cancer Care Network, UC Davis is collaborating with a number of hospitals and clinical centers throughout the Central Valley and Northern California regions to offer the latest cancer-care services. For more information, visit cancer.ucdavis.edu.