Trajectories of Patient-Reported Outcomes After Palliative Gastrointestinal Surgery in Advanced Cancer: Is Good Quality of Life Sustainable? : Annals of Surgery Open

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Trajectories of Patient-Reported Outcomes After Palliative Gastrointestinal Surgery in Advanced Cancer

Is Good Quality of Life Sustainable?

Wong, Jolene S. M. MMed (Surg), FRCS (Ed)*,†,‡,§; Ng, Irene A. T. MBBS*,†; Juan, Wen Kai D. BSc*,†; Ong, Whee Sze MAppStats; Yang, Grace M. MPH; Finkelstein, Eric A. MSc, PhD#; Gandhi, Mihir PhD**; Ong, Chin-Ann J. MMed (Surg), FRCS (Ed), PhD*,†,‡,§,††,‡‡; Seo, Chin Jin MMed (Surg), FRCS (Ed)*,†,§; Zhu, Hong-Yuan MD, PhD*,†,††; Chia, Claramae S. MMed(Surg), FRCS(Ed)*,†,‡,§

Author Information
Annals of Surgery Open 3(4):p e206, December 2022. | DOI: 10.1097/AS9.0000000000000206

Cancer is prevalent in an aging population and accounts for up to 30% of deaths worldwide.1 With growing affluence, a majority of terminally ill patients and their families hope for a “good death”—free of suffering and living with good health-related quality of life (HRQoL) till the end-of-life.2 Responding to the need for comprehensive end-of-life care service, palliative medical care has been developed and expanded astonishingly in the last decade.3,4 Yet, unlike its medical counterpart, the role of palliative surgery in meeting the demand of a “good death” remains under-explored.

Surgery can eradicate and cure cancer.5 As such, it is not intuitive for most patients, their caregivers, and physicians to consider surgery as a palliative strategy. There is also a misconception that noninvasive therapy provides the best palliation and insufficient recognition of the potential benefits of palliative surgery.6 However, existing evidence suggests that a surgical approach is feasible and is associated with good success rates in symptom palliation. For example, a review of 1022 palliative surgical procedures performed at the Memorial Sloan Kettering Cancer Center found that 80% of patients achieved complete symptom resolution after surgery.7 A systematic review of 17 retrospective studies on surgical management of malignant bowel obstruction revealed that obstructive symptoms were successfully palliated in 32% to 100% and resumption of diet was possible in 75% of the patients.8

Despite the reported benefits of palliative surgery, the utility of a surgical approach during end-of-life remains controversial due to the risks of potential postsurgical complications that can occur in up to 30 to 40% of patients.8,9 As most of the existing palliative surgery literature focuses on “conventional” measures of surgical success such as symptom resolution, survival, and surgical complications, it is little known if overall HRQoL—an outcome measure important to terminally ill cancer patients—improves after surgical intervention and the extent of such improvements. We hypothesize that palliative gastrointestinal (GI) surgery by directly eliminating sites of intestinal obstruction can provide effective relief of symptoms such that sustainable improvements in HRQoL may be achieved. Therefore, the overall aim of this study is to critically evaluate whether palliative surgical interventions improve patients’ HRQoL, the sustainability of these improvements, and identify perioperative factors that are associated with varying degrees of HRQoL improvements.

METHODS

Study Design and Participants

Advanced cancer patients undergoing palliative GI surgery at the National Cancer Centre Singapore and Singapore General Hospital were prospectively recruited from January 2020 to November 2021. Palliative GI surgery was defined as any intra-abdominal procedure requiring manipulation, resection, and diversion of the GI tract whose main intention was to mitigate physical symptoms, complications, or emergencies related to advanced cancer without the intention of cure.10 Surgeries were performed by a team of surgical oncologists from the Department of Sarcoma, Peritoneal & Rare Tumors (SPRinT) subspecializing in the treatment of advanced and complex malignancies.11,12 All patients were discussed at a multidisciplinary palliative surgical meeting involving specialist surgical oncologists, palliative medical physicians and nurses, the total parenteral nutrition (TPN) team, medical and radiation oncologists, radiologists, and medical social workers before and after surgery.

Patients who were unwilling to participate in the study or unable to complete HRQoL questionnaires in the English language were excluded. The study was approved by the SingHealth Centralized Institutional Review Board and informed consent was obtained before enrollment.

HRQoL Assessment Tool

The Functional Assessment of Cancer Therapy—General (FACT-G) and Colorectal (FACT-C) version 4 instruments were used to evaluate HRQoL outcomes.13–15 The FACT-G is a 27-item well-established, internationally validated HRQoL instrument covering 4 domains: physical well-being (7 items), social/family well-being (7 items), emotional well-being (6 items), and functional well-being (7 items).16 The FACT-C has an additional colorectal cancer subscale (CCS) (9 items) aimed at evaluating GI symptoms. Each item has response choices on a 5-point Likert-type scale with 0 indicating the absence of a symptom and 1, 2, 3, and 4 indicating that the symptom bothered the patient “a little bit,” “somewhat,” “quite a bit,” or “very much,” respectively. We administered the FACT-G to all patients and the additional FACT-C colorectal subscale to patients who had undergone either GI resection, diversion, or ostomy creation.

Data Collection

Upon recruitment, patients were led to a private room for a face-to-face session where they independently completed the FACT-G questionnaire in the presence of a trained research coordinator. Questionnaires were administered at baseline before surgery and at 2 weekly intervals to 3 months after palliative surgery. From the fourth month onwards, the questionnaires were administered monthly until 1-year after surgery. The 16 assessment timepoints were therefore at week 0, 2, 4, 6, 8, 10, 12, 16, 20, 24, 28, 32, 36, 40, 44, and 48. The interviews were conducted either in in- or outpatient settings by the same coordinator at all time points.

Data on patient demographics, clinical characteristics—Eastern Cooperative Oncology Group (ECOG) status, preoperative serum albumin, primary cancer and prior cancer treatment history, indications for palliative surgery, intraoperative surgical procedures, postoperative complications—as graded by the Clavien-Dindo classification,17 lengths of inpatient hospitalization, the use of parenteral nutrition, and postoperative treatment course, that is, continued systemic chemotherapy or radiotherapy, hospital readmissions, and their reasons were recorded. A single open-ended question asking if the patient found palliative surgery satisfactory was administered at 1-month postsurgery.

Statistical Analysis

Patients who had completed their baseline HRQoL questionnaire and at least one or more follow-up questionnaires postoperatively were included in the analysis. Follow-up data were cutoff as of December 14, 2021, for analysis, and none of the recruited patients was lost to follow-up. Overall survival (OS) was measured from palliative surgery till death from any cause or last follow-up.

Collected HRQoL items were scored according to the FACT scoring guidelines. The score range for FACT-G was 0 to 108 while FACT-C was 0 to 136 with a higher value indicating better HRQoL. The baseline FACT-G score was categorized into very low (≤60), low (>60–70), average (>70–80), and high (>80)18. The primary outcome measure was the FACT-G total score. The mean and standard error of the total and subscale score in the FACT-G and FACT-C questionnaires at each assessment time point were estimated using linear mixed effect models with time-variable included as fixed factors, patient-specific random intercepts, and unstructured covariance matrix. Change in the estimated mean score at each assessment time point from baseline was tested based on an approximate t-test, and P values were adjusted for multiple comparisons using the Dunnett method.

Time to HRQoL improvement was measured from palliative surgery till the first follow-up assessment at which patients had at least (≥) 4-points increment in FACT-G total score over baseline scores. Patients who did not have ≥4-points increment in FACT-G total score over their baseline scores were censored at their last HRQoL assessment. The threshold of 4 points used in the definition of clinically important HRQoL improvement was based on the estimated minimally important difference (MID) for FACT-G total score as described by Cella and King et al.19,20 Corresponding outcome measures were derived for physical, social, emotional, functional well-beings and the colorectal cancer subscales, and the MID used in these measurement derivations were 2-, 1-, 1-, 2-, 2-points, respectively.21–23

Among patients who demonstrated HRQoL improvement, their duration of sustained HRQoL improvement was measured as the continuous-time interval in which patients had ≥4-points increment in FACT-G total score over their baseline scores at each assessment time point.

Patients were then categorized into 3 groups: <4-points increase, 4–7 points increase, and ≥8 points increase based on their largest change in FACT-G score over baseline during the first month after surgery to examine characteristics associated with various extent of HRQoL improvements. Categorical and continuous characteristics between the 3 patient groups were compared based on Fisher’s exact test, and the Kruskal-Wallis test, respectively.

All time-to-event measures were estimated using the Kaplan-Meier method. The cumulative incidence rate of HRQoL improvement was derived based on one minus the Kaplan-Meier estimate of the survival function for time to HRQoL improvement. All P values were 2-sided and considered statistically significant if they were <0.05. SAS version 9.4 (SAS Institute, Cary, NC) was used for all statistical analyses.

RESULTS

A total of 80 patients underwent palliative GI surgery over the study period, of which 65 patients with adequate HRQoL assessments (i.e., completion of baseline and at least one postoperative HRQoL assessment) were analyzed. Fifteen patients were excluded due to refusal, absence of follow-up QoL assessments and language barriers.

Demographic information and clinical characteristics are shown in Table 1. The median age at the time of palliative surgery was 62-years old (interquartile range [IQR] 55–69). The majority had GI primaries (52.3%, n = 34) and the main indication for palliative surgery was GI obstruction (70.8%). Twenty-eight (43.1%) patients had preoperative baseline FACT-G scores that were considered low (>60–≤70) or very low (≤60).

TABLE 1. - Patient Demographics, Clinical and Surgical Characteristics
No. %
Total 65 100.0
Age at palliative surgery, years
 Median (IQR) 62 (55–69)
Gender
 Female 47 72.3
Ethnicity
 Chinese 45 69.2
 Malay 11 16.9
 Indian 5 7.7
 Others 4 6.2
Marital status
 Married 47 72.3
 Single/divorced/separated 18 27.7
ECOG performance status
 0 10 15.4
 1 33 50.8
 2 19 29.2
 3 3 4.6
Primary cancer
 Colorectal 31 47.7
 Gastric 2 3.1
 Ovarian/gynecological 21 32.3
 Appendiceal 1 1.5
 Others 10 15.4
Lines of chemo before palliative surgery
 None 21 32.3
 1 14 21.5
 2 13 20.0
 3 and over 17 26.2
Median (IQR) 1 (0–3)
Baseline FACT-G total score
 Very low (≤60) 19 29.2
 Low (>60–70) 9 13.8
 Average (>70–80) 12 18.5
 High (>80) 25 38.5
Main reason for palliative surgery*
 Intestinal obstruction 46 70.8
 Bleeding 1 1.5
 Pain 2 3.1
 Sepsis 7 10.8
 Fistula 5 7.7
 Others 4 6.2
Baseline albumin, g/L
 Median (IQR) 32 (26–36)
Bowel resection
 Yes 39 60.0
*Four patients had additional reason for palliative surgery.
ECOG indicates Eastern Cooperative Oncology Group; IQR, interquartile range.

Conventional Measures of Surgical Success

Conventional measures of surgical success including postoperative complications, length of stay, time to diet, and use of TPN are shown in Table 2. Postoperative complications occurred in 33.8% of patients with 13.8% experiencing grade 3 or more major complications. The 30-day mortality rate was 4.6%, with cancer-progression related demise accounting for 2 of 3 deaths. In-hospital mortality occurred in one patient who experienced an anastomotic leak.

TABLE 2. - Conventional Measures of Surgical Success
No. %
Total 65 100.0
Stoma
 Yes 47 72.3
Perioperative TPN
 No TPN 37 56.9
 Postoperation TPN only 19 29.2
 TPN pre- and postoperation 9 13.8
Duration of TPN post palliative surgery, days
Among patients who were on TPN post palliative surgery 28
 Median (IQR) 11 (7–16)
TPN at home
Among patients who were on TPN post palliative surgery 28 100.0
 Yes 4 14.3
Time to diet post palliative surgery, days
Among patients who were able to tolerate orally post palliative surgery 61
 Median (IQR) 5 (4–7)
Postoperation complications
 None 43 66.2
 Minor* 13 20.0
 Major* 9 13.8
30-day mortality post palliative surgery
 Yes 3 4.6
Duration of admission attributable to palliative surgery, days
 Median (IQR) 12 (8–26)
Readmission post discharge
 Yes, total 31 47.7
 Yes, once 14 21.5
 Yes, twice 17 26.2
Reason for first readmission
Among patients who had at least one readmission 31 100.0
 Operation-related complication 2 6.5
 Cancer progression 15 48.4
 Others 14 45.2
Chemotherapy post palliative surgery
 Yes 22 33.8
Overall survival (OS), months
 No. of deaths/ patients 31/65
 Median OS, months (95% CI) 8.2 (3.6–NR)
 3-month OS, % (95% CI) 69.9 (56.9–79.6)
 6-month OS, % (95% CI) 54.9 (41.2–66.7)
 9-month OS, % (95% CI) 47.8 (33.9–60.5)
*Based on Clavien-Dindo Classification, minor (grade 1–2); major (grade 3–4).
CI, confidence interval; IQR, interquartile range; NR, not reached; OS, overall survival.; TPN, total parenteral nutrition.

The median length of stay attributable to palliative surgery was 12 days (IQR 8–26). Resumption of diet was possible in 93.8% of patients at a median of 5 days (IQR 4–7) after palliative surgery. TPN support was common in the postoperative period (43%, n = 28). Around half of the patients (47.7%) had readmissions, which were often a result of symptoms due to cancer progression.

Median follow-up was 8.8 months (IQR 5.4–13.2). Median OS was 8.2 months (95% CI, 3.6–not reached), and 3-, 6-, 9-month OS were 69.9% (95% CI, 56.9–79.6), 54.9% (95% CI, 41.2–66.7), and 47.8% (95% CI, 33.9–60.5), respectively.

QoL Outcomes After Palliative Surgery

Questionnaire Compliance

Half of the patients had 7 or more HRQoL assessments. Excluding demised patients and those whose follow-up visits were not due at each HRQoL assessment time point, at least 60% of the patients were compliant at each HRQoL assessment timepoint. Rates of missing questionnaire items remained consistently low at >5% over time (see Figure, Supplemental Digital Content 1, https://links.lww.com/AOSO/A166).

QoL Trends and Improvement

The mean baseline FACT-G total score was 70.7 (95% CI, 66.3–75.1), it was 16.7 (95% CI, 15.3–18.1), 24.3 (95% CI, 23.1–25.6), 16.2 (95% CI, 14.8–17.6), and 13.5 (95% CI, 11.8–15.1) in the physical, social, emotional, and functional well-being subscales respectively (Table 3, Fig. 1). After surgery, mean FACT-G total scores remained largely above baseline value, with larger increments seen in the first 4 months. A cumulative total of 49.2% and 67.4% of patients had ≥4-point increment in FACT-G total scores at 2 weeks and 1 month after surgery (Fig. 2). This improvement was sustained over a median duration of 14 weeks (around 3.5 months) (see Figure, Supplemental Digital Content 2, https://links.lww.com/AOSO/A166).

TABLE 3. - FACT-G Score Changes After Palliative Surgery
Assessment timepoint (N = 65)
W2 W4 W6 W8 W10 W12 W16 W20 W24 W28 W32 W36 W40 W44 W48
No. of patients 63 54 43 43 33 30 21 17 17 16 15 8 7 6 6
Total score 3.8 10.5* 8.3 12.1* 10.8* 13.9* 13.0* 6.6 7.3 7.5 3.3 4.8 6.2 3.1 –2.9
Subscal:
Physical well-being 3.1* 4.5* 3.7* 4.6* 4.6* 4.5* 4.4* 3.4 3.1 3.5 1.9 2.7 2.5 2.2 0.9
Social/family well-being –0.2 1.6 1.8 2.0 1.5 1.0 2.5 0.4 2.1 2.7 1.8 0.8 3.0 3.6 –4.6
Emotional well-being 1.4 2.8 1.6 2.5 2.5 3.8* 3.3 1.5 2.8 1.2 1.4 3.0 0.6 –1.4 0.4
Functional well-being –0.5 1.7 1.2 3.0 2.2 4.8* 3.1 1.7 –0.3 0.3 –1.6 –1.4 0.4 –1.1 0.6
*P value <0.01.
P value <0.05.
W indicates week.

F1
FIGURE 1.:
Trend of FACT-G scores after palliative surgery. Each error bar represents the 95% confidence interval of the mean FACT-G total score at each assessment timepoint. FACT-G indicates functional assessment of cancer therapy—general.
F2
FIGURE 2.:
Cumulative incidence of a ≥4-point FACT-G increase after palliative surgery. FACT-G indicates functional assessment of cancer therapy—general.

In the physical well-being subscale, postoperative scores remained above baseline scores over the entire follow-up period; it saw an early increase by week 2 and continued to remain significantly higher than baseline until the fourth month after palliative surgery. Postoperative emotional well-being scores were also higher than baseline scores during most of the follow-up period, with the largest increment reported at the third month after surgery. Functional well-being scores dipped below baseline in the early postoperative period (at week 2) but gradually increased and were significantly improved by the third-month postsurgery. Social well-being scores remained stable throughout with no significant changes from baseline. A cumulative total of 59.4%, 27.5%, 68.2%, and 57.8% of patients achieved MID changes in the physical, social, emotional, and functional well-being subscales at 1-month after surgery, respectively (Fig. 3).

F3
FIGURE 3.:
Cumulative incidence of FACT-G subscales.

Characteristics of Patients by Varying Extents of QoL Improvements

There were significant differences in preoperative albumin levels between patients who had <4 points, 4–7 points, and ≥8 points increase in FACT-G scores at 1-month postsurgery (P = 0.043). Patients who experienced a <4-points QoL increase had the lowest median albumin at 28 g/L (Table 4).

TABLE 4. - Extent of QoL improvement after palliative surgery.
<4 points
(N=22)
4–7 points
(N=8)
≥8 points
(N=34)
p
Age at palliative surgery, years
 Median (IQR) 64 (56–68) 57 (53–71) 62 (54–72) 0.843
Gender
 Female 15 (68.2) 7 (87.5) 25 (73.5) 0.624
ECOG performance status
 0 3 (13.6) 1 (12.5) 6 (17.6) 0.914
 1 11 (50.0) 3 (37.5) 18 (52.9)
 2 7 (31.8) 4 (50.0) 8 (23.5)
 3 1 (4.5) 0 (–) 2 (5.9)
Primary cancer
 Colorectal 8 (36.4) 4 (50.0) 18 (52.9) 0.194
 Gastric 1 (4.5) 0 (–) 1 (2.9)
 Ovarian/gynecological 5 (22.7) 4 (50.0) 12 (35.3)
 Appendiceal 1 (4.5) 0 (–) 0 (–)
 Others 7 (31.8) 0 (–) 3 (8.8)
Baseline FACT-G total score
 Very low (≤60) 3 (13.6) 1 (12.5) 14 (41.2) 0.118
 Low (>60–70) 3 (13.6) 1 (12.5) 5 (14.7)
 Average (>70–80) 3 (13.6) 2 (25.0) 7 (20.6)
 High (>80) 13 (59.1) 4 (50.0) 8 (23.5)
Main reason for palliative surgery
 Intestinal obstruction 13 (59.1) 6 (75.0) 26 (76.5) 0.337
 Bleeding 1 (4.5) 0 (–) 0 (–)
 Pain 1 (4.5) 1 (12.5) 0 (–)
 Sepsis 3 (13.6) 1 (12.5) 3 (8.8)
 Fistula 1 (4.5) 0 (–) 4 (11.8)
 Others 3 (13.6) 0 (–) 1 (2.9)
Baseline albumin, g/L
 Median (IQR) 28 (24–33) 37 (27–41) 33 (28–36) 0.043
Bowel resection
 Yes 13 (59.1) 4 (50.0) 22 (64.7) 0.727
Stoma
 Yes 14 (63.6) 5 (62.5) 27 (79.4) 0.327
TPN at home
Among patients who were on TPN post surgery: 9 (100) 3 (100) 15 (100)
 Yes 1 (11.1) 0 (–) 3 (20.0) 1.000
1 patient excluded as the patient did not have HRQoL assessment in the month post surgery.
ECOG indicates Eastern Cooperative Oncology Group; IQR, interquartile range; TPN, total parenteral nutrition.

FACT-C Scores

Of the 65 patients, 63 completed the CCS of the FACT-C questionnaire. Mean baseline overall FACT-C and CCS scores were 86.5 (95% CI, 81.4–91.5) and 16.1 (95% CI, 15.0–17.2), respectively. The trend of mean FACT-C scores followed closely that of mean FACT-G scores, as their differences (CCS) remained relatively constant over time (see Figure, Supplemental Digital Content 3, https://links.lww.com/AOSO/A166 and Table, Supplemental Digital Content 4, https://links.lww.com/AOSO/A166). A cumulative total of 36.9%, 47.7%, and 57.8% of patients had ≥ 2-point increment in CCS scores at 2 weeks, 1 month, and 6 weeks, respectively, after surgery (see Figure, Supplemental Digital Content 5, https://links.lww.com/AOSO/A166).

(v) Patient-Reported Satisfaction After palliative Surgery

A high 92.3% (n = 60) of patients found palliative surgery to be satisfactory when interviewed at 1-month after surgery. Among the 5 patients who did not, the main reasons stated were due to inadequate symptom resolution and a failure of surgery to improve their functional status.

DISCUSSION

The results of the present study revealed that up to 70.8% of patients experienced significant improvements in HRQoL after palliative GI surgery. Increments in mean FACT-G scores were seen as early as 2 weeks after surgery, and this was followed by a steady and sustained upward trend in the subsequent months. By evaluating the efficacy of palliative surgical interventions beyond conventional measures of surgical success such as postoperative morbidity and survival, we provide new insights into the true value of these interventions to patients during end-of-life.24 In addition, through systematic and close longitudinal follow-up over a 1-year duration, we were able to observe HRQoL trends during end-of-life and evaluate the sustainability of improvements following surgery.

Understanding that palliative surgical patients face a wide range of physical, social, emotional, and functional challenges, the FACT-G HRQoL tool is ideal for assessing the impact of surgery on these domains.25 In our study, we found that improvements in overall HRQoL were driven mainly by increases in the physical well-being subscale. This is consistent with existing palliative surgical literature where surgery has been proven to result in high rates of symptom resolution.7 Among patients with malignant intestinal obstruction, evidence also suggests that palliative GI surgery enabled the early resumption of oral intake and facilitated discharge to home.8 Given the importance of oral intake in our “food-loving” society, and emotional distress associated with the inability to tolerate meals and prolonged hospitalization, this may explain the improvements that were seen in emotional well-being scores among our palliative surgical patients.26 Overall, our findings suggest that in addition to providing effective symptom relief, surgery also had a positive impact on the emotional and functional health of palliative patients during end-of-life.

In the current study, preoperative albumin levels were significantly different among patients experiencing varying degrees of HRQoL improvements after palliative surgery. This corroborates with our previous institutional experience where ECOG status and preoperative albumin levels were independently associated with good short-term conventional surgical outcomes after palliative GI surgery.27 Similarly, an evaluation of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database also found impaired functional status and low albumin to be predictive of high postoperative morbidity and mortality.28 Given the impact of preoperative albumin levels on both conventional and HRQoL outcomes, this suggests a possible role for the use of parenteral nutrition to optimize palliative surgical outcomes. In inflammatory bowel disease, characterized by gut failure, not dissimilar to palliative GI surgical patients in intestinal obstruction, total parenteral nutrition (TPN) given 60 days before major abdominal GI surgery resulted in reduced rates of postoperative complications.29 As such, it is possible that a trial of preoperative TPN can improve albumin levels and lead to improved HRQoL and surgical outcomes among selected palliative patients who do not present with surgical emergencies.

The inpatient morbidity and mortality rates in this study conducted between January 2020 and November 2021 were 33.8% and 4.6%, respectively. Although morbidity rates were consistent, in-hospital mortality in this cohort appeared much lower when compared with existing palliative surgical literature and with our institution’s historical cohort.30–32 A plausible explanation for this phenomenon is the establishment of a multidisciplinary palliative intervention team comprising of surgical oncologists from the Department of Sarcoma, Peritoneal & Rare Tumours (SPRinT), medical oncologists, radiation oncologists, specialist palliative care physicians, interventional gastroenterologists and radiologists, nutritionist and medical social workers at our institution.11 Since January 2020, clinical decisions surrounding the care of each palliative surgical patient were discussed and made jointly by the multidisciplinary team. This increased inter-subspecialty collaboration has the potential to enhance evidence-based palliative centered care and could have contributed to improved patient selection and superior perioperative palliative care processes. Although the focus of this study was HRQoL, we nonetheless found conventional surgical outcomes to be improved with this approach.

While comprehensive, HRQoL assessments are not without their limitations and challenges. In our study, questionnaire compliance rates were approximately 60% with patient refusal as one of the most common reasons for noncompliance (see Figure, Supplemental Digital Content 1, https://links.lww.com/AOSO/A166). Natural attrition owing to the eventual demise of these palliative cancer patients also contributed to decreasing sample sizes at later assessment time points. Such challenges are common in end-of-life related research due to the nature of palliative patient populations.33 In the absence of a randomized control trial design, selection bias is inevitable as surgeons are inherently more likely to select “better” candidates for palliative surgery—though we do have a good mix of patients with varying ECOG status and baseline FACT-G scores in our study. The SWOG S1316 trial was a prospective randomized control trial designed to determine the optimal treatment approach for malignant bowel obstruction in a palliative cohort.34 An interim publication concluded that randomization though possible was highly challenging due to patient and clinician bias toward treatment options offered. As such, while the authors acknowledge the limitations in our study design, ethical and palliative considerations will continue to limit the design of future end-of-life related surgical trials. In addition, the fairly small sample size owing to difficulties in recruitment in a palliative cancer population and our unique multidisciplinary set-up limits the generalizability of our HRQoL findings.

The true value of palliative surgery lies in its ability to improve overall HRQoL and relieve troublesome symptoms while respecting the preferences, expectations, and goals of care of patients during end-of-life. Although our findings affirm the benefits of surgery in “palliative terms,” future studies will be necessary to further explore the impact of these interventions on patients’ satisfaction, overall end-of-life experience, social-emotional well-beings, and the repercussions on caregivers.

In conclusion, we found a significant and sustained improvement in the HRQoL in advanced cancer patients undergoing palliative GI surgery. Patients with good nutrition perioperatively may stand to benefit most from palliative surgical interventions.

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Keywords:

advanced cancer; intestinal obstruction; palliation; palliative surgery; quality of life; HRQoL; FACT-G; End of life care

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