Prepared by: Dr. Robin Fainsinger

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

Background: We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies.
Methods: Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient.
Results: Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-nine patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score > 70, was achieved in 64% of symptomatic patients.
Conclusions: Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.
Key Words: Palliative surgery - Quality of life - Outcomes - Advanced malignancy.

Comments:

Strengths/uniqueness:
Using carefully selected definitions and good follow-up focused on symptoms, rather than simply surgical complications and survival, the authors have produced an innovative report investigating the benefits of palliative surgery.

Weaknesses:
Results are limited by the relatively small patient numbers and the apparent predominance of gastro-intestinal tumors in this patient cohort. Using and reporting pain assessment results would have strengthened the apparent improvement in the 78% of patients with pain.

Relevance to Palliative Care:
The authors have reported findings that raise interesting questions and provide good advice to guide future research in this area. Surgeons attempting to report results that do not include symptom issues and more accurate definitions will have failed the raised standards of this report.

Ethics of palliative surgery in patients with cancer Downloadable PDF File

Hofmann B, Haheim LL, Soreide JA. British J of Surgery 2005; 92:802-809.

Prepared by: Dr. Robin L. Fainsinger

Received during: Case Rounds (6th December 2005), Regional Palliative Care Program, Grey Nuns Hospital

Abstract:

Background: Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base.
Method and Results: Pertinent moral challenges are addressed and analysed with respect to prevailing perspectives in normative ethics. The vulnerability of patients with non-curable cancer calls for moral awareness. Demands regarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the 'duty to help', benevolence, respect of autonomy and proper patient information. Moreover, variations in definition of palliative surgery as well as limited scientific evidence with respect to efficacy, effectiveness and efficiency pose methodological and moral problems. Therefore, a definition of palliative surgery that addresses these issues is provided.
Conclusion: Both surgical skill and much moral sensibility are required to improve palliative care in surgical oncology. This should be taken into account not only in clinical practice but also in education and research.

Comments:

Strengths/uniqueness:

This report provides a good overview of the issues related to ethical decision making in the arena of palliative surgery.

Weakness:

The addition of practical case examples would have been helpful.

Relevance to Palliative Care:

This report highlights the complex issues and the need for surgeons to be well trained to think these issues through. This would require an understanding that communication around surgical options is just as important as the development of technical skills.

Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. (downloadable pdf file)

Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ et al. Lancet 2005; 366: 643-48.

Prepared by: Winnie Leung

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Dec 14, 2006

Abstract

Background: The standard treatment of spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of surgery has not been established. We assessed the efficacy of direct decompressive surgery.
Methods: In this randomized, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence, muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by intention to treat.
Findings: After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123 patients were assessed for eligibility before the study closed and 101 were randomized. Significantly more patients in the surgery group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group.
Interpretation: Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.

Comments

Strengths/uniqueness:
This is a well-designed study. The groups were equal and represented the main cancers that cause cord compression from metastases. More recent studies have shown benefit with direct decompressive surgery, but this is the first study to use a randomized design. The surgery + radiotherapy group had a NNT=4 for the primary outcome of ability to walk.

Weaknesses:
It is unusual that it took 10 years to recruit the study patients, and the authors did not specify how the patients were recruited. Multiple groups were excluded, which may introduce selection bias. There is no information about baseline co-morbidities of the study patients; co-morbidities may influence their ability to walk.

Relevance to Palliative Care:
The findings of this trial may confer improved quality of life and independence in the palliative population. Surgery in palliative patients is often limited by their general condition.

Radiosurgery for spinal metastases: Clinical experience in 500 cases from a single institution. (downloadable pdf file)

Gerszten PC, Burton SA, Ozhasoglu C, Welch, WC. Spine 2007; 32(2):193-199.

Prepared by: Hasina Visram, Medical Student, Queen's U, Kingston, ON

Received during: Journal Club (April 2007)
Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

STUDY DESIGN: A prospective nonrandomized, longitudinal cohort study. OBJECTIVE: To evaluate the clinical outcomes of single-fraction radiosurgery as part of the management of metastatic spine tumors.
SUMMARY OF BACKGROUND DATA: The role of stereotactic radiosurgery for the treatment of spinal lesions has previously been limited by the availability of effective target immobilization and target tracking devices. Large clinical experience with spinal radiosurgery to properly assess clinical experience has previously been limited. METHODS: A cohort of 500 cases of spinal metastases underwent radiosurgery. Ages ranged from 18 to 85 years (mean 56). Lesion location included 73 cervical, 212 thoracic, 112 lumbar, and 103 sacral. RESULTS: The maximum intratumoral dose ranged from 12.5 to 25 Gy (mean 20). Tumor volume ranged from 0.20 to 264 mL (mean 46). Long-term pain improvement occurred in 290 of 336 cases (86%). Long-term tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. Twenty-seven of 32 cases (84%) with a progressive neurologic deficit before treatment experienced at least some clinical improvement.
CONCLUSIONS: The results indicate the potential of radiosurgery in the treatment of patients with spinal metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.

Comments:

Strengths/uniqueness:
This paper addresses the efficacy of radiosurgery as a relevant up and coming treatment option for treating spinal metastases. The study involves a large number of participants with a variety of primary malignancies with a respectable median follow-up time of 21 months.

Weakness:
A protocol for participant follow-up was not used and as such follow-up varied greatly between patients. Radiological progression and change in neurological progression were not defined and subjectively evaluated by two authors leaving room for bias in the results.

Relevance to Palliative Care
In recent years radiosurgery for treatment of intracranial malignancies and metastases has been increasingly used. The methods used in this study are an extension of this present technology and may be widely available in the foreseeable future.