Patients with stage IV cancer fare poorly after surgery

Patients who underwent surgery for stage IV cancer experienced high rates of hospital readmissions, referrals to extended care facilities, morbidity and mortality, according to study results published in PLOS One.

They also required longer hospital stays.

The analysis included nearly 18,000 patients with stage IV cancer who underwent surgery, as well as matched, cancer-free controls who underwent similar surgical procedures. The groups were comparable with regard to age, sex and functional status prior to surgery.

Patients with stage IV cancer demonstrated higher rates of postoperative morbidity (24.4% vs. 18.7%; P < .001), serious morbidity (14.9% vs. 12%; P < .001), mortality (7.6% vs. 2.5%; P < .001), prolonged hospital stay (32.2% vs. 19.8%; P < .001), hospital readmission (15.7% vs. 9.6%; P < .001) and discharges to facilities (16.2% vs. 12.9%; P < .001).

Results of a subgroup analysis showed patients with stage IV disease who did not have any postoperative complications experienced significantly higher rates of prolonged hospital stays (23% vs. 11.8%; P < .001), hospital readmissions (10% vs. 5.2%; P < .001), discharges to a facility (13.2% vs. 9.5%; P < .001) and 30-day mortality (4.7% vs. 0.8%; P < .001).

Sarah B. Bateni, MD, of the department of surgery at UC Davis Health System, spoke with HemOnc Today about the study findings and their implications.

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Question: Why did you and your colleagues conduct this study?

Answer: Surgeons are commonly consulted for patients with advanced cancer presenting with an acute surgical condition, such as bowel obstructions related to their cancer. We know that this condition can be treated medically or surgically. When we have operated on these patients, we have seen many surgical complications and the impact of these complications on their quality of life. We did not set out to determine if patients were at increased risk for surgical complications and acute mortality, because we already know the answer to this. We wanted to assess prolonged length of hospital stay, hospital disposition and hospital readmissions, because we felt like these outcomes have the potential to affect patient quality of life.

Q: What did the main findings suggest?

A: We found that patients with stage IV cancer who underwent similar operations as patients without this cancer diagnosis had greater rates of prolonged hospital length of stay, greater rates of discharge to a facility rather than home and greater rates of hospital readmission. Patients with stage IV cancer additionally had greater rates for complications and 30-day mortality.

Q: Were you surprised by the findings?

A: We were not surprised about our main findings, because we knew from prior research that patients with stage IV cancer have greater rates for postoperative complications and greater rates for mortality. With this knowledge, in addition to understanding from our clinical practice, we predicted that patients with stage IV cancer also would have greater rates of our primary endpoints. However, what we did find surprising was that, when we looked at the subset of patients who did not experience any complication, patients with stage IV cancer were twice as likely to have these negative effects of prolonged hospital stay and hospital readmissions than patients without this diagnosis. This result was important, because it showed the potential frailty and vulnerability of this patient population.

Q: What implications do these data have for practice?

A: Our findings emphasize the need for physicians and surgeons to engage with their patients and families in thorough end-of-life discussions prior to recommending or performing any surgical intervention in order to make sure these interventions are in line with patients’ end-of-life goals. It is also important — when surgeons discuss the risk of surgeries with patients — that we discuss all the potential risks of surgical intervention beyond standard postoperative complications, including other clinically relevant outcomes. For example, we do not often mention that, because of the patient’s diagnosis, they have a greater risk for staying in the hospital for a prolonged period of time, being discharged to a facility instead of home and having to be readmitted to the hospital. It is, therefore, very important for clinicians and surgeons to emphasize these factors with patients and their families.

Q: How important is it for clinicians to consider these factors prior to making treatment decisions for their patients?

A: It is extremely important for clinicians to consider the risks of prolonged hospitalization, discharges to nursing and rehab facilities, and hospital readmissions for patients with advanced cancer. These outcomes have the ability to adversely impact patients’ quality of life, especially among terminal patients with a limited life expectancy. For example, the majority of patients would prefer to die at home rather than in a hospital or nursing facility. However, if the patient experiences a prolonged hospital stay or is discharged to a nursing facility after surgery, the surgery has negatively impacted the patient’s end-of-life care. Therefore, it is very important for clinicians to consider these potential postoperative outcomes when making treatment decisions for patients with advanced cancer.

Q: What might future research entail?

A: Future research should look at specific conditions and specific surgeries among patients with stage IV cancer so it can be determined if there is a time when surgery is especially dangerous, or when it is beneficial with minimal risk to patients. We had a study accepted into the journal Surgery looking at lung resections among patients with stage IV cancer, and we found there was no difference in rates of complications, mortality, disposition and prolonged hospitalization for patients with stage IV cancer and those without stage IV cancer. We concluded that, in this select group of patients with stage IV cancer, surgery for these patients was safe with equivalent risks.

Q: Is there anything else that you would like to mention ?

A: The current body of research for patients with advanced cancer has focused largely on medical care and palliative care, especially when looking at end-of-life care. There really is minimal research looking how surgery affects the quality of life for patients with stage IV cancer. We truly feel this is where we should be going with our research. – by Jennifer Southall

Reference:

Bateni SB, et al. PLOS One. 2016;doi:10.1371/journal.pone.0165315.

For more information:

Sarah B. Bateni, MD, can be reached at UC Davis Comprehensive Cancer Center, 4610 X St., Suite 2301, Sacramento, CA 95817; email: sbbateni@ucdavis.edu.

Disclosure: Bateni reports no relevant financial disclosures.