Psychosocial factors increase complication risk with cancer surgery

Ira Leeds

Psychosocial risk factors considerably increased risk for complications among patients with medical comorbidities who underwent cancer surgery, according to study results published in Annals of Surgical Oncology.

Patients with a biomedical risk factor who also had two or more psychosocial risk factors were three times as likely as those with zero or one psychosocial risk factor to experience a complication, Ira Leeds, MD, MBA, ScM, research fellow in the department of surgery at Johns Hopkins University School of Medicine, and colleagues found.

“We were truly surprised at that kind of a risk increase, which is on par with other major biomedical risks that we typically see,” Leeds told HemOnc Today. “That’s similar to the risk when patients have diabetes, heart failure or COPD.”

Leeds and colleagues developed a questionnaire to assess psychosocial risk factors among 142 patients (median age, 65 years; interquartile range, 55-71) preparing to undergo surgery for gastrointestinal cancer.

The questionnaire — which took approximately 10 minutes to complete — assessed resourcefulness and resilience, as well as depression, smoking history, alcohol use and addiction history. Questions included how well patients recover from a difficult event, and how likely they were to cope with and care for a minor infection at home after surgery.

Most study participants (58.2%) underwent resection of a hepato-pancreato-biliary primary tumor, and 31.9% had a colorectal primary tumor. Nearly half (43.5%) of patients had high-risk biomedical comorbidities, and 73.4% of patients had at least one psychosocial risk.

Patients with at least one psychosocial risk factor appeared significantly more likely than those with no psychosocial risks to experience a surgical complication (54.4% vs. 26.2%; P = 0.039). Multiple psychosocial risk factors were associated with a 3.37-fold (95% CI, 1.08-10.48) increased risk for complications compared with no or one psychosocial risk factor.

HemOnc Today spoke with Leeds about the study findings, the potential implications of the results, and what interventions can be employed to identify or mitigate psychosocial risk factors.

Question: What prompted this study?

Answer: In the surgical care of patients with cancer, biomedical comorbidities have a close association with poorer surgical outcomes. The most prominent examples are diabetes, heart failure and kidney disease. Often discussed but much less studied are nonbiomedical risk factors about a patient’s life situation — also known as their psychosocial risk factors — and how they may influence surgical outcomes. If patients don’t have strong social support, they may not be as ready for surgery. There has been limited work to study these nontraditional risk factors formally. More importantly, there is a need to quantitatively compare these risk factors against more traditional risk factors. Interest is growing in preoperatively managing patients’ risk factors to produce better outcomes after surgery. These programs include managing a patient’s diabetes, getting them to stop smoking and so forth. It also entails determining how much time or effort should be put into optimizing the patient’s psychosocial risk factors. For example, do they have someone to care for them before and after surgery? Do they have someone to get them through mental or emotional challenges? Do they have enough money for a cab to get to the hospital if they are having a problem at home? No one has looked at these issues in-depth, and we set out to do that.

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Q: How did you conduct this study?

A: This prospective observational cohort study was designed to capture individuals’ psychosocial risk factors along with other important information, such as demographics and biomedical risks. The cohort included patients presenting to the center with gastrointestinal, pancreatic, liver or colorectal cancers. We followed them for 30 days after their operation to see if they experienced surgical complications, were discharged on time or returned to the hospital. We then statistically compared surgical outcomes between patients with several psychosocial risk factors and those who had fewer psychosocial risk factors.

Q: Why do nontraditional risk factors seem to be linked with higher risk for surgical complications?

A: Our hypothesis is that psychosocial risk factors are a proxy measure for one’s ability to cope with stress after surgery —in other words, what psychosocial reserve patients have after surgery. A patient whose life is already being strained by a cancer diagnosis and medical difficulties now must undergo major surgery. If that surgery goes well, we are probably unlikely to see them again, no matter the psychosocial risk factors. But for those who have small speed bumps after surgery, our hypothesis is that having limited psychosocial reserve leads to small problems worsening and, ultimately, turning into a surgical complication.

Q: What intervention can mitigate these risk factors before surgery?

A: From these data alone, it’s clear a psychosocial risk stratification method is warranted. Assessing psychosocial risks before surgery and then including them in the risk counseling that all surgeons give patients before surgery is important. Most psychosocial risks are modifiable. If a patient has a poor psychosocial support network, there may be ways to provide more support during recovery or leading up to surgery and reduce the increased risk for a complication. – by Joe Gramigna

For more information:

Ira Leeds, MD, MBA, ScM, can be reached at The Johns Hopkins Hospital, 600 N. Wolfe St., Tower 110, Baltimore, MD 21287; email: ileeds@jhmi.edu.

Reference:

Leeds IL, et al. Ann Surg Oncol. 2019;doi:10.1245/s10434-018-07136-3.

Disclosure: Leeds reports no relevant financial disclosures.