Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer

Abstract

ImportanceSpecialist palliative care benefits patients undergoing medical treatment of cancer; however, data are lacking on whether patients undergoing surgery for cancer similarly benefit from specialist palliative care.ObjectiveTo determine the effect of a specialist palliative care intervention on patients undergoing surgery for cure or durable control of cancer.Design, Setting, and ParticipantsThis was a single-center randomized clinical trial conducted from March 1, 2018, to October 28, 2021. Patients scheduled for specified intra-abdominal cancer operations were recruited from an academic urban referral center in the Southeastern US.InterventionPreoperative consultation with palliative care specialists and postoperative inpatient and outpatient palliative care follow-up for 90 days.Main Outcomes and MeasuresThe prespecified primary end point was physical and functional quality of life (QoL) at postoperative day (POD) 90, measured by the Functional Assessment of Cancer Therapy–General (FACT-G) Trial Outcome Index (TOI), which is scored on a range of 0 to 56 with higher scores representing higher physical and functional QoL. Prespecified secondary end points included overall QoL at POD 90 measured by FACT-G, days alive at home until POD 90, and 1-year overall survival. Multivariable proportional odds logistic regression and Cox proportional hazards regression models were used to test the hypothesis that the intervention improved each of these end points relative to usual care in an intention-to-treat analysis.ResultsA total of 235 eligible patients (median [IQR] age, 65.0 [56.8-71.1] years; 141 male [60.0%]) were randomly assigned to the intervention or usual care group in a 1:1 ratio. Specialist palliative care was received by 114 patients (97%) in the intervention group and 1 patient (1%) in the usual care group. Adjusted median scores on the FACT-G TOI measure of physical and functional QoL did not differ between groups (intervention score, 46.77; 95% CI, 44.18-49.04; usual care score, 46.23; 95% CI, 43.08-48.14; P = .46). Intervention vs usual care group odds ratio (OR) was 1.17 (95% CI, 0.77-1.80). Palliative care did not improve overall QoL measured by the FACT-G score (intervention vs usual care OR, 1.09; 95% CI, 0.75-1.58), days alive at home (OR, 0.87; 95% CI, 0.69-1.11), or 1-year overall survival (hazard ratio, 0.97; 95% CI, 0.50-1.88).Conclusions and RelevanceThis randomized clinical trial showed no evidence that early specialist palliative care improves the QoL of patients undergoing nonpalliative cancer operations.Trial RegistrationClinicalTrials.gov Identifier: NCT03436290

Palliative Care for Patients Undergoing Surgery—Reply

“…In Reply We appreciate the thoughtful response to our recently published trial . We agree that the null findings stem from studying a population with low unmet palliative care needs.…”

Palliative Care for Patients Undergoing Surgery

“…To the Editor Two important articles have been published in the JAMA Network in the last month regarding the early implementation of palliative care for patients undergoing surgery with a curative intent. Shinall et al investigated the effect of a palliative care intervention on physical and functional quality of life at 3 months, and Aslakson et al evaluated the effect of surgeon-palliative care co-management on patient-reported health-related quality of life at 3 months.…”

Surgical Palliative Care—Who, When, and Why?

“…Yet many questions remain unanswered when it comes to which populations would benefit from primary vs specialty palliative care services and who is best to provide those services. In this issue of JAMA Surgery , the study by Shinall et al identified a clear and distinct surgical population—namely, patients with resectable cancer undergoing major operations with curative intent. The trial was well designed and faithfully executed.…”

“…Ultimately Shinall et al have given us pause to reconsider the role of routine perioperative-specialist palliative-care consultation in surgical oncology for curative intent. But rather than throwing the baby out with the bathwater, their work helps define important questions to be addressed by further investigations.…”