Impact of palliative intervention on end-of-life outcomes for patients undergoing surgery for cancer.

Abstract

Studies in patients with advanced cancer have shown that earlier palliative care involvement can improve quality of life, caregiver burden, resource utilization, and even survival. However, 2 recent clinical trials failed to show similar benefit at 90 days postoperatively among patients undergoing curative surgery for abdominal cancer. The impact of palliative care on end-of-life outcomes in these patients has not been examined. This study presents an exploratory analysis of the end-of-life outcomes from one of these randomized controlled trials. The Surgery with Option of Palliative Care Expert trial was an assessor-blind randomized controlled trial performed at an urban academic hospital. Patients undergoing curative surgery for 1 of 8 different abdominal cancer types were randomized to usual care or early involvement of a specialist palliative provider. Patients were followed for a 3-year period, and caregivers were contacted for patients who died to complete the end-of-life assessment. Outcomes included 3-year mortality, receipt of chemotherapy within the last 2 weeks of life, hospice length of stay, days at home without an emergency department visit in the last 30 days of life, death outside a health care facility, and the Family Assessment of Treatment at End of Life-Short Version survey, a measure of caregivers' perception of the quality of support received at the end of the patient's life. To evaluate 3-year mortality, a Cox proportional hazards model was fit, adjusting for type of cancer. Unadjusted proportional odds logistic regression models were utilized to analyze continuous outcomes, and unadjusted logistic regression models were used for binary outcomes. Two hundred thirty-five eligible patients were randomized in the trial, with 117 in the intervention group and 118 in the usual care group. Ninety-three (40%) patient deaths were recorded in the study database, with 61 of those patients' caregivers (66%) completing part or all the end-of-life assessments (32 in the intervention group and 29 in the usual care group). Comparing the intervention group to the usual care group, no statistically significant differences were seen in mortality (hazard ratio, 1.14; 95% confidence interval, 0.85-1.51; P = .39), receipt of chemotherapy in the last 2 weeks of life (odds ratio, 5.19; 95% confidence interval, 0.57-47.32; P = .14), hospice length of stay (odds ratio, 0.67; 95% confidence interval, 0.27-1.66; P = .38), days at home without an emergency department visit (odds ratio, 0.96; 95% confidence interval, 0.39-2.36; P = .93), death outside a health care facility (odds ratio, 0.82; 95% confidence interval, 0.30-2.25; P = .71), or Family Assessment of Treatment at End of Life-Short Version scores (odds ratio, 0.81; 95% confidence interval, 0.32-2.03; P = .65). This study did not show the benefit of early palliative care on end-of-life outcomes in patients undergoing surgery for cancer. This finding is in keeping with the trial's original conclusion that routine specialist palliative involvement may not be warranted among these patients, and limited palliative care resources can best be allocated elsewhere or on a case-by-case basis.