Importance
Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population.


Objective
To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery.


Design, Setting, and Participants
This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023.


Exposure
Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education.


Main Outcomes and Measures
The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation.


Results
Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01).


Conclusions and Relevance
An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

Early Integrated Palliative Care Within a Surgical Oncology Clinic.

Patients with peritoneal metastasis have limited treatment options.

ASO Author Reflections: Challenges in the Management of Bowel Obstruction after Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy

When clinicians encounter patients with malignant small bowel obstruction, it is often unclear whether surgical or non-surgical treatment would be associated with the most benefit and the least harm. 1 Cousins SE Tempest E Feuer DJ Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database Syst Rev. 2016; 2016: CD002764 PubMed Google Scholar , 2 Mor E Shemla S Assaf D et al. Natural history and management of small-bowel obstruction in patients after cytoreductive surgery and intraperitoneal chemotherapy. Ann Surg Oncol. 2022; 29: 8566-8579 Crossref PubMed Scopus (2) Google Scholar The best choice for an individual patient cannot be known a priori, and until now, no prospective randomised data have existed to inform an evidence based approach to this discussion and decision with patients. 1 Cousins SE Tempest E Feuer DJ Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database Syst Rev. 2016; 2016: CD002764 PubMed Google Scholar , 3 Boland JW Boland EG Malignant bowel obstruction. in: Cherny N Fallon MT Kaasa S Oxford textbook of palliative medicine 6th edn. Oxford University Press, Oxford2021: 904-917 Google Scholar In The Lancet Gastroenterology & Hepatology, Robert Krouse and colleagues have reported the results of their study, which aims to address this evidence gap. 4 Krouse RS Anderson GL Arnold KB et al. Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): a pragmatic comparative effectiveness trial. Lancet Gastroenterol Hepatol. 2023; (published online Aug 1.) Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Specifically, this under-researched population of patients with malignant small bowel obstruction were examined in a hybrid pragmatic trial over a 5-year recruitment period. This study represents the first prospective approach to compare surgical and non-surgical treatment, to determine the best approach for managing malignant small bowel obstruction in patients who were surgical candidates but for whom there was treatment equipoise (just over 50% of participants had evidence of carcinomatosis). 4 Krouse RS Anderson GL Arnold KB et al. Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): a pragmatic comparative effectiveness trial. Lancet Gastroenterol Hepatol. 2023; (published online Aug 1.) Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): a pragmatic comparative effectiveness trialIn our study, whether patients received a surgical or non-surgical treatment approach did not influence good days during the first 91 days after registration. These findings should inform treatment decisions for patients hospitalised with malignant bowel obstruction. Full-Text PDF 

Ensuring patients with malignant bowel obstruction are central in research and clinical decisions

Background/Objectives: The impact of surgical resection versus non-resection on cancer-specific mortality (CSM) in soft tissue pelvic sarcoma remains largely unclear, particularly when considering histologic subtypes such as liposarcoma, leiomyosarcoma, and sarcoma NOS. The objective of the present study was to first report data regarding the association between surgical resection status and CSM in soft tissue pelvic sarcoma. Methods: Using data from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2019, we identified 2491 patients diagnosed with pelvic soft tissue sarcoma. Cumulative incidence plots were used to illustrate CSM and other-cause mortality rates based on the histologic subtype and surgical resection status. Competing risk regression models were employed to assess whether surgical resection was an independent predictor of CSM in both non-metastatic and metastatic patients. Results: Among the 2491 patients with soft tissue pelvic sarcoma, liposarcoma was the most common subtype (41%), followed by leiomyosarcoma (39%) and sarcoma NOS (20%). Surgical resection rates were 92% for liposarcoma, 91% for leiomyosarcoma, and 58% for sarcoma NOS in non-metastatic patients, while for metastatic patients, the rates were 55%, 49%, and 23%, respectively. In non-metastatic patients who underwent surgical resection, five-year CSM rates by histologic subtype were 10% for liposarcoma, 32% for leiomyosarcoma, and 27% for sarcoma NOS. The multivariable competing risk regression analysis showed that surgical resection provided a protective effect across all histologic subtypes in non-metastatic patients (liposarcoma HR: 0.2, leiomyosarcoma HR: 0.5, sarcoma NOS HR: 0.4). In metastatic patients, surgical resection had a protective effect for those with leiomyosarcoma (HR: 0.6) but not for those with sarcoma NOS. An analysis for metastatic liposarcoma was not possible due to insufficient data. Conclusions: In non-metastatic soft tissue pelvic sarcoma, surgical resection may be linked to a reduction in CSM. However, in metastatic patients, this protective effect appears to be limited primarily to those with leiomyosarcoma. 

The Effect of Surgical Resection on Cancer-Specific Mortality in Pelvic Soft Tissue Sarcoma According to Histologic Subtype and Stage

Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy

Resection of Recurrent Pelvic Soft Tissue Sarcoma: Is the Risk Worth the Reward?

/pdf/aso-visual-abstract-natural-history-and-management-of-small-7marqa76.pdf

ASO Visual Abstract: Natural History and Management of Small Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy

Retroperitoneal sarcomas (RPS) present a surgical challenge with high rates of local recurrence (LR). We investigated the role of intraoperative electron radiotherapy (IOeRT) in reducing LR after surgical resection of RPS.A retrospective analysis of all patients who underwent surgical resection for RPS between 2014 and 2021 at a tertiary academic referral center (n = 172). Patients included underwent surgical resection of their RPS and received IOeRT (n = 36) and were compared by case control matching to patients with similar tumor characteristics (recurrence status and tumor grade) that did not receive IOeRT (n = 36).The median length of hospitalization was 8 days (range, 4-34) in the IOeRT group and 10 days (range, 2-42) in the non-IOeRT group (p = 0.25). The mean operating room (OR) time was 4h (±1.3) and 4h (±1.9) in the IOeRT and non-IOeRT groups respectively, (p = 0.37). Complete resection with R0 margins was achieved in 30 patients (83.3%) and 24 patients (66.6%) in the IOeRT and non-IOeRT groups, respectively (p = 0.1). R1 resection was achieved in 6 patients (16.6%) and 12 patients (33.3%) respectively, (p = 0.1). The resected organ weighted score was significantly different between the groups; score 0 observed in 19 (52.7%) patients in the IOeRT group and 3 (8.3%) in the non-IOeRT group (p < 0.001), score 1 observed in 7 (19.4%) in the IOeRT group and 17 (47.2%) in the non-IOeRT group (p = 0.012). The rate of severe complications (CD score>3) did not differ between the groups, 5 (13.8%) patients in the IOeRT group and 9 (25%) patients in the non-IOeRT group (p = 0.23). No radiation associated complications were noted. The 2-year local recurrence free survival (LRFS) was 75.9% in the IOeRT group and 60.3% in the non-IOeRT group (p = 0.4). The 2-year IOeRT field recurrent free survival (IRFS) was 88.4% in the IOeRT group and 60.3% in the non-IOeRT group (p = 0.04).The use of IOeRT did not increase the rate of surgical complications and was associated with superior local control in the radiation field, improved organ preservation without an impact on overall survival. 

IOeRT in retroperitoneal sarcoma: Towards more organ preservation with comparable oncological outcomes.

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Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy

Resection of Recurrent Pelvic Soft Tissue Sarcoma: Is the Risk Worth the Reward?

ASO Visual Abstract: Natural History and Management of Small Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy

IOeRT in retroperitoneal sarcoma: Towards more organ preservation with comparable oncological outcomes.