doi:10.1111/codi.12478
Editorial
Palliative care in colorectal surgery – are we prepared? Currently, most patients diagnosed with colorectal cancer will undergo surgery with curative intent and the probability of cure has never been higher [1]. The focus of surgical practice has been mainly on curative treatment, with much less attention given to patients with incurable disease. Accordingly the surgical literature deals overwhelmingly with surgery for cure. The literature on palliative surgical treatment is insufficient to offer core knowledge about surgical palliative care, particularly because of a preponderance of small, inadequately powered retrospective studies and divergent definitions of palliative surgery [2]. Indeed, the article by Sigurdsson et al. [3], writing in 2007 on non-surgically treated patients with stage IV rectal cancer, was the first publication in 50 years dealing with this patient group. Despite advances in the diagnosis and treatment of colorectal cancer, one in five patients has disseminated disease at the time of the diagnosis. Large national databases such as the Norwegian Rectal Cancer Registry do not provide data on the outcome relevant for palliative care patients [4], which is of great concern because most patients with disseminated disease at diagnosis will need a palliative approach [5]. The term palliative is derived from the Latin word pallium, which means cloak or cover. To palliate, therefore, means to ‘cover’ or relieve the manifestations of incurable disease by optimal symptom control. As defined by the WHO, palliative care aims to relieve physical and psychological distress and resolve social and spiritual problems [6]. Most of the literature on palliative surgery uses the term palliative in the sense of non-curative since it leaves microscopic or macroscopic tumour in situ, without addressing symptom relief or quality of life. As a consequence, the literature contains very little evidence on the effect of procedures for symptom control in patients with incurable disease, or on the adverse events related to such procedures. In the era of modern multimodal treatment, however, the border between a traditional understanding of curative and palliative has become blurred and is steadily moving towards more aggressive treatment to downsize, downstage, and eventually resect advanced disease [7]. Survival of patients with incurable colorectal cancer has substantially increased to a median of more than 24 months, as compared with 6 months in the preceding two decades [8]. Today with more patients living with what could be described as chronic cancer, we encounter an increasing number of patients presenting with serious symptoms,
often related to local complications of the primary tumour such as obstruction, bleeding, or fistulisation. These patients in need of proper palliative support are often under the care of surgeons. We meet them in the outpatient clinic, on the ward, or in the emergency room. We participate in decision-making at multidisciplinary team meetings for surgical or other treatments, and we can follow well-established guidelines, but these include only patients for whom the goal can reasonably be cure. Factors in addition to disease stage determine the treatment and include age, comorbidity and personal wishes based on the patient’s phase of life and stage in the disease trajectory. For patients with incurable disease, we must appreciate and understand the principles of palliative care. This must aim to identify the individual treatment goal, which may be totally different from the common goal of removing the tumour and to understand the physical, emotional, and spiritual needs of the patient and family and communicate with them about their needs [9]. These principles were recognized by the American College of Surgeons (ACS) in 1998, when the ACS Surgical Palliative Care Task Force was established, which published the statement of principles and guidelines of palliative surgical care [10] and a resident’s guide to surgical palliative care [11]. For patients with advanced disease, the consideration of all available options is of the greatest importance, and these include palliative treatment approaches. We must identify patients who will be better served by symptom-relieving measures, including relevant surgical or non-invasive interventions, than by extensive tumour-directed treatment [12]. The interdisciplinary approach is a hallmark of palliative care. Surgeons are essential as members of the palliative care team, having the key knowledge and skills in applying surgical interventions as part of optimal symptom management. Palliative surgery, defined as any surgical intervention to improve the quality of life in patients with incurable disease [11], can carry complications like any other intervention. Although complications may be acceptable in a curative setting, they may be unacceptable when the aim is symptom relief in endof-life care. Accordingly, any palliative intervention must be based on sound judgement and discussion with the patient and the family [13]. The feasibility of performing a procedure is not an indication by itself and futile actions must be avoided. Furthermore treatment of an asymptomatic patient is more prone to lead to burdensome adverse effects than true benefit.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, 1465–1466
1465
Editorial
Given the complex context, the question arises: are we, as colorectal surgeons, prepared to deal with our palliative care patients? The main challenges in daily practice are: 1 to identify those patients who have treatment goals other than cure 2 to present and select appropriate treatment options in line with the patient’s wishes 3 to avoid futile treatment 4 to acknowledge the physical, emotional, and spiritual needs and communicate empathetically and effectively with the patient and family. We face huge challenges in building up the evidence base needed for palliative surgical interventions, relying on patient-reported outcome measures instead of survival [5,13,14]. To manage these challenges, the community of colorectal surgeons may have to reconsider education and specialist training programmes, research efforts, and organization of services to deliver appropriate care for the surgical palliative care patient.
Conflicts of interest No conflicts of interest to declare.
Hartwig Kørner*†‡ and Dagny Faksv ag Haugen†§ *Department of GI Surgery, Stavanger University Hospital, Stavanger, Norway, †Regional Centre of Excellence for Palliative Care Western Norway, Haukeland University Hospital, Bergen, Norway, ‡Department of Clinical Medicine 1, University of Bergen, Bergen, Norway and §European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway E-mail: [email protected]
References 1 Nedrebø BS, Søreide K, Eriksen MT et al. Survival effect of implementing national treatment strategies for curatively resected colonic and rectal cancer. Br J Surg 2011; 98: 716–23.
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2 Hofmann B, H aheim LL, Søreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005; 92: 802– 9. 3 Sigurdsson HK, Kørner H, Dahl O, Skarstein A, Søreide JA, Norwegian Rectal Cancer Group. Clinical characteristics and outcomes in patients with advanced rectal cancer: a national prospective cohort study. Dis Colon Rectum 2007; 50: 285–91. 4 Sigurdsson HK, Kørner H, Dahl O, Skarstein A, Søreide JA, Norwegian Rectal Cancer Group. Palliative surgery for rectal cancer in a national cohort. Colorectal Dis 2008; 10: 336–43. 5 Anwar S, Peter MB, Dent J, Scott NA. Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease. Is there a survival benefit? A systematic review. Colorectal Dis 2012; 14: 920–30. 6 WHO. “WHO Definition of Palliative Care”. http://www. who.int/cancer/palliative/definition/en/ (accessed October 2013). 7 Gallagher DJ, Kemeny N. Metastatic colorectal cancer: from improved survival to potential cure. Oncology 2010; 78: 237–48. 8 de Gramont A, Figer A, Seymour M et al. Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer. J Clin Oncol 2000; 18: 2938–47. 9 Miner TJ. Communication as a core skill of palliative surgical care. Anesthesiol Clin 2012; 30: 47–58. 10 Committee on Task Force on Surgical Palliative Care. Statement of principles of palliative care. Bull Am Coll Surg 2005; 90: 34–5. 11 Dunn GP, Martensen R, Weissmann D. (2009 1st edition). Surgical Palliative Care: A Resident’s Guide. American College of Surgeons, Chicago. 12 Dixon MR, Stamos MJ. Strategies for palliative care in advanced colorectal cancer. Dig Surg 2004; 21: 344–51. 13 Søreide JA. Palliative surgical care. Br J Surg 2010; 97: 970–1. 14 Larssen L, Medhus AW, Hjermstad MJ et al. Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study. Surg Endosc 2011; 25: 3162–9.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, 1465–1466
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
Palliative care in colorectal surgery – are we prepared? Currently, most patients diagnosed with colorectal cancer will undergo surgery with curative intent and the probability of cure has never been higher [1]. The focus of surgical practice has been mainly on curative treatment, with much less attention given to patients with incurable disease. Accordingly the surgical literature deals overwhelmingly with surgery for cure. The literature on palliative surgical treatment is insufficient to offer core knowledge about surgical palliative care, particularly because of a preponderance of small, inadequately powered retrospective studies and divergent definitions of palliative surgery [2]. Indeed, the article by Sigurdsson et al. [3], writing in 2007 on non-surgically treated patients with stage IV rectal cancer, was the first publication in 50 years dealing with this patient group. Despite advances in the diagnosis and treatment of colorectal cancer, one in five patients has disseminated disease at the time of the diagnosis. Large national databases such as the Norwegian Rectal Cancer Registry do not provide data on the outcome relevant for palliative care patients [4], which is of great concern because most patients with disseminated disease at diagnosis will need a palliative approach [5]. The term palliative is derived from the Latin word pallium, which means cloak or cover. To palliate, therefore, means to ‘cover’ or relieve the manifestations of incurable disease by optimal symptom control. As defined by the WHO, palliative care aims to relieve physical and psychological distress and resolve social and spiritual problems [6]. Most of the literature on palliative surgery uses the term palliative in the sense of non-curative since it leaves microscopic or macroscopic tumour in situ, without addressing symptom relief or quality of life. As a consequence, the literature contains very little evidence on the effect of procedures for symptom control in patients with incurable disease, or on the adverse events related to such procedures. In the era of modern multimodal treatment, however, the border between a traditional understanding of curative and palliative has become blurred and is steadily moving towards more aggressive treatment to downsize, downstage, and eventually resect advanced disease [7]. Survival of patients with incurable colorectal cancer has substantially increased to a median of more than 24 months, as compared with 6 months in the preceding two decades [8]. Today with more patients living with what could be described as chronic cancer, we encounter an increasing number of patients presenting with serious symptoms,
often related to local complications of the primary tumour such as obstruction, bleeding, or fistulisation. These patients in need of proper palliative support are often under the care of surgeons. We meet them in the outpatient clinic, on the ward, or in the emergency room. We participate in decision-making at multidisciplinary team meetings for surgical or other treatments, and we can follow well-established guidelines, but these include only patients for whom the goal can reasonably be cure. Factors in addition to disease stage determine the treatment and include age, comorbidity and personal wishes based on the patient’s phase of life and stage in the disease trajectory. For patients with incurable disease, we must appreciate and understand the principles of palliative care. This must aim to identify the individual treatment goal, which may be totally different from the common goal of removing the tumour and to understand the physical, emotional, and spiritual needs of the patient and family and communicate with them about their needs [9]. These principles were recognized by the American College of Surgeons (ACS) in 1998, when the ACS Surgical Palliative Care Task Force was established, which published the statement of principles and guidelines of palliative surgical care [10] and a resident’s guide to surgical palliative care [11]. For patients with advanced disease, the consideration of all available options is of the greatest importance, and these include palliative treatment approaches. We must identify patients who will be better served by symptom-relieving measures, including relevant surgical or non-invasive interventions, than by extensive tumour-directed treatment [12]. The interdisciplinary approach is a hallmark of palliative care. Surgeons are essential as members of the palliative care team, having the key knowledge and skills in applying surgical interventions as part of optimal symptom management. Palliative surgery, defined as any surgical intervention to improve the quality of life in patients with incurable disease [11], can carry complications like any other intervention. Although complications may be acceptable in a curative setting, they may be unacceptable when the aim is symptom relief in endof-life care. Accordingly, any palliative intervention must be based on sound judgement and discussion with the patient and the family [13]. The feasibility of performing a procedure is not an indication by itself and futile actions must be avoided. Furthermore treatment of an asymptomatic patient is more prone to lead to burdensome adverse effects than true benefit.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, 1465–1466
1465
Editorial
Given the complex context, the question arises: are we, as colorectal surgeons, prepared to deal with our palliative care patients? The main challenges in daily practice are: 1 to identify those patients who have treatment goals other than cure 2 to present and select appropriate treatment options in line with the patient’s wishes 3 to avoid futile treatment 4 to acknowledge the physical, emotional, and spiritual needs and communicate empathetically and effectively with the patient and family. We face huge challenges in building up the evidence base needed for palliative surgical interventions, relying on patient-reported outcome measures instead of survival [5,13,14]. To manage these challenges, the community of colorectal surgeons may have to reconsider education and specialist training programmes, research efforts, and organization of services to deliver appropriate care for the surgical palliative care patient.
Conflicts of interest No conflicts of interest to declare.
Hartwig Kørner*†‡ and Dagny Faksv ag Haugen†§ *Department of GI Surgery, Stavanger University Hospital, Stavanger, Norway, †Regional Centre of Excellence for Palliative Care Western Norway, Haukeland University Hospital, Bergen, Norway, ‡Department of Clinical Medicine 1, University of Bergen, Bergen, Norway and §European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway E-mail: [email protected]
References 1 Nedrebø BS, Søreide K, Eriksen MT et al. Survival effect of implementing national treatment strategies for curatively resected colonic and rectal cancer. Br J Surg 2011; 98: 716–23.
1466
2 Hofmann B, H aheim LL, Søreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005; 92: 802– 9. 3 Sigurdsson HK, Kørner H, Dahl O, Skarstein A, Søreide JA, Norwegian Rectal Cancer Group. Clinical characteristics and outcomes in patients with advanced rectal cancer: a national prospective cohort study. Dis Colon Rectum 2007; 50: 285–91. 4 Sigurdsson HK, Kørner H, Dahl O, Skarstein A, Søreide JA, Norwegian Rectal Cancer Group. Palliative surgery for rectal cancer in a national cohort. Colorectal Dis 2008; 10: 336–43. 5 Anwar S, Peter MB, Dent J, Scott NA. Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease. Is there a survival benefit? A systematic review. Colorectal Dis 2012; 14: 920–30. 6 WHO. “WHO Definition of Palliative Care”. http://www. who.int/cancer/palliative/definition/en/ (accessed October 2013). 7 Gallagher DJ, Kemeny N. Metastatic colorectal cancer: from improved survival to potential cure. Oncology 2010; 78: 237–48. 8 de Gramont A, Figer A, Seymour M et al. Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer. J Clin Oncol 2000; 18: 2938–47. 9 Miner TJ. Communication as a core skill of palliative surgical care. Anesthesiol Clin 2012; 30: 47–58. 10 Committee on Task Force on Surgical Palliative Care. Statement of principles of palliative care. Bull Am Coll Surg 2005; 90: 34–5. 11 Dunn GP, Martensen R, Weissmann D. (2009 1st edition). Surgical Palliative Care: A Resident’s Guide. American College of Surgeons, Chicago. 12 Dixon MR, Stamos MJ. Strategies for palliative care in advanced colorectal cancer. Dig Surg 2004; 21: 344–51. 13 Søreide JA. Palliative surgical care. Br J Surg 2010; 97: 970–1. 14 Larssen L, Medhus AW, Hjermstad MJ et al. Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study. Surg Endosc 2011; 25: 3162–9.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, 1465–1466
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
