From HIPEC to End-of-Life Care in Patients with Advanced Cancer: Getting to “NO” - Abstract
Background: Radical debulking with cytoreductive surgery (CRS) and hyperthermic intraperionteal chemotherapy (HIPEC)has been shown to potentially increase disease-free survival in highly-selected patients with certain advanced malignancies, such as pseudomyxoma peritonei, primary peritoneal mesothelioma, ovarian, gastric, and colorectal cancer; and soft tissue sarcoma with peritoneal dissemination. The goal of cytoreductive surgery is to remove all gross disease, at which point HIPEC is administered [1]. However, given the advanced state of disease and the extent of operations required to achieve optimal cyto reduction, the natural history of disease, procedure-related toxicity, anticipated meaningful recovery times, and expected symptom- and disease-free survival must be particularly considered.
Prior literature evaluating overall survival (OS) following CRS and HIPEC ranges from 19.4 to 24 months in ovarian cancer, 32.4 to 34.7 months in colorectal cancer with peritoneal spread, and 45.2 to 53 months in primary peritoneal mesothelioma and median 11.9 months for gastric cancer. Case series have demonstrated 53.4 to 86% five-year OS in pseudomyxoma peritonei [5-7,10]. Median OS for peritoneal sarcomatosis following CRS and HIPEC is 12 months [11]. Completeness of cytoreduction is associated with survival following CRS and HIPEC [10,11]. Patients who undergo initial debulking and HIPEC with good functional recovery who subsequently develop disease recurrence may undergo repeat attempts at CRS and HIPEC. However, as disease recurrence or other sequelae of those operations manifest, further operative intervention is frequently associated with diminished benefit [1]. With recurrent disease, the best opportunity for disease cure has passed, and goals of treatment may need to shift from operation with curative intent for control of disease to palliative intent to improve symptoms [2,3]. In appropriately selected patients, improved quality of life may be achieved with palliative operations while minimizing treatment toxicity [4].
Surgical palliation of cancer is defined as procedures performed explicitly with non-curative intent to improve quality of life, decrease pain, and mitigate symptoms of advanced disease [2,3]. The palliative triangle has been defined as the process of communication and shared decision-making among the patient, patient family, and surgeon in order to develop a successful therapeutic relationship and optimize patient selection and outcomes. By focusing on patient-driven goals such as symptom relief and quality of life, rather than traditional outcome measures such as morbidity and mortality at thirty days, patient satisfaction is improved following palliative operation. Our group has demonstrated high patient-reported symptom relief (90.7%) while also minimizing thirty-day morbidity (20.1%) and mortality (3.9%) when utilizing the palliative triangle in counseling patients and their families [3,8]. Frequent reassessment of patients’ goals of care within the framework of the palliative triangle aids in reorienting patient counseling over the spectrum of disease [9].
Aim: To illustrate the complexity of end-of-life care in patients with advanced cancer, specifically patients who undergo maximally invasive surgery such as HIPEC, and the changing goals of care associated with disease progression, which is facilitated by utilizing the palliative triangle
Methodology: Retrospective review of prospectively-maintained Rhode Island Hospital palliative surgery and HIPEC databases was performed, from 2008 to 2015. A case series of patient cases that illustrate the breadth and complexity of palliative surgical decision-making are provided.