Sarah Wilcott-Sapp, MD
Oncologists have traditionally been the major specialists delivering supportive care to patients with cancer. However, surgeons may be the first physicians to diagnose metastatic disease or cancer recurrence and are frequently consulted to assist in the care of terminally ill patients with cancer. In addition to providing timely referrals to palliative care specialists, having difficult end-of-life discussions with patients and families, and managing pain in the setting of advanced malignancy, there is still a role for surgery in certain palliative situations.
It is important for oncology surgeon trainees to learn to recognize when a palliative surgical procedure for an advanced malignancy might be appropriate, be familiar with the conduct of these operations, and understand the nuances of postoperative care and management of complications in this unique patient population. As stated by Hanna et al, “Palliative care is not so much a new specialty as a rediscovery of a tradition of surgery in which palliative surgical interventions that do not cure are once again acknowledged to be of tremendous benefit for those with disease.”1
Research, including randomized controlled trials and meta-analyses, has demonstrated that the addition of palliative care to oncology care improves symptom control and patient quality of life (QoL). There are even data which suggest that receipt of palliative care can decrease the rate of suicide in patients with high-risk lung cancer, which may be applicable to patients with gastric cancer, who are also at increased risk for suicide.2
QoL benefits have been shown to increase with earlier referral to palliative care, emphasizing the importance of training all physicians in the basic tenets and potential benefits of palliative care.3
The American College of Surgeons recognizes the importance of palliative care, and the American Board of Surgery (ABS) mandates that “Certified general surgeons additionally must possess knowledge of the unique clinical needs of the following specific patient groups: Terminally ill patients, to include palliative care and pain management . . . and counseling and support for end-of-life decisions and care.” 4-6 Nonetheless, many surgeons continue to lack formal training in palliative surgical care.
A 2005 survey reported that 84% of surgeons did not receive any palliative care training in residency and 44% did not receive training during continuing medical education (CME).7
More recently, a 2018 study reported that 20% of surgeons received no palliative care education during residency, fellowship, or as part of CME while in practice despite the incorporation of palliative care into the Accreditation Council for Graduate Medical Education’s 6 competency domains.4,8
In complicated patients with advanced malignancies, the potential palliative benefits of invasive procedures and operations must be balanced with the risks associated with surgery, particularly because complications could have profound effects on a patient’s QoL in a limited timeframe. Investigators conducting a recent study compared palliative care training between surgeons and medical physicians and analyzed the effects of this training on clinical decision making. They found that surgeons received significantly fewer hours of palliative care training than medical oncologists or pulmonary critical care physicians and that physicians without palliative care training were more likely to recommend major operative intervention.8
A meta-analysis showed that surgeons are generally aware of the potential benefits of palliative care but lack knowledge about palliative care and are uncomfortable providing such care to their patients.9 Surgeons, like oncologists, have a responsibility to provide realistic data regarding anticipated treatment outcomes and long-term prognoses while preserving hope, but they often lack the training necessary to accomplish this goal.
Moreover, the benefits of palliative care training go beyond patients and their families. Such training has been shown to combat burnout in medical oncology fellows and has the potential to help mitigate symptoms of burnout in surgical trainees and attendings.10
Efforts are increasing to include palliative care training during medical school and surgical residency, but it is even more important to include this training in fellowships in which physicians frequently care for patients with terminal diagnoses.1
Ninety-eight percent of respondents in 1 survey of surgical oncology and hepatobiliary fellows generally or completely agreed that learning to care for dying patients is important.11
A recent study of surgical oncology and hepatopancreaticobiliary fellowship program directors found that only 60% of programs currently offer formal training in pain management, communication of bad news, or framing a conversation about disease prognosis.12
The availability of this type of training is likely to grow as more institutions recognize the importance of education in these aspects of oncology care. Successful training in palliative care will require integrating existing departmental and institutional palliative care resources with fellowship and CME curricula.
According to results from the same survey, many resources for increased and improved training already seem to be available.12
All of the responding programs reported having a palliative care consultation team, 42% have a surgical faculty member with clinical interest or expertise in palliative care, and 35% have a surgical faculty member with board certification in hospice and palliative medicine.
Lack of department support and a belief by curriculum program directors that fellows are uncomfortable dealing with death and dying patients—which could be due, at least in part, to the absence of training in the appropriate care of these patients—can act as barriers to the implementation of palliative care training. Furthermore, although the American Board of Surgery has a partnership with the American Board of Internal Medicine to provide certification in hospice and palliative medicine, not all surgeons who treat cancer will be able to complete an additional full year of training in palliative care.
The Society of Surgical Oncology and American Hepato-Pancreato-Biliary Association have recognized the value of palliative care training during fellowship, but these national leadership organizations can better integrate palliative care training into the defined curriculum objectives for fellows by developing short, intensive courses that can be provided at medical conferences and by advancing partnerships with existing committees on palliative care education.
Progress has been made in the presentation of palliative care research at prominent surgical meetings and the integration of patient-centered care goals in the general surgery residency curriculum objectives, but surgical departments need to further recognize that improved palliative care training, particularly for surgeons treating patients with cancer, has the potential to dramatically improve patient satisfaction and outcomes.
The ongoing development of CME related to palliative care is undeniably important for surgeons in practice. There is great potential to integrate palliative care training into the curriculum of surgical fellowships to better prepare the next generation of surgeons to practice evidence-based, multidisciplinary patient care to maximize patient QoL.
- Hanna NN, Bellavance E, Keay T. Palliative surgical oncology. Surg Clin N Am. 2011;91(2):343-353. doi: 10.1016/j.suc.2010.12.004.
- Sullivan DR, Forsberg CW, Golden SE, Ganzini L, Dobscha SK, Slatore CG. Incidence of suicide and association with palliative care among patients with advanced lung cancer. Ann Am Thorac Soc. 2018;15(11):1357-1359. doi: 10.1513/AnnalsATS.201805-299RL.
- Hui D, Hannon BL, Zimmerman C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. CA Cancer J Clin. 2018;68(5):356-376. doi: 10.3322/caac.21490.
- Brasel KJ, Weissman DE. Palliative care education for surgeons. J Am Coll Surg. 2004;199(3):495-499.
- Dunn GP. Surgery, palliative care, and the American College of Surgeons. Ann Palliat Med. 2015;4(1):5-9. doi: 10.3978/j.issn.2224-5820.2015.01.03.
- The American Board of Surgery: Specialty of General Surgery Defined. http://www.absurgery.org/default.jsp?aboutsurgerydefined. Accessed December 31, 2018.
- Galante JM, Bowles TL, Khatri VP, Schneider PD, Goodnight JE Jr, Bold RJ. Experience and attitudes of surgeons toward palliation in cancer. Arch Surg. 2005;140(9):873-880.
- Bateni SB, Canter RJ, Meyers FJ, Galante JM, Bold RJ. Palliative care training and decision-making for patients with advanced cancer: a comparison of surgeons and medical physicians. Surgery. 2018;164(1):77-85. doi: 10.1016/j.surg.2018.01.021.
- Suwanabol PA, Kanters AE, Reichstein AC. Characterizing the role of U.S. surgeons in the provision of palliative care: a systematic review and mix-methods meta-synthesis. J Pain Symptom Manage. 2018;55(4):1196-1215. doi: 10.1016/j.jpainsymman.2017.11.031.
- Mougalian SS, Lessen DS, Levine RL, et al. Palliative care training and associations with burnout in oncology fellows. J Support Oncol. 2013;11(2):95-102.
- Amini A, Miura JT, Larrieux, et al. Palliative care training in surgical oncology and hepatobiliary fellowships: a national survey of the fellows. Ann Surg Oncol. 2015;22(6):1761-1767. doi: 10.1245/s10434-014-4226-0.
- Larrieux G, Wachi BI, Miura JT, et al. Palliative care training in surgical oncology and hepatobiliary fellowships: a national survey of program directors. Ann Surg Oncol. 2015;22(suppl 3):S1181-S1186. doi: 10.1245/s10434-015-4805-8.