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1 ORIGINAL ARTICLE A Prospective, Related, Outcomes Aalysis of 1022 Palliative s for Advaced Cacer Thomas J. Mier, MD,* Murray F. Brea, MD,* ad David P. Jaques, MD* Objective: To prospectively evaluate surgical performed with palliative itet. Summary Backgroud Data: There is a paucity of outcomes data ecessary to allow soud surgical decisio-makig ad iformed coset for palliative. Methods: s to palliate symptoms of advaced cacer were idetified prospectively from all operatios performed. Patiets were observed for 90 days or util death. Resutls: There were 1022 palliative performed i 823 patiets from July 2002 to Jue Operative (713/1022) or edoscopic (309/1022) were performed for gastroitestial obstructio (34%), eurologic symptoms (23%), pai (12%), dyspea (9%), jaudice (7%) or other symptoms (15%). improvemet or resolutio withi 30 days was achieved i 80% (659/823). Media duratio of symptom cotrol was 135 days. Recurrece of the primary symptom occurred i 25% (165/659) while treatmet of debilitatig additioal symptoms was required i 29% (191/659). Palliative were associated with 30-day postoperative morbidity (29%) ad mortality (11%). A major postoperative complicatio reduced the probability of symptom improvemet to 17%. Media survival was 194 days from the time of the palliative procedure ad was adversely associated with poor performace status (ECOG 2 P or NCI fatigue score of 1 P ), poor utritio (albumi 3.5 P or sigificat weight loss P ), ad o previous cacer therapy (P 0.002). Coclusios: I carefully selected patiets, relief of symptoms followig palliative ca be expected, but ew or recurret symptoms limit durability. Potetial beefits are miimized by postoperative complicatios ad are less predictable for patiets with poor performace status, malutritio ad o prior cacer therapy. (A Surg 2004;240: ) From the *Departmet of Surgery, Memorial-Sloa Ketterig Cacer Ceter, New York, NY; ad the Departmet of Surgery, Brow Medical School, Providece, RI. Reprits: David P. Jaques MD, Departmet of Surgery, Memorial Sloa- Ketterig Cacer Ceter, 1275 York Ave, New York, NY Copyright 2004 by Lippicott Williams & Wilkis ISSN: /04/ DOI: /01.sla dd Recommedatios from the Istitute of Medicie ad Natioal Cacer Policy Board have stressed the eed for a expaded role of palliatio i the comprehesive maagemet of cacer patiets. 1 Iitiatives by the America College of Surgeos, summarized by the Priciples Guidig Care at the Ed of Life, are providig essetial kowledge about the curret cocepts ad practice of palliative care that may help to overcome the lack of formal traiig that most surgeos have i palliative care ad supplemet shortcomigs i the surgical peer-reviewed ad textbook literature. 2,3 Surgical palliatio of cacer is characterized best by employed with ocurative itet with the primary goal of improvig symptoms caused by a advaced maligacy. The effectiveess of a palliative itervetio should be judged by the presece ad durability of patiet ackowledged symptom resolutio. Whe accompaied by overall improvemet i quality of life, limited morbidity ad mortality of therapy ad modest resource utilizatio, its value is ehaced. Although symptom palliatio may result i icreased survival for the idividual patiet, it is iappropriate to select a palliative procedure solely based o a desire for improved duratio of survival. 4 6 Whe therapy is give with curative itet, the prologatio of life or elimiatio of disease ofte allow the potetial cosequeces of treatmet such as severe toxicity, patiet discomfort, ad ifrequet mortality to be viewed as acceptable risks. Cliical decisio-makig ofte revolves aroud well-characterized surgical priciples ad based o a robust body of literature ad cliical trials. There have bee few such trials cocered with surgical palliatio ad a paucity of data geerated to build a evidece-based body of kowledge which could ultimately lead to improved surgical care of patiets ear the ed of life. 3 The goal of this study is to prospectively follow all patiets udergoig a palliative operative or edoscopic procedure durig a oe year period to obtai some of the data that are required to guide soud cliical decisios ad allow more adequate patiet couselig. This comprehesive aalysis also serves as a framework for future symptom, disease, ad procedure specific aalyses of surgical palliatio. Aals of Surgery Volume 240, 4, October

2 Mier et al Aals of Surgery Volume 240, 4, October 2004 TABLE 1. Patiet Characteristics at Iitial Palliative Variable N 823 Age, y, mea, rage (19 95) Geder, (%) Male 362 (44) Female 461 (56) Previous therapy, (%) Chemotherapy 535 (65) Radiotherapy 363 (44) Surgery 477 (58) Extet of documeted disease, (%) Distat metastasis 239 (29) Locoregioal disease 173 (21) Both 411 (50) ECOG (16) (48) (15) 3 76 (9) 4 3 (1) Not examied 95 (11) NCI Fatigue Scale (29) (31) (17) 3 68 (8) Not examied 122 (15) Weight loss 10 lbs i prior 30 days 263 (32) Albumi (mea) Hemoglobi (mea) METHODS The medical records of all patiets udergoig a surgical procedure at Memorial Sloa-Ketterig Cacer Ceter betwee July 2002 ad July 2003 were screeed daily to desigate cases as palliative or opalliative. s performed primarily for symptom maagemet o patiets with metastatic or advaced locoregioal cacer were idetified. A itervetio was cosidered palliative oly whe the medical record clearly documeted palliative itet or whe iterview of the attedig surgeo cofirmed that it was performed to relieve specific symptoms, cotrol pai or improve quality of life. Patiets foud to have had a palliative procedure either by surgeo cofirmatio or explicit chart aalysis were etered ito a prospective database. The subjects demographic iformatio, primary cacer, chief complait, prior treatmet history, ECOG level, NCI fatigue scale, hemoglobi, albumi, ad type of palliative procedure, were obtaied from the 720 FIGURE 1. The primary tumor site of 823 patiets at the time of their iitial palliative procedure. Other group represets a additioal 15 types of primary maligacies. cliical record. s performed primarily with a brochoscope, cystoscope, or gastroitestial edoscope were cosidered edoscopic. All other cases were classified as operative. Surgical complicatios withi 30 days of operatio were graded usig a previously described surgical secodary evets gradig system i which a grade 1 complicatio required local or bedside care, a grade 2 complicatio required ivasive moitorig or itraveous medicatio, a grade 3 complicatio required a operatio, itervetioal radiology, itubatio, or therapeutic edoscopy, a grade 4 complicatio resulted i a persistet disability or required major orga resectio, ad a grade 5 complicatio resulted i death. 7 The highest severity level was recorded whe a patiet had more tha oe complicatio associated with a specific procedure. Grade 3 ad 4 complicatios were cosidered high grade. The legth of hospitalizatio associated with the iitial palliative procedure was determied. Followig the iitial palliative procedure, the presece or absece of symptoms was determied ad followed over time. assessmet scales, pai scores, ad quality of life istrumets from the patiet s records were evaluated. Although these tools were used to classify all patiets before surgery, they were available i approximately half of the patiets durig the follow-up period. I the absece of these istrumets, a patiet was cosidered to have a specific symptom if there was a documeted fidig o radiographic, edoscopic, laboratory, or physical examiatio related with the complait. Patiets were classified as havig cliically sigificat pai if they required arcotic pai relief for 30 days, were treated by a pai specialist, or complaied of pai i a locatio compatible with their cliical sceario o more tha 2 cliic visits. Cliically sigificat weight loss was defied as a uplaed weight loss greater tha 10 pouds 2004 Lippicott Williams & Wilkis

3 Aals of Surgery Volume 240, 4, October 2004 Prospective Palliative Data TABLE 2. Palliative s Performed o the Gastroitestial System patiets resolutio (%) Gastroitestial system Ay (82) Total palliative 1, (80) % of palliative 50% 49% Upper GI obstructio Ay (79) Edoscopic dilatatio/stetig (84) Operative or edoscopic gastrostomy (draiage) (72) Gastrojejuostomy (75) Gastrectomy (100) Mid/Lower Ay (90) GI obstructio Small bowel resectio/bypass (91) Coloic resectio/bypass (86) Colostomy (100) Edoscopic dilatatio/stetig (100) Ileostomy (70) Lysis of adhesios (80) Jaudice Ay (92) Edoscopic itervetio (94) Operative biliary bypass (90) Nutritio Ay (77) Edoscopic feedig tube (79) Operative feedig tube (67) Other Ay (58) Bleedig/aemia Edoscopic maagemet (67) Operative maagemet (67) Pai Tumor debulkig (100) Orga resectio (100) Heria repair (67) Fistula Operative maagemet (10) Edoscopic maagemet (0) Other Other (33) resolutio at 30 days is summarized followig the iitial palliative procedure. over a 90-day period. Evidece of symptom resolutio or the developmet of ew symptoms was collected from the patiet record. Further surgical, medical, or radiatio therapy give durig the follow-up period ad additioal to maage recurret or ew symptoms were recorded. All palliative patiets were followed for a miimum of 90 days or util death. Data were aalyzed usig SAS statistical software (Release 5.0, SAS Istitute Ic., Cary, NC). Data were expressed as percetages i the case of categorical variables ad as medias i the case of cotiuous variables. Meas were compared with the use of the Studet t test ad frequecies were compared by the 2 test where appropriate. Survival curves were costructed usig the Kapla-Meier method. The uivariate associates betwee cliical variables ad survival were examied by the log-rak test. Idepedetly associated factors were idetified by proportioal hazard regressio aalysis (Cox model). P values less tha 0.05 were cosidered sigificat. RESULTS From July 2002 through Jue 2003, 1022 palliative operative or edoscopic were performed at Memorial Sloa-Ketterig Cacer Ceter. This costituted 6% of the approximately 17,000 cases performed at the istitutio. s were performed o patiets by all services i the Departmet of Surgery irrespective of the primary tumor type. Followig the iitial palliative itervetio i Lippicott Williams & Wilkis 721

4 Mier et al Aals of Surgery Volume 240, 4, October 2004 TABLE 3. Palliative s Performed o the Neurologic System patiets resolutio (%) Neurologic system Ay (76) Total palliative 1, (80) % of palliative 21% 24% Neurologic Ay (76) Craiotomy/resectio of symptomatic brai metastasis (78) Spial decompressio/stabilizatio (73) VP shut (83) Other (40) resolutio at 30 days is summarized followig the iitial palliative procedure. TABLE 4. Palliative s Performed o the Cardiorespiratory System patiets resolutio (%) Cardiorespiratory system Ay (75) Total palliative 1, (80) % of palliative 11% 11% Dyspea Ay (84) Operative pleuordesis (84) Pericardial widow (84) Larygotracheal obstructio Ay (63) Edoscopic tumor ablatio (38) Larygoplasty (80) Tracheostomy (86) resolutio at 30 days is summarized followig the iitial palliative procedure. patiets, a additioal 109 were performed for recurret symptoms ad 90 more cases were performed for the developmet of ew symptoms. The cliical characteristics of patiets at the time of their iitial palliative procedure are summarized i Table 1 ad primary tumor site is depicted i Figure 1. I all of these, the patiet had a palliative itervetio deliberately proposed to address specific symptoms or improve quality of life. Before iclusio ito this study, palliative itet was cofirmed directly by the surgeo i 58% (480/823) of the subjects. I the remaiig cases, the operative report explicitly stated that the case was performed with palliative itet to maage specific symptoms or to improve quality of life i patiets with a advaced maligacy. The procedure was performed electively i 82% (676/823), urgetly i 16% (128/823), ad emergetly i 2% (19/823). The were operative i 70% (713/1022) 722 ad edoscopically based i 30% (309/1022). Followig the iitial palliative procedure, 47% (387/823) of the patiets were give palliative chemotherapy ad 17% (143/823) received radiatio therapy. Explicit documetatio of symptom improvemet or resolutio was oted i 80% (659/823) of the subjects. All patiets who experieced symptom relief did so withi 30 days of operatio. System-specific outcomes are summarized i Tables 2 through 6. The iitial palliative procedure was associated with symptom improvemet i the gastroitestial system for 82%, the eurologic system for 76%, the cardiorespiratory system for 75%, the ski ad musculoskeletal system for 87%, ad the geitouriary system for 78%. There was o differece betwee edoscopic or operative i the frequecy of symptom resolutio (P 0.20). The media duratio of symptom cotrol was 135 days. The 2004 Lippicott Williams & Wilkis

5 Aals of Surgery Volume 240, 4, October 2004 Prospective Palliative Data TABLE 5. Palliative s Performed o the Ski ad Musculoskeletal System patiets resolutio (%) Ski ad musculoskeletal system Ay (87) 1, (80) % of palliative 10% 10% Boe Pai/Istability Ay (87) Operative repair hip fracture (80) Operative repair extremity fracture (95) Resectio of boe met (88) Woud/tumor hygiee Ay (88) Excisio of tumor for local cotrol (83) Amputatio (100) Lymphadeectomy for regioal cotrol (100) Other (100) resolutio at 30 days is summarized followig the iitial palliative procedure. TABLE 6. Palliative s Performed o the Geitouriary System patiets resolutio (%) Geitouriary system Ay (78) Total palliative 1, (80) % of palliative 8% 6% Obstructio Ay (79) Ureteral stets (76) Other (100) TURP (100) Bleedig Ay (67) Cystoscopic procedure (67) resolutio at 30 days is summarized followig the iitial palliative procedure. durability of symptom relief was ot associated with the type of presetig symptom (P 0.79) or the primary maligacy (P 0.54). As see i Figure 2, maagemet of a recurret primary symptom (25%) ad treatmet of additioal debilitatig symptoms (29%) were frequetly required. No sigs of cliical improvemet were oted i a total of 164 (20%) of the 823 patiets. This group of patiet was composed of: 1 those who received o beefit because they died i the hospital as a result of either complicatios or progressio of disease withi 30 days the procedure; 2 those who required further palliative care to maage their chief complait prior to documeted improvemet; ad, 3 those who demostrated o evidece of subjective improvemet as documeted i the medical record. I the cohort of patiets who have bee followed to death, symptom resolutio without the developmet of recurret or ew symptoms was observed i 16% (52/315). Table 7 lists the maximum grade complicatio followig the iitial palliative itervetio. I the postoperative period, a complicatio was idetified i 40% (334/823) of all patiets. The mea legth of hospitalizatio was loger i those patiets who had a postoperative complicatio ( days versus days, P 001). Patiets who experieced a complicatio were less likely to have documeted improvemet i their chief complait (67% 225/334 versus 89% 434/489, P 0.001). A high-grade postoperative complicatio was associated with a reductio i observed symptom improvemet to 17% (14/84), P The 2004 Lippicott Williams & Wilkis 723

6 Mier et al Aals of Surgery Volume 240, 4, October 2004 overall survival were poor performace status (ECOG 2 or NCI fatigue score of 1), poor utritio (albumi 3.5 or sigificat weight loss) ad o previous cacer therapy. FIGURE 2. Although symptoms usually improved followig the iitial palliative procedure, recurret or additioal symptoms ofte develop durig follow-up. 30-day postoperative mortality rate was 11% (92/823). Palliative cotributed to 36% (92/253) of the total 30-day postoperative mortality (P 0.001) ecoutered at our istitutio durig the period of study. These ofte reflect the termial ature of this care ad are reflective of progressio of disease i may istaces. Although patiets with a edoscopically based procedure had fewer ofatal perioperative complicatios (edoscopic 18% (37/209) versus operative 39% (205/522) ), P 0.001), they experieced a higher 30-day mortality (edoscopic 15% (38/247) ) versus operative (9% 54/576, P 0.017). To idetify the opportuity for durable symptom relief, the overall survival followig a palliative procedure (media 194 days) was documeted i Figure 3. Uivariate ad multivariate aalysis was performed to idetify factors associated with overall survival i this uique patiet populatio (Table 8) ad demostrated that ECOG 2, albumi 3.5, NCI fatigue scale 1, o previous history of cacer therapy, a history of recet weight loss, ad hemoglobi 10.5 were associated with a dimiished overall survival. O multivariate aalysis, idepedet factors adversely associated with DISCUSSION Over 600,000 Americas will lose their battle agaist cacer each year ad be faced with ed of life issues. As they trasitio from curative to comfort care, the patiet, family ad physicia will seek reliable iformatio to properly frame difficult treatmet choices at a highly vulerable time. The patiet is forced to cosider a therapy that may elimiate a cocer but caot deliver the most desired outcome. No loger able to support the patiet through the toxicity of difficult curative treatmets, the family may feel compelled to protect the patiet from ay harm. Well-schooled i risk assessmet of patiets prior to iitiatig multidiscipliary strategies supported by radomized cliical trials, the physicia must propose therapy for gravely ill patiets solely seekig resolutio of a symptom. At this time of great eed, palliative decisios are ofte based o idividual expectatios ad aecdotal experiece rather tha well-characterized iformatio regardig the risks ad beefits for specific groups of patiets. A patiet-cetric uderstadig of the value assiged to resolutio of a symptom is essetial i allowig this importat cocordace betwee patiet, family ad physicia to occur. Cosideratios relatig to the medical coditio ad performace status of the patiet, the extet ad progosis of the cacer, kowledge of the atural history of the primary ad secodary symptoms, potetial durability of the ad quality of life expectatios of the idividual patiet will aid this discussio. A established ad reproducible defiitio of palliative surgery predicated o providig symptom cotrol ad optimizig quality of life was used i this study to evaluate all operatios performed at our istitutio. 1,3,4,9,10 Palliative itervetios accouted for 6% of all performed i this comprehesive cacer ceter ad exceeded the umber of esophagectomies, gastrectomies, pacreatectomies ad hepatectomies combied. This fidig is cosistet with a report from the City of Hope Natioal Medical Ceter, which demostrated, usig a broader defiitio of surgical pallia- TABLE 7. Maximum Grade of Complicatio Followig Iitial Palliative Maximum Grade Complicatio Palliative ( 823) 0 (oe) 489 (60%) 1 (local of bedside) 56 (7%) (19%) 2 (ivasive moitorig or IV medicatio) 102 (12%) 3 (operatio, IR, itubatio or therapeutic edoscopy) 74 (9%) (10%) 4 (persistat disability or major orga resectio) 10 (1%) 5 (death) Mortality rate 92 (11%) Lippicott Williams & Wilkis

7 Aals of Surgery Volume 240, 4, October 2004 Prospective Palliative Data FIGURE 3. Overall survival i patiets followig iitial procedure performed with palliative itet. tio, that 12.5% of the surgical performed were palliative i ature. 11 Palliative are performed by all surgical specialties. Though perhaps ot experts i breast cacer, eurosurgeos will treat the brai or spial metastases, orthopedic surgeos the pathologic fractures ad thoracic surgeos the maligat pleural effusios at a icurable stage of this disease. Comparable symptoms may demad differet resposes based upo the biology of each primary disease. These, ofte subtle, distictios must be appreciated to provide the fiest care. Factors such as symptom severity, the degree of symptom resolutio, the timig ad choice of procedure, the durability of the itervetio, associated complicatios, ad patiet prefereces all play major roles i determiig the overall beefit of the palliative operatio. I this study, experieced cliicias selected patiets for palliative that resulted i improvemet or resolutio of specific symptoms 80% of the time. There are o validated quality of life istrumets solely focused o palliative surgical outcomes. It is far easier to idetify patiets who fail to improve tha it is to distiguish those who experiece the greatest beefits. The impact of a specific palliative itervetio also will differ for each idividual patiet. 3,4 Complete relief of dyspea for a patiet with a maligat pleural effusio for eve a few days may be of sigificat value while lifelog partial improvemet of gastroitestial obstructio with a gastrostomy may be of modest importace. Experiece with a prospective pilot study usig stadardized quality of life istrumets exposes the challege i iterpretig this represetatio of outcome followig palliative itervetios. 4 As patiets progress through ed of life phases, global quality of life status may so overwhelm the picture that a accurate depictio of the overall beefit of a itervetio to solve a specific symptom may be lost. It is difficult to measure degrees of success i the actively dyig patiet. The opportuity for durable improvemet i quality of life is evideced by the media symptom-free survival of 135 days i patiets havig a media survival of 194 days. Nearly oe half of the palliative patiets developed ew or recurret symptoms that required additioal palliative itervetios withi 2 moths of the iitial palliative procedure. The observatio that ew symptoms may arise or that the iitial symptom ca recur is a importat fidig i this study ad cofirms earlier retrospective studies i advaced gastric cacer ad locally recurret rectal cacer that similarly demostrated this pheomeo. 8,10 The limited media overall TABLE 8. Cliical ad Pathologic Factors Associated With Dimiished Overall Survival i Patiets Udergoig Iitial Palliative Variable N Uivariate Multivariate P value Hazard Ratio (CI) P value All patiets 823 ECOG ( ) Albumi ( ) NCI fatigue score ( ) No prior cacer therapy ( ) History of recet weight loss ( ) Hemoglobi ( ) 0.25 (NS) Age (NS) Type of presetig symptom (NS) Type of maligacy (NS) Edoscopically based operatio (NS) Female geder (NS) 2004 Lippicott Williams & Wilkis 725

8 Mier et al Aals of Surgery Volume 240, 4, October 2004 survival of 194 days followig a palliative itervetio was demostrated i this study ad was idepedetly associated with patiet specific factors such as poor utritio, poor fuctioal status, ad previous treatmet history. Cosideratio of aticipated survival helps to defie a period whe the requiremets of symptom cotrol must be met ad adds a perspective that is useful whe cosiderig the risk-beefit ratio for a idividual patiet. 10 Accurate estimatios of survival also are valuable i helpig patiets defie their ow treatmet prefereces. I a large cohort of termially ill cacer patiets, substatially differet treatmet prefereces were expressed by patiets based o their uderstadig of aticipated survival. 12 To achieve the goal of makig care at the ed of life cosistet with their values, patiets ad families eed to be opely iformed of such estimates. 1,4 Palliative care ideally selects treatmet that will maximize quality of life ad miimize complicatios. Although cosideratio of risk i terms of treatmet related toxicity or morbidity ad mortality is a importat part of the surgical decisio makig process, attetio to this elemet should ot be the sole factor i makig decisios about palliative therapy. A balaced view is essetial as risk assessmet techiques hoed i the practice of patiet selectio for curative may overly ifluece the cliicia s decisio to dey a opportuity for quality of life improvemet durig the obvious termial phase of a patiet s life. Yet the overly zealous itervetio i the actively dyig patiet seekig a futile procedure must be recogized ad avoided. I this study, perioperative complicatios had a cosiderable ifluece of the patiets already limited aticipated survival. Sigificat 30-day perioperative morbidity (29%) was see followig the palliative evaluated i this study ad was associated with icreased time i hospital (mea 16 days) ad a decreased chace of symptom resolutio (17%). Death occurred withi 30 days of operatio i 11% of the palliative patiets represetig both progressio of disease ad acceleratio of time to death due to complicatios. This is i marked cotrast to the 30-day operative mortality of 0.4% associated with elective curative itet surgical ocology at this istitutio. Palliative itervetios were associated with a disproportioate 30-day operative mortality accoutig for approximately oe third of all deaths while represetig oly 6% of the. The sigificat ifluece of palliative o the overall operative mortality data from a istitutio also suggests that palliative itet should be cosidered as a specific data elemet whe comparig surgical outcomes across istitutios. Observatios from this study ow provide some of the critical data required to frame these palliative decisios. resolutio ca be aticipated i 80% of patiets though further itervetio may be required for either ew (25%) or recurret (25%) symptoms. These are associated with sigificat operative morbidity (40%), mortality (10%) ad limited aticipated overall survival (approximately moths). Further expasio of this database will permit more precise symptom, disease ad patiet specific descriptios of these global observatios ad aid i the determiatio of therapeutic superiority, optimal timig ad overall effectiveess of surgical palliatio of advaced cacer. REFERENCES 1. Foley KM, Gelbrad H. Improvig palliative care for cacer, Washigto, DC: Natioal Academy Press; The America College of Surgeos Committee o Ethics. Statemet o priciples guidig care at the ed of life. Bull Amer Col Surg. 1998;83:4. 3. Mier TJ, Jaques DP, Tavaf-Motame H, et al. Decisio makig o surgical palliatio based o patiet outcome data. Amer J Surg. 1999; 177: Mier TJ, Jaques DP, Shriver CD. A prospective evaluatio of patiets udergoig surgery for the palliatio of a advaced maligacy. A Surg Ocol. 2002;9: McCahill LE, Krouse RS, Chu DZ, et al. Decisio makig i palliative surgery. JACS. 2002;195: Easso AM, Crosby JA, Librach SL. Discussio of death ad dyig i surgical textbooks. Am J Surg. 2001;182: Marti RC, Jaques DP, Brea MF, et al. Achievig R0 resectio for locally advaced gastric cacer: is it worth the risk of multiorga resectio? JACS. 2002;194: Mier TJ, Jaques DP, Karpeh MS, et al. Defiig palliative surgery i patiets receivig o-curative resectios for gastric cacer. JACS. 2004; i press. 9. Porzsolt F, Taock I. Goals of palliative cacer therapy. J Cli Ocol. 1993;11: Mier TJ, Jaques DP, Paty P, et al. cotrol of locally recurret rectal cacer. A Surg Ocol. 2002;10: Krouse RS, Nelso RA, Farell BR, et al. Surgical palliatio at a cacer ceter: icidece ad outcomes. Ach Surg. 2001;136: Weeks JC, Cook EF, O Day SJ, et al. Relatioship betwee cacer patiets predictios of progosis ad their treatmet prefereces. JAMA. 1998;279: Discussios DR. WILLIAM C. WOOD (ATLANTA, GEORGIA): Dr. Mier, I cogratulate you first o reportig this experiece, which is 10 times the size of the majority of the publicatios o surgery for palliatio i the literature to this poit. It is aother i a series of cotributios by you ad your co-authors to this field. We ow have some outcome data from extesive experiece i a area with little prior critical examiatio, ad it is humblig that i oly 80% are we able to achieve symptom cotrol, ad that i less tha half of these does this persist. I have a observatio ad 2 questios for you, Dr. Mier. First, I have foud that the toughest decisios are those made with the patiet ot to perform palliative surgery; for example, to allow a uremic death from a recurret pelvic tumor rather tha relieve that obstructive uropathy ad allow progressive pelvic erve pai ad a more miserable death. My first questio: Ca you ow idetify for us the 20% of operatios that are ot likely to result i symptom im Lippicott Williams & Wilkis

9 Aals of Surgery Volume 240, 4, October 2004 Prospective Palliative Data provemet, those that we should avoid? For example, attempts at GI fistula closure, if I uderstad your table. The secod questio: Persold s group from Ulm, Germay, have suggested that much improvemet could be achieved i the care of termially ill patiets if we move from palliative symptom cotrol to aticipatory surgery for impedig evets ad operated o the patiets who are more fit rather tha waitig util they are more frail ad actually sufferig from these symptoms? Your commets, please. DR. THOMAS J. MINER (PROVIDENCE, RHODE ISLAND): The patiets i this series were clearly highly selected for operatio. They represet the patiets we decided to perform a procedure o. Mostly, oe would assume, people we thought would do best. Because the selectio bias i our patiets is so high, it is difficult to determie, however temptig, which patiets are best qualified for each particular palliative itervetio. The much harder questio is: What happes to those patiets we say o to? This is somethig we are usure of ad curretly ivestigatig. These data will be required to aswer that questio i the future. Durig the study we also asked the surgeo the surgical itet of the procedure. We specifically asked whether the procedure was doe explicitly for active symptoms or i aticipatio of future symptoms. Iitial results from this data set have yet to be preseted but cofirm a priciple demostrated i this report. We are fairly good at fixig aticipated symptoms. However, as patiets progress through their disease, other symptoms ofte develop. Furthermore, procedure related morbidity is still sigificat ad aticipated survival does ot appear to be substatially loger. Additioal care ad ivolvemet from the surgeo is ofte required beyod the maagemet of those aticipated symptoms Lippicott Williams & Wilkis 727