Ana Wilson

A Singular Hope: How the Discussion Around Cancer Surgery Sometimes Fails

BackgroundPatients with cancer often have an overly optimistic view of prognosis, as well as potential benefits of treatment. Patient–surgeon communication in the preoperative period has not received as much attention as communicating prognosis or bad news in the postoperative setting.MethodsThe published literature on patient–physician communication in the preoperative setting among patients considering surgery for a malignant indication was reviewed. PubMed was queried for MESH terms including “surgery,” “preoperative,” “discussion,” “treatment goals,” “patient perceptions,” and “cure.” Information on how surgeons and patients may be empowered to improve communication about goals of care was also outlined.ResultsPhysicians tended not to dwell on prognosis in early discussions, instead emphasizing the uniqueness of individuals and the uncertainty of statistics. The treatment plan often became the dominant feature of the conversation and functioned to deflect attention from discussions of prognosis. Surgeons tended to understate possible complications and provided little detail regarding potential severity or long-term consequences. While most patients wished to be informed of their prognosis, only a subset actually received an estimate of life expectancy. Because optimism with respect to prognosis (often simplified as “hope”) has been largely considered essential for positivity and optimism—even a false or inappropriate optimism—many providers have created, tolerated, or enabled it. Several studies have emphasized, however, that hope can be maintained with truthful discussion, even if the topic is a bad prognosis or eventual death.ConclusionsOpen, honest, and patient-driven discussions before surgery will lead to more robust shared decision making and create more engaged and satisfied patients (and caregivers). Enhanced preoperative discussion can also facilitate clarity about the possibility of cancer recurrence, cure, preferences about advance care planning, and formation of advance directives.

Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives

ObjectiveRegret is a powerful motivating factor in medical decision making among patients and surgeons. Regret can be particularly important for surgical decisions, which often carry significant risk and may have uncertain outcomes. We performed a systematic review of the literature focused on patient and physician regret in the surgical setting.MethodsA search of the English literature between 1986 and 2016 that examined patient and physician self-reported decisional regret was carried out using the MEDLINE/PubMed and Web of Science databases. Clinical studies performed in patients and physicians participating in elective surgical treatment were included.ResultsOf 889 studies identified, 73 patient studies and 6 physician studies met inclusion criteria. Among the 73 patient studies, 57.5% examined patients with a cancer diagnosis, with breast (26.0%) and prostate (28.8%) cancers being most common. Interestingly, self-reported patient regret was relatively uncommon with an average prevalence across studies of 14.4%. Factors most often associated with regret included type of surgery, disease-specific quality of life, and shared decision making. Only 6 studies were identified that focused on physician regret; 2 pertained to surgical decision making. These studies primarily measured regret of omission and commission using hypothetical case scenarios and used the results to develop decision curve analysis tools.ConclusionSelf-reported decisional regret was present in about 1 in 7 surgical patients. Factors associated with regret were both patient- and procedure related. While most studies focused on patient regret, little data exist on how physician regret affects shared decision making.

From bench to bedside: Clinical implications of KRAS status in patients with colorectal liver metastasis

INTRODUCTION While the role of KRAS in the molecular genetics of colorectal cancer has been studied extensively, its prognostic impact in colorectal liver metastases (CRLM) has only recently been examined. This review aimed to summarize currently reported findings on the clinical implications of KRAS mutant (mut-KRAS) status for patients with CRLM. MATERIALS AND METHODS The Pubmed database was searched for relevant articles published from 01/01/2010 to 02/01/2016. Overall survival (OS) and recurrence free survival (RFS) as well as patterns of recurrence were the primary endpoints, but consideration was given to secondary outcomes when the respective findings were of clinical interest. RESULTS Out of the 266 studies screened, 15 were included in our review. Fourteen studies were retrospective cohorts while one was a systematic review/meta-analysis. Among the 14 retrospective studies, 12 reported OS with 9 detecting a negative association with mut-KRAS status. Similarly, 11 out of 14 retrospective cohorts reported RFS with 6 detecting a negative association with mut-KRAS status. Five studies examined patterns of recurrence, with 4 detecting increased extrahepatic recurrence in the mut-KRAS group. One study examined the different effects of codon-specific KRAS mutations on prognosis. CONCLUSION mut-KRAS status predisposes to worse RFS and OS in patients with CRLM, possibly as a result of aggressive tumor biology. Early unresectable extrahepatic recurrence is more frequent in this patient group and may underlie the unfavorable prognosis. Future research should focus on characterizing the distinct effects of codon-specific KRAS mutations as well their interplay with other less common genetic mutations.

A cross‐sectional study of patient and provider perception of “cure” as a goal of cancer surgery

Patients with advanced cancer often misperceive the purpose and likely effectiveness of cancer treatments. The aim of this study was to characterize patient and provider perceptions in the setting of surgery for potentially curable cancer.

Impact of chemotherapy and external beam radiation therapy on outcomes among patients with resected gallbladder cancer: A multi-institutional analysis.

387 Background: Use of adjuvant chemotherapy (CTx) and chemoradiation therapy (cXRT) in the treatment of resectable gallbladder cancer remains varied. We sought to define the utilization and effect of adjuvant therapy on patients having undergone curative-intent resection for gallbladder cancer. Methods: Using a multi-institutional national database, 291 patients with gallbladder cancer who underwent curative-intent resection between 2000 and 2015. Patients with metastasis or an R2 margin were excluded. The impact of adjuvant therapy on survival was analyzed among patients who received surgery alone versus CTx versus cXRT. Results: Median patient age was 66 years. Most patients had a T2 (41.9%) or T3 (35.1%) lesion and 37.8% of patients had lymph node (LN) metastasis. A total of 186 (63.9%) patients underwent surgery alone, 61 (21.0%) received CTx, whereas the remaining 44 (15.1%) patients received cXRT. At a median follow-up of 16.3 months, median and 5-year overall survival (OS) was 28.3 months and 33.0...

Optimal prognostic lymph node staging system for gallbladder adenocarcinoma: A multi-institutional study.

364 Background: The American Joint Committee on Cancer (AJCC) classification is the most universally accepted lymph node (LN) staging system for gallbladder adenocarcinoma (GBA); however, it focuses more on location of LN metastasis than number of LN metastasis. Other lymph node staging systems have been proposed for GBA. We therefore sought to examine the performance of different staging systems including AJCC LN staging system, number of metastatic LN (NMLN), log odds of metastatic LN (LODDS), and LN ratio (LNR). Methods: Patients who underwent curative-intent resection for GBA between 2000 and 2015 and who had lymphadenectomy were identified from a multi-institutional database. The prognostic performance of four staging systems was compared by Harrell’s C and Akaike information criterion (AIC). Results: Overall 214 patients with a median age of 66.7 years (IQR 56.5, 73.1) were identified. A total 1,334 LNs were retrieved from 214 patients, with a median of 4 (IQR 2-8) LNs per patient. In the study coho...