Medico

Palliative Surgical Oncology
Nader N. Hanna, MDa,*, Emily Bellavance, Timothy Keay, MDc
KEYWORDS  Palliative care  Surgical oncology  Ethics  Prognosis  Cancer
MD
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,

A total of 1,529,560 new cancer cases and 569,490 deaths from cancer are projected to occur in the United States in 2010. The lifetime probability of being diagnosed with an invasive cancer is 44% for men and 38% forwomen. Advances in cancer treatment have lead to improvement in overall cancer survival rates, with the current 5-year relative survival rate of 68% for all cancers diagnosed in 1999 to 2005 (compared with 54% for all cancers diagnosed in 1984 to 1986). Approximately 10.8 million Americans with a history of cancer were alive in January 2004. The majority of cancer death is caused by progression ofmetastatic disease, and most cancer patients receive palliative treatment during their last few months of life. Palliative surgical oncology is a relatively new concept, but builds on a long tradition in surgery. As the field of palliative medicine grows and becomes its own specialty, surgeons have been receiving some specialized training in palliative care; devising specific palliative surgicalprocedures; and reevaluating the ethics of their interactions with patients, especially for the selection of palliative surgical procedures. This is leading to a new form of surgical practice in which the emphasis is on relief of present or anticipated symptoms, even if the interventions do not prolong a patient’s life span. The objectives of this article are to (1) describe some of the history ofpalliative care related to the practice of surgical oncology, including educational efforts; (2) discuss goals and justifications for palliative surgery performed with the intent to alleviate existing symptoms and improve quality of life until death with less emphasis on overall patient survival; and (3) provide a discussion of ethical issues in palliative surgical oncology, especially as theserelate to advance care planning and the maintenance of hope in the setting of cancer.
Division of Surgical Oncology, University of Maryland School of Medicine, 22 South Greene Street, Suite S4B-12, Baltimore, MD 21201, USA b Department of Surgery, University of Chicago, 5841 South Maryland Avenue, MC 5031, Chicago, IL 60637, USA c Department of Family and Community Medicine, University of MarylandSchool of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA * Corresponding author. E-mail address: nhanna@smail.umaryland.edu Surg Clin N Am 91 (2011) 343–353 doi:10.1016/j.suc.2010.12.004 surgical.theclinics.com 0039-6109/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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WHAT IS PALLIATIVE CARE?

The very term “palliative care” was firstput into use by a surgeon, Balfour Mount, MD, to describe a type of comprehensive, interdisciplinary, patient-centered care that provided symptom relief to dying patients.1 Palliative care is the type of care currently delivered in the hospice insurance model of care as well as by independent palliative care services but has also been practiced by physicians and surgeons in most of theirinterventions for millennia.2 The Billroth procedures, the Halsted radical mastectomies, the Whipple procedure, all were initially designed to provide a more peaceful and less symptomatic death in patients with terminal cancer. This palliative care tradition continues in the surgical exploration of new ways to enhance the care of patients with incurable illnesses, especially by focusing on the relief ofpresent or imminent symptoms. The basic domains of palliative care competency have been delineated in recent publications, especially in the development of a National Quality Forum’s consensus statement on preferred practices for palliative care and hospice quality.3 This forum divides the field into 8 domains, with 38 preferred practices, which provides a comprehensive overview of the field. The...