Role Of Surgery In Palliative Care For Metastasis

  • Swati Sharma Master of Dental Science - Operative Dentistry, King George’s Medical College, Lucknow, India

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Introduction

Palliative care is a method in health care that relieves the pain and other discomfort of the patient. It is to enhance the quality of life of a patient suffering from diseases like cancer. In this area of interdisciplinary approach, surgery reverts to playing its role in symptom management and relieving the symptoms of patients suffering from advanced diseases.

To some, surgery might be a modality for the treatment of cancer., It can also be done within the scope of palliation to relieve pain and improve functional and general well-being. 

Specific issues such as pains, obstruction, and fluid build-up make a great difference in the quality of life for the patient in the palliative setting. It is, therefore, upon health providers to know when to consider palliative care surgery or not for the completion and effectiveness of care to the patients.

Definition of palliative care

Palliative care is a medical speciality where the goal is to provide relief from the symptoms and suffering of the patient.1 

It is to improve the quality of life, which a patient has a right to even to the last days of their life, attending to issues like pain, emotional support, and spiritual care among others. Although in most cases, palliative care applies to terminal diseases, it is given at any time after a life-threatening illness has been diagnosed alongside the treatment to cure a disease.

It is a holistic treatment that includes services to satisfy physical, psychological, social, and spiritual needs. Palliative care focuses on helping the patient to live as comfortably as possible and aiding their relatives through the course of the disease.

Definition of metastasis

Metastasis means the passage of cancer cells from the primary site to other sites of the body. Metastasis diminishes the quality of life for patients and is a source of pain, organ dysfunction, and psychological distress.

Studies have shown that metastatic cancer can lead to physical symptoms such as fatigue, loss of appetite, and difficulty breathing, which affects patients' daily functioning and overall well-being. Furthermore, the uncertainty and unpredictability of metastasis can create psychological distress and anxiety for patients and their loved ones further diminishing quality of life.2

Importance of surgery in palliative care

Although not a first line of intervention, the very multidimensional nature of palliative care makes it clear that surgery is necessary to manage symptoms and enhance the quality of life of patients diagnosed with advanced or metastatic cancer. 

Radiation therapy and chemotherapy are treatments but surgery may be helpful to address some requirements in regard to palliative care. Radiation therapy plays a role in symptom palliation and preservation of function. The potential contribution of surgery covers both local tumour control and symptom control.3

Surgical interventions in palliative care

In palliative care, surgery, as an intervention, creates a positive impact on the quality of life of patients. Surgery is m associated with a cure to r alleviate  symptoms and control the disease.4 

Examples of such interventions include nerve blocks or stent placement that are successful in controlling and relieving pain among patients who typically present with advanced cancer, but could also be applicable in other diseases where the prognosis is poor 5. Some other surgical procedures include Amputations, disarticulations, wide excisions, debulking surgery, feeding jejunostomy, ileostomy, simple mastectomy and many others 6

These surgical procedures removeparts of the tumor causingpain or discomfort. Conversely, this reduces pain.

Quality of life benefits of surgical interventions

Surgical interventions extend beyond the pain management and improve the quality of life of the patients undergoing palliative care. The symptoms that surgery handles, include obstruction and bleeding forpatient's comfort and general well-being. 

Surgery improves the patient's chances to conduct daily activities with the family and loved ones. The surgery improves the psychological aspect of palliative care through a reduction in distress and anxiety oversymptoms. 

Research has shown that the administration of surgical interventions to patients, when involved in palliative care, enhances the quality of life for the patient and the satisfaction of the individual with the care.7 It is an excellent way to address physical symptoms in patients under care and promote their well-being. 

Challenges and considerations in surgical palliative care

There are challenges and considerations related to surgical palliative care. They are

  • Timing of surgical intervention among the patients with advanced illness. 
  • Providing quality life.  Surgeries conducted in palliative care may bring forth complications that might prolong the suffering of the patient. 

Another critical part of palliative care is communication,  since the treatment of any patient cannot be generalized, the patient and family should be well informed of the benefits, risks, and potentials of such a surgery, even the outcomes. More importantly, under such delicate situations, the ethics demand that patient autonomy is highly adhered to, and dignity upheld. In general, there are a vast number of barriers and issues that must be considered in surgical palliative care.8

Future directions and potential advancements in surgical palliative care

Surgery is going to revolutionize palliative care. With minimally invasive and robotic techniques, patients will be back on their feet soon with much less pain and the ability to resume normal activities as usual.  The progress of personalized medicine will mean that surgeons can ensure that procedures are designed according to the precise biology of each patient's type of cancer, avoiding unnecessary interventions but with maximal symptom control. The future holds promise through the integration of other fields of medicine. Nanomedicine specialists to implant such targeted systems for drug delivery during surgery. These microscopic wonders could release the medication continuously at the site, controlling symptoms with very minimal systemic side effects for longer durations. This could be a significant improvement in surgery that other disciplines could make and bring an improvement in the quality of life for patients with metastatic cancer.

FAQs

Is palliative care necessary for all patients?

Palliative care is necessary to reduce the suffering from serious diseases. It manages the symptoms and improves the quality of life of seriously ill patients. It relieves pain, enhances functions and helps improve conditions like obstruction and diffusion.

Should surgery be performed on a metastatic site?

Worldwide, many people suffer from cancer. Surgical removal is the mainstay in cure and control of cancers. Surgical excision of primary or metastatic tumours can extend and save lives. However, it is widely acknowledged that surgical insults precipitate or accelerate tumour recurrence. It has been found that all those who underwent resection of their cancer did not survive as long as those who did not. Recent studies have proved that surgical operations may generate a permissive environment for cancer growth.

Will chemotherapy stop my metastatic cancer?

Metastasis is when cancer cells spread beyond the primary tumour. Some cancers may go into remission with chemotherapy, others may require chronic treatment, and some may even be untreatable.

How should I deal with my metastatic cancer?

Living with metastatic cancer can be challenging and stressful. It is important to work on mental health and get support from your loved ones, counsellors and community programmes.

Summary

Palliative care reduces the suffering from serious diseases. It also provides symptom management so the quality of life for seriously ill patients will continue to improve. Surgery, almost always considered a curative modality, plays an important role within palliative care, in the relief of pain, enhancement of function, and conditions such as obstruction and effusion. The review identifies the role of surgery in palliative care by enumerating the benefits that surgical interventions have on the quality of life through symptom, function, and distress reduction in a patient. 

Quite literally, that puts surgery right at the heart of palliative care. The timing of the surgery and possible complications are to be taken seriously. Open communication with the patient and family is necessary to ensure respect for patient autonomy and informed decision-making. While challenges exist, surgery is an important tool in the palliative care toolbox.

References

  1. Palliative care [Internet]. [cited 2024 Jun 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/palliative-care
  2. Hunt A, Handorf E, Blau M, Chertock Y, Fang C, Hall MJ, et al. Psychological distress in patients with metastatic cancer enrolling on phase I clinical trials. J Cancer Surviv [Internet]. 2021 [cited 2024 Jun 17];15(3):398–402. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955695/
  3. Palliative care in cancer - nci [Internet]. 2018 [cited 2024 Jun 17]. Available from: https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
  4. Goel A, Garg PK. The role of surgery in palliative care of cancer: a review. Gulf J Oncolog. 2018 Sep;1(28):61–71.
  5. Palliative surgery | seer training [Internet]. [cited 2024 Jun 17]. Available from: https://training.seer.cancer.gov/treatment/surgery/types/palliative.html#:~:text=Palliative%20surgery%20such%20as%20a,recorded%20as%20cancer%2Ddirected%20surgery.
  6. Deo SVS, Kumar N, Rajendra VKJ, Kumar S, Bhoriwal SK, Ray M, et al. Palliative surgery for advanced cancer: clinical profile, spectrum of surgery and outcomes from a tertiary care cancer centre in low-middle-income country. Indian J Palliat Care [Internet]. 2021 [cited 2024 Jun 17];27(2):281–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428898/
  7. Fan Z, Lin J, Chen X, Huang X. Application of palliative care in improving the quality of life of patients with cancer pain. Open Journal of Nursing [Internet]. 2017 Apr 17 [cited 2024 Jun 17];7(4):473–80. Available from: https://www.scirp.org/journal/paperinformation.aspx?paperid=75554
  8. Blumenthal B, Lee CW, Vitous CA, Robbins AJ, De Roo AC, Byrnes M, et al. Barriers to palliative care use among surgical patients: perspectives of practising surgeons across Michigan. Ann Palliat Med [Internet]. 2021 Feb [cited 2024 Jun 17];10(2):1122–32. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9437840/

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BSc. Biomedical Science Graduate, (Teaching and Research Assistant -University of Cape Coast, Department of Pharmaceutical Microbiology)

Isaac Torgbor Gborbitey is a dedicated medical writer, with substantial grounding in Biomedical Science, having hands-on experience in academic research. He has led several health committees and been part of multiple public health initiatives, all of which have honed his collaborative work and project management capabilities.

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