To answer the question proposed in the title above – no. However, in an era of increasing specialization, it is not unexpected to respond to challenges in surgery with increased training. One challenge that is confronted on an almost daily basis at cancer centers is the patient who experiences a complication requiring surgical evaluation during treatment of an advanced or incurable malignancy.
These complications come in many forms and include bowel perforation, bowel obstruction, gastrointestinal bleeding, and wound problems. These complications are also notable in that they often represent a sharp turn in the intent of the patient’s care, from improving length of life to improving quality of life. It also will not come as a surprise to any surgeon who is called upon to evaluate a patient with a metastatic incurable malignancy with bowel perforation while on systemic chemotherapy that the surgeon may even be the first health care provider who attempts to address prognosis and end-of-life issues with the patient and/or family members.
Palliative surgery can account for 1,000 or more procedures per year and as much as 20% of a surgeon’s practice at major cancer centers. In addition, up to 40% of all inpatient surgical consultations at cancer centers meet the criteria for palliative care. In understanding the scope, volume, and complexity of acute care surgical oncology, it is important to define palliative surgical care as distinct from palliative medical care, as there are clear differences that are not always recognized. Palliative medical care expertise can be obtained through a palliative care fellowship, and focuses on the treatment of problems such as cachexia, delirium, fatigue, dyspnea, pain, and end-of-life psychosocial issues. Palliative surgical care is specifically surgery for which the major intent is improvement in symptoms or quality of life. As the population ages and the “silver tsunami” of aging patients with cancer washes over our surgical practice, palliative surgical concepts will become an increasingly important aspect of surgical training. Palliative surgical training is not a pasture upon which surgeons are put to keep them out of the operating room. On the contrary, palliative surgical procedures are some of the highest-risk procedures that are performed and often require a lengthy preoperative discussion of the anticipated risk-benefit ratio. This ratio is often very narrow, and the increased risks of palliative surgery must be balanced against the difficult task of estimating the remaining length of a patient’s life or the potential for future cancer-directed treatment options.
So how do we respond to the challenge of palliative surgery in cancer patients? Actually, we do need new and improved training, but it can and should be included as part of general surgery residency and the new ACGME certification in complex general surgical oncology. Our local response at M.D. Anderson has included the creation of an Acute and Palliative Surgical Oncology Service modeled after the acute care surgery model. Acute care surgery has been recognized as providing more timely consultation and improved quality of care, and minimizing disruption of elective practice and research efforts for other faculty. In response to our current demand of one to two palliative surgical consults per day, in addition to other acute inpatient consults, we are attempting to focus the care of these patients on a smaller group of faculty in an effort to develop better algorithms of care and improved clinical expertise. Surgical oncologists may not have the best reputation for acute care clinical expertise. I can think back to my own residency experience where the surgical oncologists did not take call in response to their belief that “there are no emergency surgical oncology problems.”
Cancer care is becoming more complex; even targeted agents can create life-threatening surgical problems, and our current level of palliative surgical training can be improved. My hope is that through acceptance of surgical oncology as a specialty within the Board of Surgery, we will be recognized not only for our expertise in elective cancer surgery but for acute and palliative cancer surgery as well.
Dr. Badgwell is an ACS Fellow and an associate professor of surgery at M.D. Anderson Cancer Center in Houston. He specializes in gastric cancer and palliative surgical oncology.